胰肾联合移植的外科技术探讨

Surgical techniques used in simultaneous pancreas-kidney transplantation

目的探讨胰液空肠引流式胰肾联合移植的外科技巧和临床应用。方法中山大学附属第一医院2005年1月-2009年6月共施行了10例胰肾同期联合移植术（SPK），供体胰、十二指肠和肾均采用腹部多器官联合切取方式获得，经腹主动脉、肠系膜上静脉对胰腺及十二指肠同时快速灌注降温。移植胰的外分泌采用胰十二指肠一空肠内引流吻合方式。术后早期均以抗CD25单克隆抗体进行免疫诱导治疗，采用他克莫司、霉酚酸酯及皮质激素预防排斥反应。结果10例移植手术均获得成功。供体胰十二指肠和。肾的热缺血时间为（5．9±2．6）min；移植肾平均冷缺血时间为（5．2±2．2）h，移植胰平均冷缺血时间为（9．3±3．6）h。术后3例出现移植胰伤121感染，经治疗后3—12周愈合。2例出现胰十二指肠．空肠吻合口出血，均经保守治疗止血而治愈。未发生与胰液引流相关的外科并发症。1年内3例发生了急性排斥反应，2例经激素冲击和抗淋巴细胞球蛋白治疗而被逆转；1例顽固性急排患者术后39d在持续肾脏替代治疗过程中并发脑血管意外死亡。其余9例均痊愈，随访6～12个月，完全停用胰岛素。结论获取质量良好的供体器官及合理血管整形，是保证胰肾联合移植成功的前提；改进的胰液空肠外分泌引流术式的方法是可靠的。

Objective To evaluate the surgical techniques and short-term clinical results of simultaneous pancreaticoduodenum-kidney transplantation （SPK） with the enteric drainage （ED） of exocrine secretions of the pancreas. Method From Jan 2005 to Jun 2009, ten diabetic patients with uremia diabetes underwent SPK. The pancreas graft was placed intraperitoneally with exocrine secretions drained into the proximal jejunum by side-to-side anastomosis. The multivisceral cluster grafts （liver, kidney, pancreas and duodenum） were procured after simuhaneously rapid perfusion with cool UW solution through donor＇s abdominal aorta and superior mesenteric vein in 10 no heart beating cadeveric donors. Quadruple immunosuppressive therapy with anti-CD25 monoclonal antibody, tacrolimus, mycophenolate mofetil and steroids was adopted. Results SPK was successfully performed in all cases. The mean warm ischemia time of donor organ was （ 5.9 ± 2. 6 ） min, the mean cold ischemic time of the kidney was （ 5.2 ± 2. 2 ） hours and that of the pancreas was （9. 3± 3.6） hours. Patient and graft survival rates were 90. 0% and 90% at 6 month after transplant, respectively. None of the grafts lost due to enteric or pancreatic leakage or intraabdominal infection. The most common surgical complications were wound infection （n = 3 ）, and enteric anastomostic hemorrage （n = 2）, which were all cured by nonoperative management. Three biopsy-proven acute renal rejection episodes occurred within 12 months postoperation, 2 of them were reversed successfully, and 1 died of cerebral complication during the recovery from continuous renal replacement therapy （CRRT） after the failure of aggressive antirejection treatment. Other patients （n = 9 ） became insulin-free euglycemic at （9. 3 ±3.8） day postoperatively, and are well and insulin-free at a follow-up of 6- 12 months. Conclusions High quality procurement of donor grafts and suitable arterioplasty are prerequisites for a successful combination kidney and pancreas transplantation. Enteric exocrine drainage by direct side-to-side anastomosis seems to be a simple and reliable technique.