肝胰十二指肠器官簇移植外科技术

2004年9月1例原发性肝癌合并胰头转移的患者在我院接受肝胰十二指肠器官簇移植，整块切除全肝、胆囊、十二指肠、胰腺、脾脏、胃大部和部分上段空肠，进行了血管和消化道重建。移植后胰腺功能正常，未应用胰岛素维持。术后第4d肠道功能恢复，术后1周肝功能恢复正常；术后16d时因腹腔内出血行剖腹探查血肿清除术，同时对感染伤口进行减张缝合，愈合良好；术后2月时出现不全性肠梗阻症状，保守治疗后好转。患者目前已存活5个月，肝脏和胰腺功能均正常，痊愈出院。肝胰十二指肠器官簇移植术的成功为上腹部晚期恶性肿瘤患者提供了延长生命的机会，同时为晚期肝病伴有胰腺功能不良患者的彻底治愈探索出新的手术方式。     

1例肝移植术后再行肝胰十二指肠器官簇移植的手术配合

对1例肝移植术后肝癌复发并腹腔内广泛侵犯的患者再行上腹部器官簇移植术，手术过程顺利，术后恢复良好。提出特殊情况下上腹部器官簇移植的手术配合要点：充分的术前准备、密切的术中配合、严格无菌操作、及时准确应用各类药物和恰当的输液输血，是该手术成功的关键。     

肝胰肾三器官联合移植一例

我院2004年9月成功开展亚州首例肝胰肾联合器官移植,整个手术过程12h结束,术后8d患者突发心肌梗塞死亡,现将经验与教训总结如下。临床资料患者,男,36岁,糖尿病史15年,慢性乙型肝炎10年,视物模糊5年,大量腹水3个月,每天胰岛素注射量最高至90U。入院检查:体重45kg,血压150/100mmHg,血红蛋白59g/L,血球压积17.3%,白蛋白25g/L,总蛋白55g/L,PT54s,APTT70s,肌酐544μmol/L。心电图:各导联广泛ST段改变。心脏彩超:二尖瓣前叶斜率减慢,二尖瓣及三尖瓣轻度返流,肺动脉高压,心前包及底部积液。诊断:①慢性乙型肝炎,慢性肝功能衰竭,终末期糖尿病…     

1例肝移植术后再行肝胰十二指肠器官簇移植的手术配合

对1例肝移植术后肝癌复发并腹腔内广泛侵犯的患者再行上腹部器官簇移植术,手术过程顺利,术后恢复良好.提出特殊情况下上腹部器官簇移植的手术配合要点:充分的术前准备、密切的术中配合、严格无菌操作、及时准确应用各类药物和恰当的输液输血,是该手术成功的关键.     

肝胰十二指肠器官簇移植五例治疗分析

目的总结肝胰十二指肠器官簇移植术后并发症发生和器官功能恢复情况。方法对5例终末期肝病合并2型糖尿病患者进行肝胰十二指肠器官簇移植．术中保留受体胰和全消化道．行单纯肝切除术后,予以肝胰十二指肠器官簇移植。结果5例患者术程均顺利,手术时间9。16h,术中出血1600～3000ml。术后1例出现肺部感染;1例出现移植物抗宿主病（GVHD）并肺部感染;1例出现急性肾功能衰竭。5例患者均未出现肠瘘、吻合口瘘、胆道并发症、急慢性排斥反应及胰腺炎。5例患者丙氨酸转氨酶、天冬氨酸转氨酶及总胆红素等肝功能指标在术后1周趋于正常水平：C肽、血糖水平在1。2周达到正常范围。术后经2～23个月的随访,除1例因GVHD死亡外,其余4例患者肝功能均维持正常．无需外援性胰岛素即可维持血糖稳定。结论肝胰十二指肠器官簇移植在技术上具有可行性,是一种治疗多器官病变的有效方法。     

