HIV感染者行腹腔镜手术后主要淋巴细胞亚群的变化

Effects of micro-invasive surgery on cellular immune responses in HIV-infected persons

目的检测艾滋病病毒(HIV)阳性者行腹腔镜手术前后主要淋巴细胞亚群等的变化,并与HIV阴性者对照比较,探讨腹腔镜手术对HIV阳性者主要细胞免疫功能的影响。方法12例胆囊疾病的病人分二组:观察组(HIV阳性)和对照组(HIV阴性)各6人。分别用同样方法做腹腔镜胆囊切除术(LC)。二组于手术前1天(POD-1),手术后3天(POD3)、7天(POD7)检测血常规,白蛋白,CD3、CD4、CD8及其百分比和CD4/CD8。HIV阳性者检测HIV-RNA。结果观察组手术前1天至手术后1月HIV-RNA<50拷贝/ml。二组间比较,观察组手术前后CD4值显著低于对照组(P<0.05)。观察组内比较,POD3的CD4显著低于POD-1和POD7(P<0.05)。对照组手术前后CD4变化无显著性差异(P>0.05)。观察组手术前后CD4/CD8也显著低于对照组(P<0.01)。二组内比较手术前后该比值无显著性差异(P>0.05)。二组手术后恢复好,无并发症。随访观察(≤20个月)无艾滋病相关症状。结论LC可能对HIV阳性者主要细胞免疫功能有短暂轻度抑制。总体上HIV阳性者行腹腔镜手术是安全的。术前应常规检测CD4和CD4/CD8,将CD4作为手术风险主要评估指标,术前CD4≥200是确保手术安全性的基本条件。

Objective To investigate the subset of T lymphocyte in perioperative period and evaluate the effects of micro-invasive surgery（MIS）on cellular immune responses in HHIV-infected persons and to estimate prognosis of HIV-positive persons receiving MIS. Methods Twelve cases of gallbladder disorder were divided into 2 groups-HIV positive group and HHIV negative group（control）, with 6 persons in each group. They were admitted to the same hospital for cholecystitis, gall- bladder stones or polypus and received identical laparoscopic cholecystectomy（ LC）. All of them were retrospectively analyzed for preoperative and postoperative subset of T lymphocyte counts（CD3 , CD4 and, CD8 , with their respective percentages, and CD4/CD8 ratio）with flow cytometric assessment, and for peripheral blood cells and plasma albumin, plasma HIV- 1 RNA（HIV-positive）with bDNA method on preoperative day 1 （POD-1 ）and postoperative days 3 （POD3） and 7（POD7） ~ Statistical analysis was performed via Student t test and the Fisher exact test. Results There was no clinically significant loss of peripheral blood cells or plasma albumin in the HIV-positive group in comparison with the control group and HIV- RNA was measured below 50 copies/ml in all subjects of the HIV-positive group. Mean CD4 counts were 339.5,263.5 and 305 cell/ml in the HIV-positive group and 498.5,576 and 431 cell/ml in the HIV-negative group respectively on POD-1, 3 and 7. There was statistically significant difference between the two groups （P 〈 0.05）. In the HIV-positive group, CD4 counts were significantly lower on POD3 than on POD-1 and 7 （P 〈 0.05）. There were also lower CD4/CI38 in the HIV-positive group（0.525,0.665,0.47）than in the HIV-negative group（0.98,1.02,1.1） （P 〈 0.01）. No significant difference of CD4 was seen before and after the operation in the HIV-negative group. Ratio of CD4/CD8 was also signifi- cantly lower in the HIV-positive group than in the HIV negative group before and after the operation （P 〉 0.05）, but there was no significant difference before and after the operation within the same group. No postoperative complication or in-hospital deaths occurred in the two groups. No AIDS related symptoms developed by 20-month follow-up observation. Conclusions Although laparoscopic surgery has shown temporary mild immune-suppression in HIV-positive persons; it may result in less induced surgical trauma than conventional surgeical procedures, and will reduce postoperative risk for complications or deaths, and therefore it is a safe approach in general. However, preoperative CD4 counts as well as HIV-1 RNA testing is recommended, and perioperative CD~ and HIV-1 RNA may serve as useful risk indicators for HIV-positive persons. In HIV-sero-positive persons, CD4 counts should be maximized to ≥200 cell/ml so as to minimize postoperative complications and mortality.