利用供者髂动脉搭桥的腔静脉回流式胰肾联合移植术

Simultaneous pancreas-kidney transplantation utilizing a vena cava drainage bypass though the donor's iliac artery

目的探讨利用供者髂动脉搭桥的腔静脉回流式胰肾联合移植术的手术操作及临床效果。方法天津市第一中心医院器官移植中心于2009年1月至2011年12月为35例糖尿病合并终末期肾病的患者施行了利用供者髂动脉搭桥的腔静脉回流式胰肾联合移植术，移植胰腺和肾脏分别经供体髂外、髂内动脉吻合，经供者髂总动脉吻合至受体髂外动脉，胰腺静脉回流至受者下腔静脉，供体十二指肠与受体回肠侧侧吻合，观察患者的一般结果、术后外科并发症、远期并发症及随访35～58个月结果。结果所有患者的移植胰腺及肾脏均于术后1周内恢复正常。术后住院时间为10～33天，平均22天，住监护室时间为1～4天，平均2.4天。患者中采用他克莫司（FK506）+吗替麦考酚酯（MMF）+泼尼松（Pred）联合免疫方案33例；采用环孢素A+MMF+Pred联合免疫方案2例。所有患者中发生移植肾功能延迟恢复3例，排斥反应发生率为0。患者出院时平均血清肌酐为78μmol/L，空腹血糖为4.4 mmol/L，糖化血红蛋白为4.3%。术后并发症：供体十二指肠与受者回肠吻合口出血2例，伤口愈合不良4例，术后腹腔感染4例，肺感染5例，泌尿系统感染1例，巨细胞病毒（CMV）感染2例，FK506的脱髓鞘病变1例。3例患者出现需手术干预的外科并发症；其中1例粘连性肠梗阻，予手术松解后治愈；1例胰腺广泛血栓形成，予手术切除移植胰腺后出现腹腔感染、切口裂开，予手术清理、缝合后治愈；1例移植肾破裂，切除，胰腺移植后5个月行二次肾移植术；术后再次手术率为8.6%。术后随访32～58个月，术后6个月平均血清肌酐为82μmol/L，空腹血糖为4.8 mmol/L，糖化血红蛋白为4.5%。1例患者术后4个月死于肺感染，其余患者全部存活，患者、胰腺、移植肾的1年存活率分别为97.1%、94.2%、94.2%。结论利用供者髂动脉搭桥的腔静脉回流式胰肾联合移植术手术操作简单，创伤较小，拓宽了受者范围；为患者保留一侧髂血管，为今后再次肾移植创造了条件；术后需外科干预的并发症明显降低。

Objective To discuss the procedure and the clinical effects of a vena cava drainage bypass through the donor's iliac artery during a simultaneous pancreas-kidney(SPK)transplantation. Methods In Organ Transplantation Center of Tianjin First Center Hospital,between January 2009 and December 2011,we performed a SPK transplantation with a vena cava drainage bypass through the donor's iliac artery for 35 patients with diabetes mellitus that was complicated with end-stage renal disease. The pancreatic allograft artery and renal allograft artery were anastomosed with the donor's external iliac artery and internal iliac artery,respectively. Then, the donors'common iliac artery was sewn to the recipient's external iliac artery. The donor's pancreatic vein was <br> anastomosed with the recipient's inferior vena cava for drainage. The donor's duodenum was side-to-side anastomosed to the recipients' ileum. The patients' general results,surgical complications,and long-term complications was observed, and follow-up period was 35-58 months. Results All of the renal and pancreatic allografts were restored to their normal functions within 1 week after operation. The length of hospitalization ranged from 10 to 33 days(average 22 days). The length of intensive care unit stay ranged from 1 to 4 days(average 2.4 days). 33 patients were administered with combined immunosuppression therapy with tacrolimus(FK506) +mycophenolatemofetil(MMF)+prednisone(Pred). 2 patients wereprescribed combined immunosuppression therapy with cyclosporin A + MMF + Pred. In all patients,there were three cases of DGF,and none of rejection. At the time of discharge,the patients' average serum creatinine level was 78μmol/L,with average fasting glucose level of 4.4 mmol/L,and their average glycated hemoglobin percentage of 4.3%. The following post-operative complications were observed:two cases of anastomotic bleeding between the donor duodenum and the recipient ileum,four cases of poor wound healing,four cases of post-operative abdominal infections,five cases of pulmonary infections,one case of urinary tract infection,two cases of cytomegalovirus infections,and one case of FK506 related demyelinating disease. Three cases underwent re-operations. One case underwent adhesion lysis for adhesive intestinal obstruction. One case underwent pancreatectomy for diffuse pancreatic thrombosis and suffered post-operative abdominal infection and wound dehiscence which were healed with debridement suture operation. One case underwent nephrectomy for renal graft rupture and received second kidney transplantation 5 months later. The re-operation rate was 8.6%. All patients were followed up for 32-58 months. Six months after the surgery,the patients' average serum creatinine level was 82μmol/L,with average fasting glucose level of 4.8 mmol/L,and mean glycated hemoglobin percentage of 4.5%. All of the patients survived except one case died of pulmonary infection 4 months after operation. One year survival rates of recipients,pancreatic allograft,renal allograft were 97.1%,94.2%,94.2%,respectively. Conclusion SPK transplantation with a vena cava drainage bypass through the donor's iliac artery is a simple procedure that leads to less severe trauma than traditional methods and is also appropriate for a wider range of recipients. Moreover,one side of the iliac artery is unaffected,which is useful for the second kidney transplantation in a recipient,if this procedure is later needed. The number of post-operative complications that needed surgical interventions were also significantly reduced compared to those associated with traditional methods.