肝胰十二指肠器官簇移植术后的免疫抑制治疗

目的探讨肝胰十二指肠器官簇移植术后的免疫抑制治疗的合理用药方案。方法收集本中心共实施的10例肝胰十二指肠器官簇移植手术病例,其中5例为上腹部肿瘤伴腹腔多发转移病灶患者接受了肝脏、胰腺及上消化道全切除术后行器官簇移植,5例乙型肝炎后肝硬化失代偿期合并2型糖尿病患者予以单纯肝切除术后行器官簇移植。10例患者均采用巴利昔单抗＋他克莫司＋激素＋霉酚酸酯四联免疫抑制方案,对患者的临床资料进行回顾性分析。结果10例患者手术顺利,术后肝脏、胰腺及十二指肠功能恢复良好。5例肿瘤患者最长存活326d,3例死于多器官功能衰竭,2例死于肿瘤复发。5例肝硬化合并糖尿病患者除1例于术后4周死于移植物抗宿主病（GVHD）外,其余4例均存活,最长生存时间已超过21个月。随访期内及至患者死亡,10例患者均未发生排斥反应。结论采用巴利昔单抗＋他克莫司＋激素＋霉酚酸酯四联免疫抑制方案可以有效预防肝胰十二指肠器官簇移植术后排斥反应的发生。     

肝胰十二指肠切除术治疗肝门部胆管癌:附11例

目的 总结肝胰十二指肠切除术(HPD)治疗肝门部胆管癌的经验.方法 回顾性分析2000年6月至2008年1月11例HPD治疗肝门部胆管癌的临床资料.结果 全组11例肝门部胆管癌按Bismush-corline分型,Ⅲ型8例,Ⅳ型3例.肝方叶切除+胰十二指肠切除术2例,肝尾叶切除+胰十二指肠切除术5例.右半肝+尾状叶+门静脉部分切除重建+胰十二指肠切除术1例,左半肝+胰十二指肠切除术3例,无死亡.胆漏3例,胰漏1例,肺部感染2例,肝功能衰竭1例,随访8例,最长者63个月.结论 对肝门部胆管癌累及胰十二指肠区域者,HPD可提高其生存质量,是安全可行的.     

带十二指肠全胰及肾联合移植一例

我院于 2 0 0 0年 6月 1 8日完成 1例同种异体胰、肾联合移植 ,现报告如下。一、临床资料患者为男性 ,35岁 ,胰岛素依赖型糖尿病病史 2 5年 ,3年前出现肾功能不全、尿毒症 ,胸腔积液 ,心包积液 ,高血压等 ,对症治疗无效而行血液透析 ,2～ 3次 /周。术前主要相关检查 :血红蛋白83ｇ/Ｌ,糖化血红蛋白 8.2 6 % ,血糖 (治疗后 ) 6 .0 1ｍｍｏｌ/Ｌ ,果糖胺 2 .72ｍｍｏｌ/Ｌ ,胰岛素 9.56ｍＩＵ/Ｌ ,Ｃ 肽 1 .1 5ｎｇ/Ｌ,尿素氮1 3 .0 9ｍｍｏｌ/Ｌ ,肌酐 576 .1 μｍｏｌ/Ｌ。心电图示窦性心动过速 ,ＳＴ Ｔ改变。超声心动图提示左室扩大、高血…     

肝小肠联合移植的术式探讨及术后处理一例

目的 总结1例保持门静脉连续性的小肠双造口方式肝小肠联合移植病例的手术操作和术后处理的经验.方法 受者为短肠综合征合并肝功能不良的男性患者,供者为尸体供者.联合切取器官,确保供者肠系膜上静脉和门静脉的连续性.移植肝静脉采用背驼式吻合,受者自体门静脉和供肝门静脉端侧吻合,胆道端端吻合,供者肝动脉和肠系膜上动脉吻合于受者腹主动脉;移植小肠约2 m,两端双造口于腹壁,未作肠道吻合.采用人源化抗CD52单克隆抗体诱导治疗,维持期单用他克莫司.行内镜下黏膜活检监测排斥反应.结果 术后1个月内,患者发生腹腔感染和疑似排斥反应各1次,分别经过手术和甲泼尼龙冲击治疗后痊愈.随访6个月,受者移植肝和小肠功能恢复良好,但仍有腹泻,需补充静脉营养,体重尚未完全恢复.结论 保持门静脉连续性的小肠双造口方式肝小肠联合移植可以简化手术操作,发生外科并发症的风险小,有利于肝脏和小肠功能恢复及术后排斥反应的监测,但是消化液未能进入移植小肠,也影响了受者的恢复.     

