Preoperative chemoradiation therapy for esophageal cancer is a risk factor for the elevation of high mobility group box-1, leading to an increase in postoperative severe pulmonary complications.

We herein clarified the time course of changes in the serum high mobility group box chromosomal protein-1 (HMGB-1) concentrations in esophageal cancer patients after esophagectomy, and investigated whether the perioperative serum HMGB-1 levels correlate with the administration of neoadjuvant chemoradiation therapy (NACRT) and the postoperative clinical course, especially the occurrence of pulmonary complications, in such patients. Sixty patients who underwent right transthoracic esophagectomy for esophageal cancer were enrolled in this study. The relationship between the perioperative serum HMGB-1 levels and NACRT, and the postoperative severe pulmonary complications were evaluated. Patients with severe pulmonary complications (n = 44) tended to have undergone NACRT more often than those without severe pulmonary complications (n = 16). The preoperative and postoperative day 7 serum HMGB-1 concentrations were significantly higher in patients with severe pulmonary complications than those in patients without severe pulmonary complications. In the univariate and multivariate analyses, the use of NACRT and the preoperative elevations in the serum HMGB-1 levels (>4.2 ng/mL) were found to be significantly associated with pulmonary dysfunction. Furthermore, the response to NACRT was found to be significantly associated with the preoperative serum HMGB-1 levels. The use of NACRT contributes to preoperative serum HMGB-1 elevation, and these were risk factors for the occurrence of severe postoperative pulmonary complications in patients with esophageal cancer after thoracic esophagectomy.

Increased monocyte activation in elderly patients after surgical stress.

OBJECTIVE: To investigate age-related changes in the host response to surgical stress. The clinical course, serum interleukin-6 (IL-6) levels, monocyte production of tumor necrosis factor-alpha (TNF-alpha), and monocyte expression of CD11b/CD18 were used as markers of the systemic response. METHODS: Patients with gastric cancer, undergoing distal gastrectomy were divided into 2 groups: >75 years of age (elderly group) and < or =75 years of age (young group). Serum IL-6 levels, TNF-alpha production and CD11b/CD18 expression by monocytes, and the postoperative clinical course were compared between the 2 groups. RESULTS: TNF-alpha production by lipopolysaccharide-stimulated monocytes and CD11b/CD18 expression on monocytes after surgical stress were significantly higher in the elderly than in the young group. Moreover, serum IL-6 levels on the first postoperative day in the elderly group were significantly higher than those in the young group. The incidence and duration of systemic inflammatory response syndrome (SIRS) were significantly greater in the elderly than in the young group. CONCLUSIONS: The activation of monocytes and hypercytokinemia occur readily after surgical stress in the elderly and may therefore contribute to SIRS and increased susceptibility to postoperative complications.

Mechanism of the inhibitory effect of protease inhibitor on tumor necrosis factor alpha production of monocytes.

If the inflammatory response becomes excessive or uncontrolled by some stimuli, inappropriate inflammatory responses occur. Monocytes are extremely important cells for regulating the cytokine network and tumor necrosis factor alpha (TNFalpha) and interleukin- (IL) 10, which are mainly synthesized by monocytes, are representative cytokines that play a central role in the cytokine network. Protease inhibitors such as gabexate mesilate (GM) and ulinastatin (UTI) have been shown to have various beneficial effects by inhibiting the activation of leukocytes, but the mechanism for this has yet to be fully elucidated. In this study we investigated the mechanism of the inhibitory effect of protease inhibitors on the proinflammatory cytokine production of lipopolysaccharide- (LPS) stimulated monocytes. LPS-stimulated monocytes were treated with GM or UTI. The value of TNFalpha and IL-10 in the culture medium of monocytes was measured and each mRNA expression was assayed. The inhibitory effect of protease inhibitors on the activity of intracellular signal transduction pathways such as protein kinase C (PKC) and nuclear factor kappa B (NFkappaB) were also evaluated. GM decreased the TNFalpha production of LPS-stimulated monocytes as shown by the inhibition of mRNA expression and increased the IL-10 production of LPS-stimulated monocytes. GM also suppressed the NFkappaB activity of LPS-stimulated monocytes. UTI decreased the TNFalpha production of LPS-stimulated monocytes, but did not inhibit the TNFalpha mRNA expression. The present study shows that the inhibitory effect of GM on the TNFalpha production of activated human monocytes is mediated by the suppression of NFkappaB activation, while the mechanism of UTI inhibiting TNFalpha production of human monocytes may be due to the inhibition of either the translation or secretion of TNFalpha.

