Page 14 - Journal of WALS

E Ray-Offor, RK Mishra

from list of major articles on this subject and relevant journals BP 2). The major mediators of the acute-phase response are
from Laparoscopic Research Institute, India, were read. known to be interleukin-1 (IL-1), tumor necrosis factor (TNF)
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and interleukin-6 (IL-6). The tumor necrosis factor (TNF) and
RESULTS IL-1 are responsible for nonhepatic acute-phase response,
Pneumoperitoneum affects the local peritoneal immune including fever and tachycardia, while interleukin-6 primarily
environment resulting in alterations in cytokine production and regulates the hepatic component resulting in the production of
phagocytic function. Interleukin-1 (IL-1), tumor necrosis factor acute-phase proteins. It is suggested IL-6 also influences
(TNF) and particularly interleukin-6 (IL-6) are potent systemic polymorphonuclear leukocyte-mediated inflammation via its role
mediators of acute phase response following surgery, thus, are in stimulating the proliferation of polymorphonuclear leukocyte
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useful parameters for studying immune response following these progenitors in the bone marrow. High levels of IL-6 have
advanced methods of cholecystectomy. Various animal model been associated with an increased severity of tissue trauma.
studies have shown that NOTES and laparoscopy evoke similar Studies demonstrate that it affects the production of
7-9
levels of inflammatory cytokine profiles. There is insufficient prostaglandin E, a strong immunosuppressant which induces
immunological data comparing SILS and NOTES post- the chemotaxis response of the lymphocytes and macrophages
cholecystectomy in human studies. at the damage site. 14,15 The other acute-phase proteins include
C-reactive protein, complement factor 3, haptoglobin and serum
OVERVIEW OF IMMUNE RESPONSE amyloid A.
Immunity is the body’s defense system against foreign bodies Postconventional cholecystectomy, a transient rise in pro-
and is either innate or acquired (adapted). The acquired inflammatory cytokines, has been noted unlike in laparoscopic
mechanism is highly specific for a stimulus, improving on surgery which is characterized by a decreased acute-phase pro-
successive exposure; however, the innate mechanism is non- inflammatory response of TNF-α, IL-1, C-reactive protein levels
specific for the antigen with no protective memory. Immune and IL-6. 16,17 A case study showed a late-phase tissue necrosis
10
responses are generated by cellular or noncellular (humoral) factor-alpha (TNF-alpha) depression with NOTES. Extensive
mechanisms. Studies of immune response previously conducted studies, both in animals and humans, have demonstrated better
involved peripheral blood, cytokines, C-reactive protein, preservation of the immune system in minimal access
histamine response and other useful parameters, including laparoscopic procedures with attenuation of the fall in

leukocyte and function, macrophage activation and delayed- lymphocyte count, abrogating thedecrease of monocytic HLA-

type hypersensitivity. 10 DR antigen expression associated withmajor surgical trauma. 19

Minimally invasive approaches restore the decreased IL-2,

Systemic Immune Response IFN-γ, and TNF-α production by T-cells observed with open
surgery. 20
Immune response following surgery is a complex process that
follows a specific pattern and has been defined based on clinical LOCAL PERITONEAL CHANGES
and laboratory observations. A proinflammatory immune FROM PNEUMOPERITONEUM
response mediated primarily by the cells of the innate immune
system is followed by a compensatory anti-inflammatory or The prerequisite establishment and maintenance of
immunosuppressive phenotype that is mediated primarily by pneumoperitoneum for minimal access cholecystectomy alters
cells of the adaptive immune system with host predisposition the interior milieu. Local peritoneal changes are dependent on
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to septic complications. Immune dysfunction induced by the gas used, its pressure, duration of insufflation and

surgical trauma may comprise either an inappropriately temperature. These changes may be beneficial and adverse in

exaggerated inflammatory response or a profoundsuppression effect. Carbon dioxide with the advantage of rapid absorption

of cell-mediated immunity. However, careful surgicaltechnique is the most common agent used for establishing and maintaining

by the use of a minimally invasive approach, adequate fluid pneumoperitoneum in minimal access cholecystectomy. In an
replacement, and antibiotic therapy attenuate these responses. aqueous medium, carbonic acid is formed and a drop in pH after
Notable mediators of immune response studies are cytokines. the induction of CO , pneumoperitoneum affects the
2
These are glycosylated and nonglycosylated polypeptides that biochemical and cellular immune function inherent to the
21
act as soluble immune messengers. They are of two types— peritoneal cavity. Morphological changes to the peritoneal
proinflammatory and anti-inflammatory. Proinflammatory endothelium may result in denudation, migration of PMN
cytokines include tumor necrosis factor-alpha (TNF-α), leukocytes, mast cells and macrophages. The degranulation of
interleukin-1-beta (IL-1β), interleukin-6 (IL-6), interleukin-8 mast cells effect an increase in vascular permeability with supply
(IL-8) and interferon-γ (IFN-γ). The anti-inflammatory cytokines of complement factors and opsins. Activated leukocytes and
are interleukin-10 (IL-10), IL-1 receptor antagonist (IL-1 RA), macrophages release notably, TNF-α, IL-1 and IL-6. Carbon
and soluble TNF binding proteins 1 and 2 (TNF-BP1 and TNF- dioxide has been shown to decrease peritoneal macrophage

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JAYPEE