Immunological perspectives in thoracic surgery: a narrative review on the cellular and cytokine responses induced by thoracotomy and video-assisted thoracic surgery

Abstract

Objective: To reveal and review the main effects of mechanical ventilation, anaesthesia, thoracotomy and thoracoscopy on immune responses and clinical outcomes.Background: Several trials reported that intubated video-assisted thoracic surgery (VATS) is associated with favourable recovery time, hospital stay, fewer postoperative complications, better delivery and tolerability of adjuvant chemotherapy in patients with non-small cell lung cancer (NSCLC) as compared to traditional thoracotomy. Recent studies introduced a new approach in thoracic surgery focusing on the immunological outcomes and detrimental effects of thoracotomy and VATS along with patients' clinical benefits.Methods: We reviewed main laboratory and human research based on PubMed database to reveal the immune effects of intubated and non-intubated VATS, mechanical one-lung ventilation (mOLV) and anaesthesia on inflammatory cytokine production, cell responses and clinical outcomes.Conclusions: Although, there are still inconsistencies regarding whether VATS can improve long-term survival and immune responses. VATS results in better preserved immune functions: the postoperative number of natural killer (NK) cells, lymphocytes were less suppressed and the release of immunomodulatory interleukin (IL)-6 and IL-10 were reduced, compared to thoracotomy. Both thoracotomy and VATS are known to induce immune responses, however, these effects can be observed to a different extent as it depends on the modes of surgical technique, mOLV and even general anaesthesia. Thus, non-intubated thoracic surgery (NITS) was developed to avoid harmful immune effects, prevent acute lung injury (ALI) and increase patients' long-term survival. NITS could be also associated with less prominent pro-inflammatory cytokine responses and a preserved lymphocyte cell count postoperatively.

Pathophysiology implications of the thoracic surgical interventions

“…VATS has fewer postoperative complications than thoracotomy [2]. Many retrospective and prospective studies approve that VATS can be associated with less decreased natural killer (NK) and T cell numbers, phagocyte and oxidative acticivity and reduced levels of cytokines, compared to thoracotomy [3].…”

“…To reduce the stress to the patient during thoracic surgery, minimally invasive procedures can be applied. Video-assisted thoracoscopic surgery (VATS) has fewer postoperative complications than thoracotomy [2], and the inflammatory response is reduced after VATS compared to open surgery [3,10]. Following the innovation and acceptance of VATS, non-intubated thoracic surgery (NITS) was developed to further reduce surgical stress in thoracic surgical procedures [11].…”