Severe sepsis induces deficient interferon-gamma and interleukin-12 production, but interleukin-12 therapy improves survival in peritonitis.

BACKGROUND: After severe sepsis, there is an increase of Th2 cytokine and a decrease in Th1 cytokine that may account for impaired cellular immunity. The aim of this study is to evaluate the Th1, Th2 cytokine balance in the serum, peritoneal lavage fluid (PLF) and liver mononuclear cells (MNC) of experimental peritonitis mice, and determine the effect of interleukin-12 (IL-12), a cytokine stimulating Th1 cytokine production, when administered to septic mice. METHODS: Experimental bacterial peritonitis mice was induced by cecal ligation and puncture (21-gauge needle, mild peritonitis) or cut (5 mm, severe peritonitis). Serum and PLF levels and liver MNC production of interferon (IFN)-gamma, IL-10, and IL-12 were measured after the procedure. Mild and severe peritonitis mice were treated intraperitoneally with recombinant IL-12 (r-IL-12) either 6 hours before or 6 and 24 hours after the procedure. The survival rates were then compared with nontreated mice. RESULTS: Serum and PLF IFN-gamma, IL-12 levels in severe peritonitis mice were significantly lower than those in mild peritonitis mice at 6 and 12 hours after the procedure. On the other hand, serum and PLF IL-10 levels in severe peritonitis mice were significantly higher than those in mild peritonitis mice at 6 hours after the procedure. Furthermore, liver MNC IFN-gamma production in severe peritonitis mice was significantly higher than that in mild peritonitis mice at 6 hours after the procedure, but liver MNC IL-12 production in severe peritonitis mice was significantly lower than that in mild peritonitis mice at 12 hours after the procedure. Severe peritonitis mice treated with r-IL-12 at 6 hours before the procedure improved survival rate, and mild peritonitis mice treated with r-IL-12 at 24 hours after the procedure showed significantly improved survival rates. CONCLUSIONS: Change in the Th1, Th2 cytokine balance in peritonitis mice might induce a shift toward a Th2 dominant phenotype according to the severity of peritonitis, and the capacity to produce IFN-gamma and IL-12 by liver MNC is reduced. Therapies designed to augment the production of Th1 cytokines, such as IL-12, may thus prove to be beneficial in the treatment of severe sepsis after peritonitis.

The effect of burn injury on suppressors of cytokine signalling.

The newly identified suppressors of cytokine signaling (SOCS) family of proteins act as intracellular inhibitors of several cytokine signal transduction pathways. Their expression is induced by cytokine activation of the Janus kinase/signal transducer and activator of transcription (Jak/STAT) pathway, and they act as a negative feedback loop by subsequently inhibiting the Jak/STAT pathway either by direct interaction with activated Jaks or with the receptors. In this study we investigated the expression and translation of SOCS proteins after burn injury. Thermal injury increased the expression of SOCS3 compared with sham at 4 h, 24 h, and 10 days after thermal injury in the liver. SOCS3 protein was increased at 4 and 24 h after thermal injury in the liver. Expression of SOCS1 mRNA was not detected in sham or burn liver. SOCS2 mRNA and cytokine-inducible SH2-containing protein (CIS) mRNA were detected at the same levels for both sham and burn at all time points in the liver. In the spleen there was a trend towards an increase in SOCS1 mRNA at all time points; thermal injury significantly decreased SOCS2 mRNA compared with sham at 4 h, SOCS3 mRNA was significantly increased at 24 h compared with 10 days, and CIS mRNA was detected at the same levels for both sham and burn at all time points. In conclusion, thermal injury causes elevations in SOCS3 within 4 h after a burn, reaching a maximum at 24 h post injury. Levels continue to be elevated for up to 10 days post injury. SOCS3 may be very important in regulating the balance between immunosuppression and inflammation after thermal injury.

Activation of monocytes and endothelial cells depends on the severity of surgical stress.

