肾移植术后的结肠穿孔(文献综述)

肾移植术后使用较多的免疫抑制剂,将会出现多种严重的消化道并发症,如上消化道出血、消化道溃疡及穿孔、急性胰腺炎、缺血性结肠炎、结肠憩室病及结肠穿孔等.其中结肠穿孔发病率虽低(0.92～2.3%),但病死率高,可达71%～88%.Church等曾复习1983年以前国外文献上肾移植术后并发结肠穿孔71例,并报告了11例.近年来国外文献又报告了21例.现就有关肾移植术后并发结肠穿孔的诱因、症状、诊断、治疗和预防等方面的文献作一简单综述.病因肾移植术后并发结肠穿孔的病因包括憩室病、溃疡、缺血、便秘、免疫抑制剂和尿毒症等.其中免疫抑制剂为最主要的因素,Himal认为其它病因     

腹腔镜与开腹胃十二指肠溃疡穿孔修补术后并发症的对比研究

目的:探讨腹腔镜胃十二指肠溃疡穿孔修补术的安全性、可行性及术后并发症的处理措施.方法:回顾分析2005年9月至2010年9月收治的142例胃十二指肠溃疡穿孔患者的临床资料.其中78例行腹腔镜胃十二指肠溃疡穿孔修补术(腔镜组),64例行开腹胃十二指肠溃疡穿孔修补术(对照组),对比分析两组患者术后并发症,包括切口感染、切口裂开、胃十二指肠瘘、肠间隙脓肿、盆腔脓肿及粘连性肠梗阻等.结果:腔镜组术后并发症发生率均低于对照组,住院时间缩短,差异有统计学意义(P＜0.05).结论:与开腹手术相比,腹腔镜胃十二指肠溃疡穿孔修补术在减少术后并发症方面具有明显优势,手术安全可靠,适于基层医院开展.     

基层医院58例胃十二指肠溃疡急性穿孔的诊治体会

目的:探讨胃十二括肠溃疡急性穿孔的治疗方案.方法:对我院6年来收治的58例胃十二指肠溃疡急性穿孔进行回顾性分析.结果:7例内科保守治疗,外科单纯修补38例,胃大部切除11例,死亡2例.其中切口感染3例,胃排空障碍1例.术后结合药物治疗,疗效满意.结论:胃十二指肠溃疡急性穿孔缝合修补术操作简单、安全而有效,患者负担轻,是基层医院治疗胃十二指肠溃疡急性穿孔的可行方法.     

腹腔镜下胃十二指肠溃疡穿孔修补术体会

目的探讨腹腔镜下行胃十二指肠溃疡穿孔修补术的疗效。方法对30例胃十二指肠溃疡穿孔患者行腹腔镜下修补术。回顾性分析患者的临床资料。结果全组30例患者均顺利完成手术,无中转开腹。住院时间6~9 d。术后无发生出血、切口感染及腹腔感染等并发症。随访6个月,全组无溃疡穿孔复发病例。结论腹腔镜下行胃十二指肠溃疡穿孔修补术,手术创伤小,患者恢复快,复发率低,疗效满意。     

综合护理在胃十二指肠溃疡穿孔腹腔镜修补术中的应用体会

目的分析综合护理在胃十二指肠溃疡穿孔腹腔镜修补术中的应用效果。方法对40例行腹腔镜穿孔修补术的急性胃十二指肠溃疡穿孔患者,实施围术期综合护理。回顾性分析患者的临床资料。结果本组40例患者均顺成功实施手术。术后发生切口感染2例,肠梗阻1例,经对症处理后痊愈。未发生胃排空障碍等其他并发症。住院时间7~10 d。随访12个月,未出现复发病例。结论对腹腔镜穿孔修补术的胃十二指肠溃疡穿孔患者,围手术期给予心理疏导、疼痛干预、健康指导等综合护理措施,可提高手术效果,减少术后并发症发生率及复发率。     

肾移植术后并发巨细胞病毒感染患者的护理

对31例肾移植术后并发巨细胞病毒(CMV)感染患者行抗病毒、适当减少免疫抑制剂用量、给氧、退热、保持呼吸道通畅、严格消毒隔离等治疗和护理.结果20例治愈,11例死亡.提出CMV感染是肾移植术后的严重并发症,病死率高.而密切观察,早发现、早治疗是救治成功的关键.     