Duodenoduodenostomy in pancreas transplantation

Enteric drainage (ED) using duodenojejunostomy (DJ) is an established technique in pancreatic transplantation. Duodenoduodenostomy (DD), an alternative ED technique, may provide unique advantages over DJ. We compared our experience with these two types of ED through a retrospective review of all pancreas transplants performed at our institution from November 2007 to November 2009. The allograft duodenum was anastomosed to the recipient jejunum or duodenum. Duodenal drainage was performed by a stapled or hand-sewn technique. Patient demographics, operative times, major post-operative complications, and graft survival data were analyzed. Of 57 pancreas transplants, DJ was performed in 36 patients, stapled DD in 14 patients, and hand-sewn DD in seven patients. Two DD grafts (9.5%) thrombosed compared with no DJ grafts (p = NS). Enteric leak and small-bowel obstruction occurred in 3 of 36 DJ patients and in two DD patients (p = NS). Gastrointestinal bleeding occurred more frequently in stapled DD compared with DJ (4 vs. 0, p < 0.015). In conclusion, DD is technically feasible with no increase in operative time or enteric complications. GI bleeding rates appear to be higher following DD (stapled) technique. Potential complications of DD should be balanced against the benefits conferred by this technique.     

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目的 报告国内首例同种异体肝小肠联合移植，并就肝肠联合移植适应证、排斥诊断与治疗、感染防治、肠功能恢复与营养支持进行讨论。方法 供肠长380cm，供肠肠系膜上动脉、门静脉分别与受体腹主动脉、下腔静脉端侧吻合；供肝行改良背驮式肝移植。术后免疫抑制剂采用FK506 激素 骁悉 赛尼哌方案。排斥监测采用内镜指导下肠粘膜活检病理学检查及临床观察。并采取措施防治感染和促进移植肠功能的恢复。结果病人恢复顺利，移植肠和移植肝功能良好，未发生排斥反应，术后3个月时已摆脱全肠外营养，依靠肠内营养维持营养状态。结论 肝小肠联合移植对肠衰竭合并全肠外营养所致肝功能损害病人，是可行、有效的治疗方法。     

胰肾联合移植治疗肝移植后糖尿病合并肾功能衰竭二例

目的 总结肝移植后再行胰肾联合移植治疗糖尿病合并肾功能衰竭的临床处理经验.方法 2例肝移植受者术前合并有2型糖尿病,分别于肝移植后7年余和4年余发生肾功能衰竭,遂行胰肾联合移植,2例的移植肝功能均正常.采取腹部器官联合快速切取技术整块切取双肾、全胰及十二指肠节段,先行肾移植,再行胰腺移植,供肾移植于左侧髂窝,供胰移植于右侧髂窝,供者的十二指肠与受者的空肠侧侧吻合,供者的十二指肠内置管,通过受者的空肠引流出体外.例1采用抗白细胞介素受体单克隆抗体诱导的四联免疫抑制方案预防排斥反应;例2术中给予抗胸腺细胞球蛋白和甲泼尼龙,术后继续使用2d,采用他克莫司+吗替麦考酚酯+皮质激素预防排斥反应.结果 2例手术过程顺利,术后移植胰腺功能正常,血糖均于术后10d左右恢复正常,无需胰岛素治疗,移植肾功能1周时恢复正常,第2例1周后血清肌酐渐进性升高,经验性抗排斥反应治疗效果不明显,移植肾活组织检查未见明显排斥反应征象,遂将他克莫司替换为西罗莫司,之后受者的肾功能逐渐恢复正常.目前2例受者已分别随访36个月及9个月,移植肝、肾及胰腺功能均正常.结论 肝移植后合并糖尿病、肾功能衰竭时可考虑行胰肾联合移植,但术后免疫反应复杂,需严密监测移植物功能.     

Exocrine drainage into the duodenum: a novel technique for pancreas transplantation.