Surgical injury not only induces a systemic endocrine-metabolic response but also influences the function of the leukocytes and endothelial cells leading to various systemic responses. These responses appear to depend on the severity of surgical stress, which differs according to the surgical procedures. In this study, we investigated the response of monocytes and endothelial cells, and the development of systemic inflammatory response syndrome (SIRS) in relation to the severity of surgical stress. The postoperative clinical course was evaluated between patients undergoing an esophagectomy (ER group) and a distal gastrectomy (DG group). The tumor necrosis factor alpha (TNF-alpha) production of monocytes, the serum interleukin 6 (IL-6) levels, the CD11b expression on either monocytes or granulocytes, and the intercellular adhesion molecule-1 (ICAM-1) expression on human umbilical vein endothelial cells (HUVECs) stimulated with culture supernatants of monocytes were compared between the 2 groups. The development of SIRS was observed in all patients in the ER group, whereas no patients demonstrated SIRS in the DG group. The serum IL-6 levels, TNF-alpha production of monocytes, and CD11b intensity on monocytes or granulocytes in the ER group were higher than those in the DG group. In the ER group, the ICAM-1 intensity on HUVECs with monocytes immediately after operation significantly increased compared with before the operation. In conclusion, both the CD11b expression on monocytes and the TNF-alpha production of monocytes are considered to reflect the degree of surgical stress, and the activation of endothelial cells stimulated with these activated leukocytes may therefore lead to both tissue and organ injury.

A clinical study of the effectiveness of oral glutamine supplementation during total parenteral nutrition: influence on mesenteric mononuclear cells.

Bacterial translocation (BT) is a well-known insult during total parenteral nutrition (TPN) and a high incidence of morbidity has been reported in septic patients receiving TPN. Inflammatory cytokines were shown to play an important role in the pathogenesis of critical complications following sepsis. Previous studies have indicated that supplementation of TPN with glutamine is effective in preventing BT in animals, but its effectiveness in humans is unclear. The aim of this study was to determine the effectiveness of oral glutamine supplementation to patients receiving TPN in suppressing cytokine production of mesenteric blood mononuclear cells (M-MNC). Fifteen colorectal cancer patients were divided into 3 groups according to preoperative nutrition management. (1) TPN group: TPN with conventional glutamine-free amino acid solution. (2) Gln group: TPN with oral glutamine supplementation of 30 g/d. (3) CONTROL GROUP: oral intake of normal food. M-MNC were obtained immediately after laparotomy and tumor necrosis factor-alpha (TNF-alpha) and interleukin-10 (IL-10) production of M-MNC was evaluated with or without lipopolysaccharide (LPS) stimulation. TNF-alpha and IL-10 production by LPS-stimulated M-MNC was increased in the TPN group and suppressed in the Gln group. In conclusion, oral glutamine supplementation to patients with TPN was shown to be effective for the prevention of M-MNC activation to avoid excessive production of cytokines.

Effects of a protease inhibitor on reduction of surgical stress in esophagectomy.

OBJECTIVE: To evaluate the efficacy of gabexate mesilate (GM) in reducing surgical stress after esophagectomy. METHODS: In a prospective, randomized, clinical study, 11 patients with squamous cell carcinoma of the esophagus were randomly assigned to two groups: 5 patients were continuously administered gabexate mesilate 1.5 mg/kg per hour from the beginning of anesthesia until the third postoperative day (preop GM group); and 6 patients were administered gabexate mesilate 1.5 mg/kg per hour continuously from the end of surgery and for the same postoperative period (postop GM group). Blood samples were taken from all patients before surgery, immediately after it, and 3 days after surgery. Serum interleukin-6 (IL-6) level, tumor necrosis factor-alpha (TNF-alpha) production, and Mac-1 antigen expression of peripheral blood monocytes were measured. Clinical courses of patients in the two groups were compared. RESULTS: Time courses of serum IL-6 levels in the preop GM group were significantly lower than those in the postop GM group. Ex vivo TNF-alpha production by lipopolysaccharide (LPS) stimulated monocyte was much higher than that by monocyte without LPS stimulation. Gabexate mesilate showed a little inhibition of TNF-alpha production by monocyte without LPS stimulation. On the other hand, gabexate mesilate significantly inhibited TNF-alpha production by LPS stimulated monocyte. Mac-1 antigen expression by monocyte immediately after operation in the preop GM group was significantly lower than that in the postop GM group. Duration of systemic inflammatory response syndrome was significantly shorter in the preop GM group than in the postop GM group. CONCLUSIONS: Reduction of systemic inflammatory response syndrome duration after esophagectomy by the continuous administration of gabexate mesilate started before operation may be through the suppression of TNF-alpha production capacity and Mac-1 expression on monocytes immediately after operation, and to suppression of increase in serum IL-6 level.

Role of liver NK cells and peritoneal macrophages in gamma interferon and interleukin-10 production in experimental bacterial peritonitis in mice.