高龄胃十二指肠溃疡穿孔患者术后并发症观察与护理

目的总结高龄胃十二指肠溃疡穿孔患者术后并发症情况及其护理措施。方法对接受手术治疗的50例高龄胃十二指肠溃疡穿孔患者,严密观察术后并发症情况并给予针对性护理措施。结果 50例患者术后4例心功能不全、3例出血、3例肺部感染。经及时治疗和针对性护理后,均获痊愈,住院时间(10.5±2.6)d。结论高龄胃十二指肠溃疡穿孔患者术后极易发生出血、心功能不全、感染性休克、肺部感染等并发症。加强术后病情观察、做好并发症护理等措施可促进患者早日恢复。     

腹腔镜胃十二指肠溃疡穿孔修补术13例临床体会

目的 腹腔镜急性胃、十二指肠溃疡穿孔修补术的临床经验.方法 2003年6月～2007年12月,对13例急性胃、十二指肠溃疡穿孔患者施行腹腔镜溃疡穿孔修补术.结果 13例中十二指肠球部溃疡穿孔5例,幽门管溃疡1例,胃窦部溃疡穿孔7例,穿孔直径为0.3～0.7 cm,腹腔内积液600～1200 mL.手术时间80～180 min,除1例病检胃癌,改开放手术外,其余12例手术均获成功,术后恢复顺利,切口甲级愈合10例,乙级愈合2例.住院天数7～10 d.随访1年,胃镜检查溃疡均愈合,无再穿孔、腹腔感染、肠粘连、肠梗阻等并发症发生.结论 腹腔镜手术治疗急性胃、十二指肠溃疡穿孔,与开腹手术同样安全且有效.胃溃疡穿孔患者术中需快速病理检查,若为恶性病变应中转开腹.     

肾移植术后肺部感染患者免疫抑制剂的应用

目的:探讨肾移植术后肺部感染患者救治过程中免疫抑制剂的应用方案.方法:报告22例肺部感染的肾移植患者的临床资料.重症肺部感染13例,肺部感染早期或症状较轻的9例.前者立即停用所有免疫抑制剂,给予甲基泼尼松龙;后者减少或调整免疫移植剂用药方案等.13例检出病原菌,其中混合感染10例.结果:18例治愈,移植肾功能正常;死亡2例,放弃治疗2例.结论:对肾移植术后肺部感染及时停用或调整免疫抑制剂用量和组合方案,保护移植.肾的功能和及早确定病原菌等,均有利于提高其治愈率,减少死亡率.     

腹腔镜修补急性胃十二指肠溃疡穿孔36例临床分析

目的:总结腹腔镜急性胃十二指肠清疡穿孔修补术的临床经验。方法:回顾分析36例胃十二脂肠溃疡穿孔修补术中应用腹腔镜的临床资料。36例胃十二指肠溃疡穿孔中,十二指肠球部溃疡穿孔30例,胃幽门管穿孔3例,胃窦部前壁穿孔2例,胃体部小弯侧穿孔1例。病理检查6例中良性穿孔5例,癌性穿孔1例。结果:36例中35例获得成功。1例癌性溃疬中转开腹,无手术并发症发生,无死亡病例。良性溃疡患者术后平均8天出院,出院后均予以内科根除幽门杆菌、口服质子泵抑制剂治疗。结论:腹腔镜胃十二指肠溃疡穿孔修补术治疗急性胃十二指肠溃疡穿孔,与开腹手术同样安全有效,具有良好的临床应用价值。     

