The effect of preoperative corticosteroids on peritoneal macrophage function after laparoscopic and open abdominal surgery in a rat model

American Journal of Surgery (2008) 196, 920-925

Nabha Tangchitphredanonth 10th May 2009

Background
The bodys acute phase response to injury is a complex interaction between neuroendocrine, metabolic and immune systems. Tissue trauma, caused by incisions, tissue dissection, organ manipulation and vascular compromise, stimulates the initial inflammatory response. This response is proportional to the degree of the initial insult.

Background
Peritoneal macrophages protect the peritoneal cavity through a mechanical system of clearance or phagocytosis and by specific cellular immunity mediated by both T and B lymphocytes. Overproduction of these mediators after severe surgical insult may produce local immunosuppression and harm the host (increase risk of postoperative infection, inflammatory complications).

Background
Laparoscopy has been shown to preserve peritoneal macrophage numbers, viability, improve bacterial clearance and stimulate cytokine production similar to nonoperated controls. Steroids are well known for their analgesic, immunemodulation and antiemetic effects. Several studies have examined the effect of perioperative administration of steroids on reduce perioperative stress; however, there has been no agreement on whether it is truly beneficial.

Object
This study compares the postoperative phagocytic function of peritoneal macrophages for open and laparoscopic intra-abdominal surgery when combined with preoperative corticosteroid administration in a rat cecectomy model.

Methods
Animals
8th week-old male Sprague-Dawley rats were housed in a certified animal facility with a 1- to 2-week acclimation period and were given food and water throughout the experiment.

Methods
Animals
66 Sprague-Dawley rats were randomly divided into 7 groups:
B : Baseline animals AC: anesthesia controls OC: open cecectomy LC: laparoscopic cecectomy AC with +S, -S OC with +S, -S LC with +S, -S

** Within the AC, OC, and LC groups, half received intraperitoneal dexamethasone 1 hour before surgery (+S), and the other half received an equal volume of normal saline intraperitoneal (-S)

Methods
Steroid administration
Preoperative steroid administration (intraperitonally 60 mins before skin incision) had a 10 mg/kg dose of dexamethasone. The steroid dose and timing were based on a report by Nakamuta et al which this dose was observed to have the greatest anti-inflammatory effects in rats undergoing thoracotomy. Animals in the no-steroid arms had a equivalent weight-based volume intraperitoneal injection of 0.9%NSS 1 hr before skin incision.

Methods
Rodent anesthesia, postoperative analgesia and euthanasia
All rats were given 3% isoflurane via continuous inhalation for induction and perioperative anesthesia Rats were give 0.05 mg/kg buprenorphine for analgesia 6-12 hours postoperative Animals were observed postoperatively for 24 hours and were then euthanized.

Methods
Operative procedure
Open cecectomy: midline laprotomy incision from the xiphoid to pubis (~6 cm.). Ligated and resected cecum. Laparoscopic cecectomy: incision ~5 mm. and open cut down tech. in upper midline Operative procedure both OC and LC were standardized to 20 mins from incision to completion of skin closure.

Methods
Peritoneal macrophages harvest
Peritoneal macrophages were harvested via intraperitoneal lavage with cell pellet. The cell pellet was then resuspended in 1 mL of culture media. Cell counts were performed with a hemacytometer .

Methods
Measurement of macrophages phagocytic activity
Phagocytic activity was measured using the Vibrant Phagocytosis Assay Kit and calculate the net phagocytosis and percent response to the effector agent.

Methods
Statistical analysis
result was performed using analysis of mean +/- standard deviation Statistic significance using variance and a Student t test between groups. A P value of <.05 was considered significant.

Result
No perioperative mortality was associated with the procedures. The mean +/- standard deviation phagocytic response for the 7 group is displayed in Fig.1

Result
% effect 200

180 160 140 120 100 80 60 40 20 0 B AC-S AC+S LC-S LC+S OC-S OC+S
Study Group

Fig.1 The mean phagocytic response of the peritoneal macrophages to the effectors

Result
There were significant differences between groups (table 1).

Result
Group B AC-S AC+S LC-S LC+S OC-S B .28 .16 .94 .04* .008* AC-S .28 .017* .04* .007* .08 AC+S .16 .017* .02* .26 LC-S .94 .04* .02* .003* LC+S .04* .007* .26 .003* <.000,1* OC-S .008* .08 <.000,1* <.000,1* <.000,1* OC+S .94 .07 .02* .80 .003* <.000,1*

<.000,1* <.000,1*

OC+S

.94

.07

.02*

.80

.003*

<.000,1*

*Significant values (P<.05)

Table1 A comparative analysis of study groups combining surgical techniques and preoperative corticosteroid administration reported a p-values

Result
Group B AC-S AC+S LC-S LC+S OC-S OC+S B AC-S .28 AC+S .16 LC-S .94 LC+S .04* OC-S .008* OC+S .94

.28 .017* .04* .007* .08 .07 The B group had a response rate of 94.2%+/- 56.7%, which was not different from the both <.000,1* AC groups .16 .017* .02* .26 .02* or the LC-S group. .94 .04* .008* .94 .04* .007* .08 .07 .02* .26 .003* .003* <.000,1* .003* <.000,1* <.000,1* <.000,1* .80 .003* <.000,1* -

<.000,1* <.000,1* .02* .80

*Significant values (P<.05)

Result
Group B AC-S AC+S LC-S LC+S OC-S B .28 .16 .94 .04* .008* AC-S .28 .017* .04* .007* .08 AC+S .16 .017* .02* .26 LC-S .94 .04* .02* .003* LC+S .04* .007* .26 .003* <.000,1* OC-S .008* .08 <.000,1* <.000,1* <.000,1* OC+S .94 .07 .02* .80 .003* <.000,1*