Gamma interferon (IFN-gamma), tumor necrosis factor alpha (TNF-alpha), and interleukin-10 (IL-10) production by liver, spleen, lung, peripheral blood mononuclear cells (MNC), and peritoneal exudate cells (PEC) in experimental bacterial peritonitis was examined by cecum ligation and puncture (CLP) (with an 18-gauge needle) of BALB/c mice. MNC of organs were cultured for 18 h, and cytokine levels in supernatants were examined. Cytokines contained in peritoneal lavage fluid were regarded as those produced by PEC. Only liver MNC and PEC produced substantial amounts of IFN-gamma, and PEC were the main source of IL-10, especially 12 h after CLP. As reflected by the cytokine production by liver MNC and PEC, serum IFN-gamma and IL-10 levels were elevated after CLP. C57BL/6 (B6) mice and BALB/c nude mice showed a similar pattern of cytokine production. TNF-alpha levels in culture supernatants, peritoneal lavage fluid, and sera were not significantly elevated compared to those of sham-operated mice. In vivo depletion of NK cells of B6 mice with anti-asialo GM1 or anti-NK1.1 antibody greatly decreased IFN-gamma levels in liver MNC culture supernatants and sera, suggesting that liver NK cells are IFN-gamma producers. On the other hand, plastic-adherent PEC macrophages are the major IL-10 producers. Mice subjected to a cecum ligation and cut procedure (which have a more severe peritonitis) showed much higher IFN-gamma and IL-10 levels than those subjected to CLP, while mice subjected to CLP with a smaller (22-gauge) needle showed low levels of these cytokines. These findings show that liver NK cells and PEC macrophages are important for the production of proinflammatory and anti-inflammatory cytokines in bacterial peritonitis.

Inhibitory effect of protease inhibitor on endothelial cell activation.

BACKGROUND: Endothelial cells (EC) are important for regulating the hemostatic balance of prothrombotic and antithrombotic activities. Proinflammatory cytokines such as tumor necrosis factor-alpha (TNFalpha) play an important role in the regulation of EC and also regulate the production of plasminogen activator inhibitor type 1 (PAI-1), which is an EC-producing factor with the inhibitory activity of fibrinolysis, and the expression of intercellular adhesion molecule-1 (ICAM-1), which is an adhesion molecule that plays an important role in inflammation. Protease inhibitors such as gabexate mesilate (GM) and ulinastatin (UTI) have been shown to improve the microcirculatory environment and reduce tissue damage, but the mechanism for this has yet to be fully elucidated. We investigated the effect of GM or UTI on EC regarding PAI-1 synthesis and ICAM-1 expression. METHODS: Human umbilical vein endothelial cells (HUVECs) were obtained and stimulated with TNFalpha. GM or UTI was added to HUVECs just before TNFalpha stimulation. The PAI-1 activity in the culture medium of HUVECs was measured by using an enzymatic assay kit. The PAI-1 mRNA expression was assayed by a semiquantitative reverse transcriptase polymerase chain reaction assay. The ICAM-1 expression on HUVECs was assayed by a flow cytometric analysis. RESULTS: GM inhibited the PAI-1 synthesis of HUVECs stimulated with TNFalpha in a dose-dependent manner as shown by the mRNA expression. However, UTI was not able to inhibit PAI-1 synthesis. In contrast, both GM and UTI significantly inhibited the ICAM-1 expression on HUVECs stimulated with TNFalpha. CONCLUSIONS: These data suggest that GM may thus provide a beneficial effect which improves the microcirculatory environment and prevents tissue damage by inhibiting the activation of the vascular EC themselves.

Clinical and experimental studies on the role of platelet-activating factor (PAF) in the pathogenesis of septic DIC.

Various toxic factors induced by endotoxin (Et) are thought to be deeply involved in the pathogenesis of severe infections. In this study, particular attention was paid to the role of the platelet-activating factor (PAF) in these conditions, and clinical and experimental studies were conducted on the relationship between PAF and the changes observed in the general parameters after surgical infections. In the clinical study, changes in the PAF concentration in the blood of seven patients with disseminated intravascular coagulation (DIC), five of whom were septic and two non-septic, were monitored by gas/mas spectrometry. The mean PAF level in the septic DIC group tended to be higher than that in the non-septic DIC group. Moreover, in the septic DIC group, the relationship between the increase in the PAF level and platelet count was analyzed with the lapse of time and we surmised a negative correlation between these parameters. Experimentally, we also investigated the role of PAF in Et shock and the effect of an anti-PAF agent and protease inhibitor. The Et-induced fall in blood pressure was similarly prevented by both the anti-PAF agent and protease inhibitor. However, the decrease in the platelet count was more significantly inhibited by the anti-PAF agent than by the protease inhibitor, whereas the parameters of the blood coagulation/fibrinolysis system were more affected by the protease inhibitor than by the anti-PAF agent.