Perioperative immune dynamics and infectious complications: a pooled-data analysis of prospective studies

BACKGROUND: Major surgery elicits a complex immune response involving both systemic inflammation and innate immune suppression. These changes may contribute to postoperative infectious complications. This study aimed to determine whether perioperative immune activation and suppression patterns are associated with the development of postoperative infectious complications. MATERIALS AND METHODS: A pooled analysis of six prospective clinical studies was conducted to evaluate perioperative immune function in patients undergoing diverse surgical procedures. Immune monitoring included plasma danger-associated molecular pattern and cytokine concentrations, ex vivo cytokine production after lipopolysaccharide stimulation of whole blood, and proteomic profiling. Clinical outcomes included postoperative infections, pain scores, and quality of recovery. RESULTS: A total of 487 patients were included. Danger-associated molecular patterns generally increased following surgery. All surgical procedures induced a stereotypical immune trajectory, characterized by early plasma interleukin (IL)-6 and IL-10 elevation and suppression of ex vivo tumor necrosis factor (TNF) and IL-1β production, most pronounced on postoperative day 1. Immune suppression persisted through POD3 in patients undergoing colorectal surgery, but resolved more quickly after breast surgery, a less invasive procedure. Patients who developed post-operative infections had higher plasma IL-6 and TNF concentrations on postoperative day 1 and attenuated ex vivo TNF production on postoperative day 3. Proteomic profiling confirmed IL-6 upregulation and identified consistent downregulation of multiple immune signaling proteins, including IFN-γ and chemokines involved in lymphocyte activation. CONCLUSION: Surgical injury initiates a coordinated immune response with early inflammation and delayed innate immune suppression. Failure to recover innate immune function by postoperative day 3 is associated with increased infection risk. Perioperative immune profiling may enable early risk stratification and inform targeted immunomodulatory strategies.