<.000,1* <.000,1*

OC+S .94 .07 .02* .80 .003* <.000,1* The lowest phagocytic activity rate was in the OC-S group *Significant values (P<.05) with a response rate of 33.8%+/-28.5%

Result
Group B AC-S AC+S LC-S LC+S B .28 .16 .94 .04* AC-S .28 .017* .04* .007* AC+S .16 .017* .02* .26 LC-S .94 .04* .02* .003* LC+S .04* .007* .26 .003* OC-S .008* .08 <.000,1* <.000,1* <.000,1* OC+S .94 .07 .02* .80 .003*

high phagocytic activity <.000,1* <.000,1* in the AC+S gr. .008* .08 <.000,1* rate occurred <.000,1* with a response rate of 145.2%+/-60.2% and LC+S gr. With OC+S .94 .02* .80 .003* <.000,1* a response rate .07 198.1%+/-103.5%, and these were not of *Significant valuesdifferent from each other significant (P<.05)

The OC-S

Result
Group B AC-S AC+S B .28 AC-S .28 AC+S .16 .017* LC-S .94 .04* LC+S .04* .007* OC-S .008* .08 OC+S .94 .07 .02* .80 .003* <.000,1* -

.16 .017* .26 <.000,1* The LC+S gr. had a significant .02* higher percent response than all of the other group .003* <.000,1* LC-S .94 .04* .02* .04* .008* .94 .007* .08 .07 .26 .003* <.000,1* .003* <.000,1* <.000,1*

LC+S OC-S OC+S

<.000,1* <.000,1* .02* .80

*Significant values (P<.05)

Result
Group B AC-S AC+S B .28 .16 AC-S .28 .017* AC+S .16 .017* LC-S .94 .04* .02* LC+S .04* .007* .26 OC-S .008* .08 <.000,1* OC+S .94 .07 .02* .80 .003* <.000,1* -

LC+S OC-S

The phagocytic response rate of OC+S gr. was not LC-S .04* .02* .003* <.000,1* different.94 from either the AC-S gr. or the LC-S gr. however, it was less than the AC+S
.04* .007* .08 .07 .26 .003* <.000,1* <.000,1* .008* .94 <.000,1* <.000,1* .02* .80 <.000,1* .003*

OC+S

*Significant values (P<.05)

conclusion
Open cecectomy resulted in greater impairment of the phagocytic activity of peritoneal macrophages than laparoscopic cecectomy. The addition of preoperative corticosteroids improved phagocytic activity back to baseline function. The combination of minimally invasive surgical technique and preoperative corticosteroid administration resulted in the greatest postoperative phagocytic function of peritoneal macrophages in a rat model.

Discussion
Steroid administration in the perioperative period has been a topic of much debate in the surgical community. The definite advantage of reduced surgical stress and improved outcomes must be justify the known negative side effects of corticosteroids ie, poor wound healing and increased risk of infection. Preoperative steroids resulted in significantly less fatigue and a faster return to normal activity level compared with the placebo group in a recent laparoscopic cholecystectomy trial.

Discussion
The study examines the combined effect of surgical and pharmaceutical tactics in an attempt to improve postoperative immune function. The specific aim was to evaluate macrophage function, determined by phagocytic activity. Result show significantly higher phagocytic function in laparoscopic techniques compared with open tech. when no preoprative steroids were administered.

Discussion
In fact, the laparoscopic levels were similar to baseline function, whereas in the open surgery group, phagocytic activity was suppressed from baseline. In reports of the immunologic effects of preoperative antiinflammatory medications and steroids, there has been much discussion of the impact on proinflammatory mediator (such as alpha-TNF and interleukin-1) which initiate the systemic inflammatory response.

Discussion
Result are that steroids and anti-inflammatory medications given preoperatively result in downregulation of cytokine reactions and may reduce the inflammatory response after surgical stress. Suppression of the local immune system (ie macrophage) may be detrimental in that it serves as the first-line defense against bacteria and foreign material that may be present after surgery In study found that preoperative steroids led to increased phagocytic function (local immune response) of the macrophages.

Discussion
The animals undergoing open cecectomy, which had the greatest suppression of phagocytosis by macrophages, actually had phagocytic function roughly equivalent to the peritonal macrophages of baseline nonsterssed animals These findings can be considered counterintuitive because pharmacologic doses of glucocorticoids are expected to suppress immune function Although we cannot fully explain our findings, it appears that the local phagocytic activity response is different from the more frequently studies local and systemic cytokine response

Discussion
The animals undergoing open cecectomy, which had the greatest suppression of phagocytosis by macrophages, actually had phagocytic function roughly equivalent to the peritonal macrophages of baseline nonsterssed animals These findings can be considered counterintuitive because pharmacologic doses of glucocorticoids are expected to suppress immune function Although we cannot fully explain our findings, it appears that the local phagocytic activity response is different from the more frequently studies local and systemic cytokine response

Discussion
The animals undergoing open cecectomy, which had the greatest suppression of phagocytosis by macrophages, actually had phagocytic function roughly equivalent to the peritonal macrophages of baseline nonsterssed animals These findings can be considered counterintuitive because pharmacologic doses of glucocorticoids are expected to suppress immune function Although we cannot fully explain our findings, it appears that the local phagocytic activity response is different from the more frequently studies local and systemic cytokine response

Discussion
The route of steroid administration I study was intraperitoneal, which could impact the results. Intravenous administration may yield different results, specifically when considering the effect on peritoneal macrophages. This study, the results show that the use of both minimally invasive techniques and preoperative immune augmentation with steroids appears to result in greater phagocytic function of perioneal macrophages after intra-abdominal surgery in a rat model