Original article
General thoracic
Impact of Awake Videothoracoscopic Surgery on Postoperative Lymphocyte Responses

Presented at the Poster Session of the Forty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 25–27, 2010.
https://doi.org/10.1016/j.athoracsur.2010.04.070Get rights and content

Background

Surgical stress and general anesthesia can have detrimental effects on postoperative immune function. We sought to comparatively evaluate postoperative lymphocytes response in patients undergoing video-assisted thoracoscopic surgery (VATS) under thoracic epidural or general anesthesia.

Methods

Between October 2008 and June 2009, 50 patients with nonmalignant pulmonary conditions were randomized to undergo VATS through either sole epidural anesthesia and spontaneous ventilation (awake group, n = 25) or general anesthesia with one-lung ventilation (control group, n = 25). In both groups, assessment of total lymphocytes count and changes in proportion of lymphocyte subsets including CD19+, CD3+, CD4+, CD8+, CD4+:CD8+ ratio, and CD16+CD56+ (natural-killer cell) were evaluated by two-way analysis of variance test for repeated measures at baseline and postoperative days 1, 2, and 3. The Mann-Whitney test was performed at each time point only for significant parameters at between-group analysis of variance.

Results

Comparisons of baseline data showed relatively homogeneous groups. Between-group analysis of variance was significant for proportion of natural-killer cells (p = 0.01). In particular, the control group disclosed a significantly lower median proportion of natural-killer cells as compared with the awake group on postoperative day 1 (5% interquartile range [IQR]: 3% to 8%] vs 12% [IQR: 8% to 14%], p = 0.003) and 2 (7% [IQR: 4% to 10%] vs 11% [IQR: 8% to 21%], p = 0.02). Total lymphocyte count was significantly decreased in the control group only (p < 0.00001). No difference was found between groups in the remaining lymphocyte subsets.

Conclusions

In this randomized study, awake VATS resulted in a lesser impact on postoperative lymphocyte responses than procedures performed under general anesthesia, as shown by the significant difference in postoperative proportion of natural-killer cells.

Section snippets

Study Design and Randomization Procedure

The investigation was set up as a prospective randomized two-arm study (awake group versus control general-anesthesia group). The study was approved by the Ethical Committee of the Policlinico Tor Vergata Foundation. Mandatory prerequisite for enrollment was considered the diagnosis of a nonmalignant chest disease scheduled for VATS. Other inclusion criteria are detailed in Table 1.

The study was activated in October 2008 and was closed in June 2009 after the achievement of 50 patients. Prior to

Baseline Data and Surgical Results

Out of the 59 patients initially considered for enrollment, 3 patients refused consent because they preferred general anesthesia. After randomization, 6 patients (3 for each group) were excluded because of conversion to thoracotomy under general anesthesia (n = 2), diagnosis of unexpected malignant nodules (n = 2), postoperative air leakage longer than 7 days (n = 1), and severe ventricular arrhythmia requiring electric conversion in the immediate postoperative period (n = 1). As a consequence

Comment

Preserved lymphocyte function contributes to improve resistance to postoperative infections [4, 5, 6].

In addition, natural-killer cells represent a possible first line of defense against intravascular tumor spread because, in absence of major histocompatibility-complex restriction, different types of malignant cells can be killed by these cells in a nonspecific way [5, 9, 11, 12, 13]. Furthermore, an impairment in immune function and lymphocyte activity has shown to be associated with several

References (36)

  • A. Kozian et al.

    One-lung ventilation induces hyperperfusion and alveolare damage in the ventilated lung: an experimental study

    Br J Anaesth

    (2008)
  • Y.J. Cheng et al.

    Oxidative stress during 1-lung ventilation

    J Thorac Cardiovasc Surg

    (2006)
  • J. Kutza et al.

    The effects of general anesthesia and surgery on basal and interferon stimulated Natural killer cell activity of humans

    Anesth Analg

    (1997)
  • T. Schilling et al.

    The pulmonary immune effects of mechanical ventilation in patients undergoing thoracic surgery

    Anesth Analg

    (2005)
  • J.L. Meakins

    Surgeons, surgery, and immunomodulation

    Arch Surg

    (1991)
  • W.A. Koltun et al.

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

    Am J Surg

    (1996)
  • M. Yokoyama et al.

    The effects of continuous epidural anesthesia and analgesia on stress response and immune function in patients undergoing radical esophagectomy

    Anesth Analg

    (2005)
  • E. Tonnesen et al.

    Immunological and hormonal responses to lung surgery during one-lung ventilation

    Eur J Anaesth

    (1993)
  • Cited by (0)

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