Clinical immunology
Immunonutrition after major pancreatic surgery

The objective of the study was to investigate whether early enteral immunonutrition in comparison with standard enteral feeding affects the cellular immunity and systemic production of cytokines in malnourished patients after pancreaticoduodenectomy. The prospective randomized studies included
41 patients with pancreatic cancer who had undergone pancreatic resection. In the routine evaluation of nutritional status a weight loss, BMI, albumin concentration and lymphocyte count were taken into account. In 22 patients standard postoperative enteral nutrition and in 19 patients immunonutrition were applied. Mononuclear cell subsets (CD3+, CD4+, CD4+/CD25+, CD4+/CD38+, CD8+, CD19+, CD19+/CD95+, CD19+/CD38+, CD14+, CD14+/HLADR+) and cytokines (IL-1b, IL-1ra, IL-6,
IL-8, IL-10, TNF-α, sTNFRI) were determined before and on days 1, 3, 7 and 10 after surgery using flow cytometry and ELISA test. In patients receiving immunonutrition between days 3-10 after operation, the percentage of CD19+ cells was significantly higher (standard vs. supplemented group, respectively: day 3: P=0.001, day 7: P=0.01 and day 10: P=0.001). In patients receiving standard enteral nutrition no significant changes in the subpopulation of CD4+, CD4+/CD25+, CD4+/CD38+ and CD8+ lymphocytes were noted. The percentage of remaining lymphocyte subpopulations (CD3+, CD19+/CD95+) in both groups did not significantly change. Serum concentrations of IL-1ra in the early post-operative period were significantly higher in patients treated with enteral immunonutrition than in those treated with the standard diet (day 7: P<0.001; day 10: P=0.002). Similar results were observed for IL-6 (day 10: P=0.017), IL-8 (day 1: P=0.01; days 3, 7, and 10: P<0.001) and IL-10 (days 3 and 10: P<0.001) whereas the post-operative levels of IL-1b (day 7: P<0.001) and TNF-α (day 3: P=0.006; day 7: P<0.001) were significantly higher in patients with standard enteral nutrition. Early enteral immunonutrition as compared to standard nutrition has an immunomodulative effect on the changes in the immune response after extensive surgical trauma resulting in the selective stimulation of cellular immunity and cytokines levels. Among the evaluated immune parameters only the changes in percentage of lymphocyte B (CD19+ cells) and interleukin-1 receptor antagonist (IL-1ra) in malnourished patients after pancreatic cancer resection are the earliest sensitive markers of immune response to enteral immunonutrition.