Postoperative cellular stress in the kidney is associated with an early systemic γδ T-cell immune cell response.

BACKGROUND: Basic science data suggest that acute kidney injury (AKI) induced by ischemia-reperfusion injury (IRI) is an inflammatory process involving the adaptive immune response. Little is known about the T-cell contribution in the very early phase, so we investigated if tubular cellular stress expressed by elevated cell cycle biomarkers is associated with early changes in circulating T-cell subsets, applying a bedside-to-bench approach. METHODS: Our observational pilot study included 20 consecutive patients undergoing endovascular aortic repair for aortic aneurysms affecting the renal arteries, thereby requiring brief kidney hypoperfusion and reperfusion. Clinical-grade flow cytometry-based immune monitoring of peripheral immune cell populations was conducted perioperatively and linked to tubular cell stress biomarkers ([TIMP-2]•[IGFBP7]) immediately after surgery. To confirm clinical results and prove T-cell infiltration in the kidney, we simulated tubular cellular injury in an established mouse model of mild renal IRI. RESULTS: A significant correlation between tubular cell injury and a peripheral decline of γδ T cells, but no other T-cell subpopulation, was discovered within the first 24 hours (r = 0.53; p = 0.022). Turning to a mouse model of kidney warm IRI, a similar decrease in circulating γδ T cells was found and concomitantly was associated with a 6.65-fold increase in γδ T cells (p = 0.002) in the kidney tissue without alterations in other T-cell subsets, consistent with our human data. In search of a mechanistic driver of IRI, we found that the damage-associated molecule high-mobility group box 1 protein HMGB1 was significantly elevated in the peripheral blood of clinical study subjects after tubular cell injury (p = 0.019). Correspondingly, HMGB1 RNA content was significantly elevated in the murine kidney. CONCLUSIONS: Our investigation supports a hypothesis that γδ T cells are important in the very early phase of human AKI and should be considered when designing clinical trials aimed at preventing kidney damage. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01915446 . Registered on 5 Aug 2013.

Retrograde stapling of a free cervical jejunal interposition graft: a technical innovation and case report.

BACKGROUND: Free jejunal interposition is a useful technique for reconstruction of the cervical esophagus. However, the distal anastomosis between the graft and the remaining thoracic esophagus or a gastric conduit can be technically challenging when located very low in the thoracic aperture. We here describe a modified technique for retrograde stapling of a jejunal graft to a failed gastric conduit using a circular stapler on a delivery system. CASE PRESENTATION: A 56 year-old patient had been referred for esophageal squamous cell carcinoma at 20 cm from the incisors. On day 8 after thoracoabdominal esophagectomy with gastric pull-up, an anastomotic leakage was diagnosed. A proximal-release stent was successfully placed by gastroscopy and the patient was discharged. Two weeks later, an esophagotracheal fistula occurred proximal to the esophageal stent. Cervical esophagostomy was performed with cranial closure of the gastric conduit, which was left in situ within the right hemithorax. Three months later, reconstruction was performed using a free jejunal interposition. The anvil of a circular stapler (Orvil®, Covidien) was placed transabdominally through an endoscopic rendez-vous procedure into the gastric conduit. A free jejunal graft was retrogradely stapled to the proximal end of the conduit. Microvascular anastomoses were performed subsequently. The proximal anastomosis of the conduit was completed manually after reperfusion. CONCLUSIONS: This modified technique allows stapling of a jejunal interposition graft located deep in the thoracic aperture and is therefore a useful method that may help to avoid reconstruction by colonic pull-up and thoracotomy.

Anaphylactic reaction 5 minutes after the start of surgery: a case report.

BACKGROUND: Natural latex rubber products have been known to cause severe anaphylactic reactions during surgery. Even 25 years after the first description of anaphylactic reactions in the literature, natural latex rubber products are still used in pediatric surgery. CASE PRESENTATION: The following article describes the case of a healthy 4.5-year old Caucasian boy who simultaneously developed severe hypotension, tachycardia and bronchospasm during surgery for congenital strabismus sursoadductorius under uneventful anesthesia. An allergy test conducted afterwards showed natural latex rubber as the trigger for this severe intraoperative anaphylactic reaction. This case was special because of the absence of any previous clinical or anamnestical evidence of natural latex rubber allergy. The fact that the child had been previously exposed to natural latex rubber - because the boy's mother used disposable gloves for her work as a cosmetician at home - was only discovered later. Such contact may have had a slight sensitizing effect that manifested after the initial contact with the conjunctiva through the surgeon's natural latex rubber gloves. CONCLUSION: Natural latex rubber products have caused severe anaphylactic reactions time and again. Diagnosis is impeded by the highly variable clinical symptoms of anaphylaxis, the non-responsivity of patients, anesthesia-induced changes in blood pressure, surgical drapes, and blood loss. Therefore, use of alternative products and implementation of the right course of action in clinical routine seems to be even more important than raising awareness for allergies to natural latex rubber.