Effect on Delayed Type Hypersensitivity and T Lymphocytes

Delayed-type hypersensitivity responses can indirectly reflect changes in T-lymphocyte populations in patients undergoing surgical procedures. Although it seems that delayed-type hypersensitivity is better preserved after laparoscopic than open surgery, it is still not clear which components of the cascade are responsible for this preservation of cellular immunological response (1,13).

Gutt et al. assessed cell-mediated immune function by measuring the size of skin pustules induced by intradermal injection of Staphylococcus aureus in rats undergoing laparoscopically assisted and open cecal resection. Animals having laparo-scopic procedures had smaller and more rapidly healing pustules than their open surgical counterparts (41). Similarly, Allendorf et al. investigated cell-mediated immune function following laparoscopically assisted and open bowel resections in rats using delayed-type hypersensitivity responses to keyhole limpet hemocyanin and phytohemagglutinin antigens. The delayed-type hypersensitivity responses at two days to both of these antigens were significantly greater after laparoscopically assisted resection than after open surgery, but these differences were no longer evident on the third postoperative day (42). The same group also measured the effect of incision length and exposure method for cecal resection on postoperative immune function as assessed by delayed-type hypersensitivity response. Rats underwent laparotomy (7 cm incision), minilaparotomy (3.5 cm), or laparoscopy (via four ports). Cell-mediated immune responses following laparoscopic surgery were 20% greater than those were after open surgery with a long incision, indicating better preservation of systemic immunity (10).

Gitzelmann et al. compared the cell-mediated immune response following CO2 pneumoperitoneum, extraperitoneal incision, and laparotomy in an animal model and demonstrated that delayed-type hypersensitivity responses and the ability to reject an immunogenic tumor were better preserved after CO2 pneumoperitoneum than after extraperitoneal incision or laparotomy (43).

Peripheral lymphocytes are the effectors of cellular immunity and decreased T-cell function has been reported by several investigators following surgical stress (1,44). In an experimental study, Lee et al. (45) found a significantly lower lymphocyte proliferation rate after laparotomy than after CO2 insufflation. No difference was found between insufflation and the anesthesia-only control group at any point in time. In an interesting study, they also demonstrated that the lower lymphocyte proliferation rate following open surgery was independent of the atmospheric environment, as they found no significant difference between laparotomy performed in room air or in a sealed CO2 chamber (46).

Cristaldi et al. (47) found a reduction in natural killer cell numbers following both open and laparoscopic cholecystectomy, but the reduction was less after the latter. In a contradictory study, decreased natural killer cell cytotoxicity was noted following both laparoscopic and open procedures, with no advantage for the laparoscopic approach (48). Cristaldi et al. also reported a lower total lymphocyte count after conventional surgery compared with the equivalent laparoscopic approach. They demonstrated persistent depression of CD4+ cells following open but

Studies reported to date clearly indicate that T-cell function and cellmediated immunity are better preserved after laparoscopic than after open surgery. Most clinical studies have compared laparoscopic to open cholecystectomy, and caution must be exercised when extrapolating these results to other operations where trauma of access may be significantly greater.

not after laparoscopic surgery (47). Vallina and Velasco (49) found the ratio of CD4+:CD8+ to be decreased to 13% below preoperative levels on the first day after laparoscopic cholecystectomy. This ratio normalized a week after surgery.

Lennard et al. (50) classified operations as major or minor and assessed the effect of open surgery on lymphocyte subpopulations. Based on this classification, open cholecystectomy was categorized as major surgery. Using the same classification, Evrard et al. compared changes in lymphocyte subpopulations following laparoscopic and open cholecystectomy. They reported that alterations in lymphocytes after laparo-scopic cholecystectomy were equivalent to those seen in Lennard's minor surgery group classification (51).

Studies reported to date clearly indicate that T-cell function and cell-mediated immunity are better preserved after laparoscopic than after open surgery. Most clinical studies have compared laparoscopic to open cholecystectomy, and caution must be exercised when extrapolating these results to other operations where trauma of access may be significantly greater.

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