Impact of surgery on local and systemic responses of cytokines and adhesion molecules.

BACKGROUND/AIMS: Operation may result in various kinds of biological responses in patients who undergo surgery. Recent studies revealed cytokine network is greatly involved in the biological response to surgical stress, as sepsis. Extended surgical injuries may result in a deregulated hyperinflammatory response. However, cytokine and adhesion molecule dynamics of the local area and circulatory blood in perioperative period have not been well clarified. METHODOLOGY: 18 patients with colorectal cancer undergoing operation were recruited into the study. The patients were without major systemic disease and without postoperative complications. Serum samples were taken before operation (Preop) and on post-operation day 1 (POD1), day 3 (POD3), and day 7 (POD7). Samples from the drain tube (local) were taken on POD 1, 3, and 7. Interleukin-6 (IL-6) and adhesion molecules, including ICAM-1, P-selectin, E-selectin, and L-selectin, in serum and drain fluid were measured using ELISA. RESULTS: Serum IL-6 was lowest at Preop, and elevated and peaked on POD1. IL-6 levels in serum were significantly lower than those in drain fluid on POD1, 3, and 7. Circulatory IL-6 after surgery is speculated to come mainly from the surgical traumatic area. Serum P-selectin elevated after the operation and peaked on POD1. P-selectin in drain fluid also peaked on POD1. P-selectin in serum was significantly higher than that in the drain fluid on POD1, 3, and 7. By contrast to IL-6, circulatory P-selectin may come from sources other than the local area. Serum ICAM-1 diminished from Preop to POD1, and to POD3. ICAM-1 in drain fluid elevated from POD1 to POD3, and also from POD3 to POD7. ICAM-1 in drain fluid was significantly lower than that in serum on POD1 and 3. The operation resulted in a significant decrease in systemic soluble ICAM-1 levels, which may associate the patients wtih post-operative organ failure. Serum and drain fluid E-selectin and L-selectin dynamics exhibited a similar pattern to that of ICAM-1. DISCUSSION: For the first time, we demonstrate that surgery induced distinguished dynamic differences between local and systemic cytokine and adhesion molecule response. Circulating IL-6 and P-selectin incresaed after surgery and peaked on POD1. By contrast, surgery diminished the circulating ICAM-1 and E-selectin. Modulation of cytokine and adhesion molecule responses in the perioperative period, for example with nutritional or anticytokine therapy, may have potential clinical importance.

Primary intrathoracic goiter.

Nodular goiter is a common disease in Taiwan, and substernal or intrathoracic goiters are not infrequent. However, intrathoracic goiters are mainly of the secondary type and primary intrathoracic goiters are rarely seen. We report a 55-year-old woman who was incidentally found to have an ectopic goiter located in the anterior upper mediastinum with the initial presenting symptom of productive cough. Imaging studies including chest X-ray and computed tomography identified the lesion, and 131I-uptake scan showed weak uptake in the thorax. Surgical removal via thoracotomy was performed and the diagnosis was confirmed by pathology. A primary intrathoracic goiter, although rare, should also be considered in the differential diagnosis of mediastinal tumor.

Glutamine-supplemented total parenteral nutrition attenuates plasma interleukin-6 in surgical patients with lower disease severity.

AIM: Previous reports have shown that decrease in plasma glutamine (Gln) level following major surgery may contribute to the state of immunosuppression. Gln supplementation improves the depletion of body Gln pool, and may have indirect effect on reducing proinflammatory mediator release. This study evaluated whether the effect of Gln dipeptide-enriched total parenteral nutrition (TPN) on postoperative cytokine alteration depended on the disease severity of surgical patients. METHODS: Forty-eight patients with major abdominal surgery were allocated to two groups to receive isonitrogenous (0.228 g nitrogen/kg per d) and isocaloric (30 kcal/kg per d) TPN for 6 d. Control group (Conv) using conventional TPN solution received 1.5 g amino acids/kg per day, whereas the test group received 0.972 g amino acids/kg per day and 0.417 g L-alanyl-L-glutamine (Ala-Gln)/kg per day. Blood samples were collected on d 1 and d 6 postoperatively for plasma interleukin (IL)-2, IL-6, IL-8, and interferon (IFN)-gamma analysis. RESULTS: Plasma IL-2 and IFN-gamma were not detectable. IL-6 concentrations were significantly lower on the 6(th) postoperative day in the Ala-Gln group than those in the Conv group in patients with APACHE II <=6, whereas no difference was noted in patients with APACHE II >6. There was no difference in IL-8 levels between the two groups. No difference in cumulative nitrogen balance was observed on d 2-5 after the operation between the two groups (Ala-Gln -3.2+/-1.6 g vs Conv -6.5+/-2.7 g). A significant inverse correlation was noted between plasma IL-6 levels and cumulative nitrogen balance postoperatively in the Ala-Gln group, whereas no such correlation was observed in the Conv group. CONCLUSION: TPN supplemented with Gln dipeptide had no effect on plasma IL-8 levels after surgery. However, Gln supplementation had a beneficial effect on decreasing systemic IL-6 production after surgery in patients with low admission illness severity, and lower plasma IL-6 may improve nitrogen balance in patients with abdominal surgery when Gln was administered.

