12 декабря 2018г.
Introduction: according to a number of authors, 24-68% of patients with acute destructive pancreatitis (ODP) develop immune system disorders and functional liver failure, which significantly exacerbates the severity of the disease and worsens its prognosis. In the analysis of all cases of failure in the treatment of this disease, among others, there is an unsolved problem of correction of sharply increasing metabolic needs of patients and worsening depression of the immune system.
Objective: to Assess the dynamics of the immune status in patients with infectious complications of acute destructive pancreatitis.
Material and methods: the study is based on the analysis of the treatment results of 67 patients operated on for infectious complications of ODP. The control included 35 operated patients who underwent standard treatment. The main group consisted of 32 operated patients, in whom the complex of intensive therapy included early enteral nutrition with the use of full balanced nutritional mixtures. Enteral nutrition began with 2 days. Both groups were comparable in sex, age, type of surgery, the equivalence of the total drug complex, the severity of the initial state, the level of predicted mortality. The effectiveness of nutritional therapy was evaluated on the 10th and 20th day of the postoperative period. The immune status was assessed by the total number of T-lymphocytes, T- helpers, T-suppressors, B-lymphocytes and serum immunoglobulin levels (G, A, M). The estimation of statistical significance of the indicators was considered reliable at the level of p < 0.05.
Results and discussion: at the time of surgery, both groups had a unidirectional immune response. It was the development of T-lymphopenia, an imbalance of the subpopulation composition of T-lymphocytes with a predominance of reducing the number of circulating T-helpers/inducers and immunoregulatory index. The absence of statistically significant differences leads to the conclusion about the identity of immunity indicators at the time of surgery. In patients of both groups, secondary immunodeficiency of moderate severity was registered, in which the most significant changes in the immune indicators were a reduced content of T - and B-lymphocytes, compared with the group of donors. The analysis of quantitative indicators of immune status showed that on the 10th day after the operation, significant differences were observed in the analyzed groups. Thus, the absolute number of lymphocytes in the control group was 1369 ± 65 in 1 ml, in the main group it was significantly higher and amounted to 2086 ± 84 (p < 0.001). The immune status in the control group was characterized by a decrease in the activity of T-cell and B- cell immunity. The decrease in the activity of immunoregulatory cells was expressed in a decrease in the total number of T - and b-lymphocytes. The signs of secondary immunodeficiency caused by suppression of cellular and humoral components of immune protection were preserved in the control group. In the main group, a statistically significant increase in the level of b – lymphocytes to 0.59 ± 0.04 (p < 0.01) was observed, which was accompanied by an increase in the levels of Ig G to 2.55 g/l (p = 0.04) and Ig A to 2.55±0.1 g/l (p = 0.03). A statistically significant decrease in leukocytosis (p < 0.01) in patients of the main group indicates a decrease in the severity of the systemic inflammatory response. No statistically significant differences were found in comparison with other indicators of donor immunity. On the 20th day after the operation, leukocytosis (p < 0.01) and lymphopenia (p<0.01) were still present in the control group. The content of T-lymphocytes (e-ROK) (p< 0.01), active T- lymphocytes (p < 0.01), b-lymphocytes (p< 0.01) and T-helpers (p <0.01) was significantly lower. The level of secretory Ig And was significantly lower (p< 0.01) than in patients of the main group. In the main group monitoring the levels of T lymphocytes, active T-lymphocytes, b-lymphocytes and T-helper cells were significantly higher (p < 0.01) is similar to that of the control group and did not differ significantly from a group of donors. The level of secretory immunoglobulin A was significantly higher (p < 0.01) than in the control group and donor group.
Conclusions: in the development of infectious complications of ODP at the time of surgery, an increase in the number of proinflammatory cytokines in the peripheral blood was found, which leads to the development of SIRS-syndrome and further causes the appearance of deep immunodeficiency mainly due to the cellular link. The inclusion in the complex therapy of patients with purulent pancreatitis of early enteral nutrition contributes to the compensation of the cellular component of immune reactions and phagocytosis, thereby reducing the period of rehabilitation.
