Surgery induced immunosuppression

doi:10.1016/j.surge.2010.07.011

The Surgeon

Volume 9, Issue 1, February 2011, Pages 38-43

https://doi.org/10.1016/j.surge.2010.07.011 Get rights and content

Abstract

Surgery and anaesthesia result in a variety of metabolic and endocrine responses, which result in a generalised state of immunosuppression in the immediate post-operative period. Surgery induced immunosuppression has been implicated in the development of post-operative septic complications and tumour metastasis formation. In addition the effectiveness of many treatments in the adjuvant setting is dependent on a functioning immune system. By understanding the mechanisms contributing to surgery-induced immunosuppression, surgeons may undertake strategies to minimise its effect and reduce potential short-term and long-term consequences to patients.

Introduction

Surgical operations cause a variety of immunological disturbances. With a few exceptions the overall picture is one of a generalised state of immunosuppression in the post-operative period. It would appear that the degree to which this occurs and its duration are determined in part by the magnitude of the initial surgical insult. The clinical consequences to patients as a result of this suppression are unclear. There are reports in the literature suggesting that it results in an increased incidence of post-operative wound complications and tumour progression. This review examines the effects of surgery and anaesthesia on components of the immune system, the mechanisms by which these effects may be mediated and the clinical implications of such immune disturbance. In addition we discuss strategies and novel therapies that can be used to modulate the immune system during surgery.

Section snippets

Surgery induced immunosuppression

Surgery induced immunosuppression is caused by the effect on the cellular components of the immune system. Surgery and trauma cause an increase in the total number of white blood cells circulating in the body.¹However when critical individual leucocyte subpopulations are examined it seems that important groups are suppressed in both number and function. Circulating lymphocyte numbers fall peri-operatively2, 3, 4 and the extent and duration of this fall is related to the magnitude of the surgery.

Mechanisms of immunosuppression

Immune changes occurring peri-operatively are primarily as a result of surgical trauma and subsequent neuroendocrine responses. Activation of the hypothalamic–pituitary–adrenal axis (HPA) is the key response to stress and plays a central role in mediating the effect of surgery on the immune system.32, 33 Peri-operative stresses both physical and psychological result in the increased production of adrenocorticotropic hormone (ACTH) from the pituitary gland, and subsequent release of

Clinical consequences of surgery induced immunosuppression

The clinical consequences of peri-operative immunosuppression were documented as far back as 1911 when Graham reported that ether induced a reduction in bacterial phagocytosis increasing the risk of post-operative septic complications.⁶⁵ Gaylord in 1916 showed an increased frequency of metastases from mammary carcinoma in mice following anaesthesia and blood loss.⁶⁶ More recent studies also suggest that the immunological effects of surgery have both immediate and delayed consequences for

Measures to reduce immunosuppressive effect of surgery

An understanding of the mechanisms by which surgery induces immunosuppression allows for the implementation of certain measures to minimise negative consequences to patients. Efforts to reduce the immunosuppressive effects of surgery and anaesthesia must be initiated in the pre-operative period. These efforts should be focussed on minimising the neuroendocrine stress response associated with surgery. Effective emotional support and counselling as well as appropriate pre-medication use may help

Conclusion

Surgery induced immunosuppression has considerable implications for patients. It is associated with impaired wound healing and delayed post-operative recovery. Its implications for cancer patients are more profound, being associated with an increased incidence of cancer recurrence and reduced survival. In addition the effectiveness of many adjuvant treatments is dependent on the preservation of immune integrity in patients during and following resection of the primary tumour. An understanding

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View full text

ReviewSurgery induced immunosuppression

Abstract

Introduction

Section snippets

Surgery induced immunosuppression

Mechanisms of immunosuppression

Clinical consequences of surgery induced immunosuppression

Measures to reduce immunosuppressive effect of surgery

Conclusion

Surgery

Am J Surg

Br J Anaesth

Br J Anaesth

Surgery

Surgery

Am J Pathol

Pulm Pharmacol Ther

J Allergy Clin Immunol

Brain Behav Immun

Ann Allergy Asthma Immunol

Clin Immunol Immunopathol

J Neuroimmunol

Eur J Pharmacol

Br J Anaesth

Pain

Br J Anaesth

Cytokine Growth Factor Rev

Gynecol Oncol

Immune function in patients undergoing open vs laparoscopic cholecystectomy

Arch Surg

The influence of surgical operations on components of the human immune system

Br J Surg

The influence of laparoscopy on lymphocyte subpopulations in the surgical patient

Surg Endosc

Lymphocytic subpopulation changes after open and laparoscopic cholecystectomy: a prospective and comparative study on 38 patients

Surg Laparosc Endosc

Lymphocyte responses following open and minimally invasive thoracic surgery

Eur J Clin Invest

T and B lymphocyte function in anaesthetists

Acta Anaesthesiol Scand

In vitro effects of halothane on lymphocytes

Eur J Anaesthesiol

Redistribution of lymphocytes following E. coli sepsis

Scand J Immunol

Preoperative and postoperative immunological evaluation of patients with colorectal cancer

Cancer

Endoscopic vs conventional hernia repair from an immunologic point of view

Surg Endosc

Perioperative immune responses in cancer patients undergoing digestive surgeries

World J Surg Oncol

Immunological effects of laparoscopic vs open colorectal surgery: a prospective clinical study

Arch Surg

Immunological aspects of anaesthesia and surgery–with special reference to NK cells

Dan Med Bull

The effect of surgery and chemotherapy on blood NK cell activity in patients with ovarian cancer

Cancer

Awake epidural anesthesia is associated with improved natural killer cell cytotoxicity and a reduced stress response

Am J Surg

Immunodepression after major surgery in normal patients

Surgery

Neutrophil function, serum opsonic activity, and delayed hypersensitivity in surgical patients

Surgery

Inhibition of superoxide production and Ca2+ mobilization in human neutrophils by halothane, enflurane, and isoflurane

Anesthesiology

Halothane reversibly inhibits human neutrophil bacterial killing

Anesthesiology

Influence of anaesthesia and surgery on neutrophil chemotaxis

Can Anaesth Soc J

Effects of minimally invasive surgery on hypochlorous acid production by neutrophils

Br J Surg

Propofol specifically inhibits mitochondrial membrane potential but not complex I NADH dehydrogenase activity, thus reducing cellular ATP biosynthesis and migration of macrophages

Ann N Y Acad Sci

Propofol suppresses macrophage functions and modulates mitochondrial membrane potential and cellular adenosine triphosphate synthesis

Anesthesiology

Normal T lymphocyte and monocyte function after minimally invasive surgery

Surg Endosc

Unimpaired immune functions after laparoscopic cholecystectomy

Surgery

The hypothalamic–pituitary–adrenal axis and immune-mediated inflammation

N Engl J Med

Review
Surgery induced immunosuppression

Inhibition of superoxide production and Ca²⁺ mobilization in human neutrophils by halothane, enflurane, and isoflurane