Characteristics of thyroidectomy in Taiwan.

BACKGROUND AND PURPOSE: Thyroidectomy is a common treatment for thyroid disorders in Taiwan, and constitutes a significant percentage of medical expenses. This study investigated the characteristics of thyroidectomy in Taiwan. METHODS: A total of 21 senior general surgeons from 16 medical centers and 5 regional hospitals participated. One surgeon from each hospital reviewed the hospital's medical records of thyroid operations performed in the year 2001. Medical records for 3846 thyroidectomies were retrospectively analyzed, including surgical indications and modalities, complications, pathology reports, and the use of antibiotics. RESULTS: Most of the patients were women (85%). Indications for surgery included proven malignancy (9%), suspicious malignancy (30%), evident compression symptoms (20%), hyperthyroidism (20%), and cosmetic reasons (12%). The majority of patients (78%) underwent a surgical procedure with lobectomy or bilateral thyroidectomy; 13% had unilateral partial thyroidectomy. Prophylactic antibiotics were administered in 46% of procedures, and continued postoperatively in 12%. Postoperative complications occurred in 12% of patients. Hypocalcemia was the most common complication (8%), and its incidence was significantly correlated with the frequency of total thyroidectomy (p < 0.01). Complete pathology reports for the thyroidectomized specimens were available in only 65% of the cases. The frequency of cosmetic reasons for surgery, unilateral subtotal resection, routine antibiotic administration, and incomplete pathology reports were significantly higher in regional hospitals than in medical centers. CONCLUSIONS: Reduction in the high rates of cosmetic reasons for surgery, unilateral partial thyroidectomy, incomplete pathology reports, and use of antibiotic prophylaxis are needed to improve the quality of thyroidectomy in Taiwan.

Operative strategy in follicular thyroid cancer.

BACKGROUND AND PURPOSE: Surgery is the main treatment for most thyroid cancers. However, the indications for subtotal or radical thyroidectomy in cases of follicular thyroid cancer remain controversial. This study examined the indications for subtotal thyroidectomy or radical total thyroidectomy in patients with follicular cancer. METHODS: A total of 196 cases of follicular cancer diagnosed among 1,545 thyroid cancer cases between 1960 and 2000 at National Taiwan University Hospital (NTUH) were included in this study. Diagnosis of follicular cancer was based on the findings of pathologic examination. All surgeries were performed in the Department of Surgery at NTUH. The average period of postoperative follow-up was 11.7 years. Subtotal thyroidectomy was defined as thyroid resection performed on not more than two-thirds of the whole lobe. Radical thyroidectomy was defined as total removal of the thyroid plus cervical lymph node removal if surgical examination revealed malignancy. Local recurrence was defined as tumor reappearance in soft tissue in the neck or cervical lymph node after initial treatment. Distal metastasis was also surveyed from medical records. Patients were classified into three groups according to the size of the surgical specimen as less than 3 cm in diameter, 3 to 5 cm, and more than 5 cm. RESULTS: Between 1960 and 2000, the percentage of follicular cancer patients undergoing follicular cancer surgery decreased from 22.0 to 7.7%, while papillary cancer surgery increased from 65.5 to 87.1%. This change was associated with the addition of iodine to table salt island-wide from 1967. The change in percentage of surgically treated cases was greater between 1991 and 2000. Subtotal thyroidectomy was performed in 56 cases and radical thyroidectomy was performed in 140 cases during the study period. None of the 63 cases with a tumor diameter of less than 3 cm undergoing either radical or subtotal thyroidectomy had local recurrence during a mean follow-up of 11.7 years. However, six of those cases (9.5%) had distant metastasis. CONCLUSIONS: For follicular cancers of less than 3 cm in diameter, subtotal thyroidectomy instead of radical thyroidectomy may be considered, but close follow-up is necessary.