Simultaneous pancreas-kidney transplantation is the treatment of choice for patients suffering from type 1 diabetes mellitus and end-stage renal failure secondary to diabetic nephropathy. Until 1995, about 90% of pancreas transplantations were performed with exocrine drainage into the bladder. Since then the proportion of pancreas transplants with enteric drainage increased steadily because of frequency of complications and long-term disadvantages of bladder drainage. However, the use of enteric drainage removes the opportunity to monitor pancreatic allograft function either by measuring urinary amylase or by carrying out biopsy via cystoscopy. We report a new technique of exocrine pancreatic drainage into the recipient duodenum. This modification places the pancreas graft including the duodenal anastomosis in a retroperitoneal location and, importantly, allows easy graft monitoring via gastroscopy.     

Initial hepatic metabolic function in canine liver and pancreas cluster transplantation

In this study, initial hepatic metabolic function was evaluated by determining the arterial ketone body ratio (AKBR) and plasma amino acid concentrations in an experimental orthotopic combined hepatopancreatic transplantation (OHPT), and comparing the same values in orthotopic liver transplantation (OLT). In OHPT, AKBR decreased in the anhepatic phase and recovered to the preoperative value just 1 h after reperfusion. On the other hand, in OLT, the recovery of AKBR took 3 h after reperfusion with a significant difference compared to OHPT (P<0.05). Plasma amino acid levels, especially alanine and total free plasma amino acids increased in the anhepatic phase and recovered within 1 h of reperfusion in OHPT. However, they did not recover until 3 h after reperfusion in OLT. This rapid recovery of hepatic metabolic function in OHPT should be attributed to the order of reperfusion in which the reconstruction of arterial blood flow precedes that of portal blood flow. This model is useful for assessing the best way by which the grafted liver can control the timing, order, rate, and volume of blood that should be released.     

The case for pancreas after kidney transplantation

Abstract:  Pancreas after kidney (PAK) transplantation has historically demonstrated inferior pancreas allograft survival compared to simultaneous pancreas and kidney (SPK) transplantation. Under our current immunosuppression protocol, we have noted excellent outcomes and rare immunological graft loss. The goal of this study was to compare pancreas allograft survival in PAK and SPK recipients using this regimen. This was a single center retrospective review of all SPK and PAK transplants performed between January 2003 and November 2007. All transplants were performed with systemic venous drainage and enteric exocrine drainage. Immunosuppression included induction with rabbit anti-thymocyte globulin (thymoglobulin), early steroid withdrawal, and maintenance with tacrolimus and sirolimus or mycophenolate mofetil. Study end points included graft and patient survival and immunosuppression related complications. Transplants included PAK 61 (30%) and SPK 142 (70%). One-yr patient survival was PAK 98% and SPK 95% (p = 0.44) and pancreas graft survival was PAK 95% and SPK 90% (p = 0.28). Acute cellular rejection was uncommon with 2% requiring treatment in each group. Survival for PAK using thymoglobulin induction, early steroid withdrawal and tacrolimus-based immunosuppression is at least comparable to SPK and should be pursued in the recipient with a potential living donor.     

Addition of a total pancreatectomy and pancreas transplantation in a liver transplant recipient with intraductal papillary mucinous neoplasm of the pancreas

Abstract: Background: Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are increasingly recognized in clinical practice. There are no published data suggesting a management approach for the potential organ transplant recipient with the incidental finding of this pre‐malignant lesion. Methods: The recipient was a 65‐yr‐old man with hepatocellular carcinoma in a background of Laennec’s cirrhosis. During evaluation for transplant, he was found to have diffuse IPMN. This patient underwent liver transplantation with a planned simultaneous total native pancreatectomy and pancreas transplant from the same donor. Results: The patient has had normal liver function and has been free of diabetes and exocrine insufficiency at 18 months post‐transplant. Conclusion: IPMN in the potential transplant recipient should be managed more aggressively than in the general population because these patients will be committed to life‐long immunosuppression. If a total pancreatectomy is contemplated, this is a unique opportunity to replace the pancreas with an allograft at the time of transplantation.     

Liver transplantation for multiple liver metastases from solid pseudopapillary tumor of the pancreas

Solid pseudopapillary tumor (SPT) of the pancreas usually shows a benign clinical course. However, sometimes, distant metastasis may occur. Even in such case, the prognosis is good only if metastatic lesions are resected completely. We report the case of a 14-year-old girl with SPT of the pancreas and unresectable synchronous liver metastasis who underwent successful living donor liver transplantation. For 2 years, she has been disease free. This is the first report on transplantation to relieve liver metastasis of SPT.