Gastrointestinal complications in renal transplantation

One wonders whether the use of cyclosporin, histamine receptor antagonists, low doses of steroids, and early diagnosis and treatment actually modify the incidence, morbidity, and mortality of gastrointestinal (GI) and pancreatic complications in renal transplantation. To find out, we reviewed 614 kidney transplant recipients between January 1984 and December 1988. One hundred patients (16.2%) were found to have GI and/or pancreatic complications in the following distribution: 9.6% gastroduodenal, 1.3% pancreatic, 4% colonic, and 0.4% small bowel. None of the patients presenting a gastroduodenal ulcer had perforation or bleeding. Fifty-five percent of the patients with this complication had a past history of esogastroduodenal disease, compared to 19.6% in recipients without gastroduodenal complications. Some 4.4% of the patients had a small bowel or a colonic complication and four died of peritonitis due to bowel perforation. Mortality was 35% in those having intestinal resection and/or perforation with peritonitis. Sixteen percent of patients with colonic complications had a known history of diverticula, compared to 3% for those without colonic complications. The incidence of GI and/or pancreatic complications in renal transplant recipients remains high and has caused 1.1% of the deaths in our series. Mortality is essentially due to upper GI bleeding, peritonitis following perforation, and infectious colitis. Better detection of gastroduodenal and colonic disease before transplantation seems to be mandatory. Prevention with histamine H2 receptor antagonists and early surgical treatment of complicated colonic diverticula help to reduce the morbidity and mortality in kidney graft recipients.     

Prevalence of diverticulosis and incidence of bowel perforation after kidney transplantation in patients with polycystic kidney disease

Sigmoid perforation due to diverticulitis is a life-threatening complication in the postoperative course of allogenic kidney transplantation. The incidence of diverticulosis is especially high among patients with autosomal dominant polycystic kidney disease (ADPKD). Thus, those who undergo allogenic kidney transplantation represent a high-risk group. The aim of this study was to evaluate the prevalence of diverticulosis in ADPKD patients awaiting renal transplantation and the incidence of bowel perforation following allogenic kidney transplantation due to ADPKD. Within the group of 1128 patients who underwent transplantation between January 1974 and January 1990, there were 46 patients (4.07 %) whose indication for transplantation was ADPKD. There was one patient who developed a sigmoid perforation under postoperative immunosuppression. Surgical treatment was a discontinuity resection of the sigmoid (Hartmann's procedure). The postoperative course was favorable, the bowel continuity has already been restored, and the graft is still functioning well. Fifteen of the 28 (53.5 %) ADPKD patients awaiting transplantation had colon diverticulosis (12 male and 3 female patients). No case of bowel perforation has thus far been observed in 15 of these patients who have undergone transplantation. A sigmoid resection was necessary in one patient due to diverticulitis without perforation. We did not find a higher prevalence of diverticulosis in patients with ADPKD, nor did we see a higher incidence of sigmoid perforation during post-transplant immunosuppression in this study. Received: 30 January 1997 Received after revision: 15 July 1997 Accepted: 19 August 1997     

Upper gastrointestinal complications after renal transplantation: a 3-yr sequential study

BACKGROUND: Upper gastrointestinal complications have historically resulted in considerable morbidity and mortality to renal transplant recipients. Over the last decade, antiulcer prophylaxis with proton-pump inhibitors and immunosuppression with tacrolimus-based regimes have been introduced. Little has been written about foregut complications after renal transplantation since the use of these agents. The aim of this study was to compare the frequency of upper gastrointestinal complications after renal transplantation in patients treated with (i) omeprazole vs. ranitidine, and (ii) tacrolimus vs. cyclosporin based immunosuppression. METHODS: Information on 236 patients undergoing renal transplantation between January 1996 and December 1998 was collected prospectively onto a computerized database. RESULTS: Overall, 20 patients (8%) developed upper gastrointestinal complications, opportunistic infections accounted for 9/20 (45%). No patient developed gastroduodenal ulceration, required laparotomy, suffered graft loss or died. There was no significant difference in the frequency of complications between patients that received antisecretory therapy with omeprazole (9/118, 8%) and those that received ranitidine (11/118, 9%), nor between those that were on tacrolimus (7/101, 7%) and those on cyclosporin (13/135, 10%) based immunosuppression regimes. Patients that developed foregut complications were significantly older than those not developing complications (mean age 50 vs. 43 yrs, p=0.05). Further, patients that developed opportunistic infections were more frequently diabetic than those in whom opportunistic infections were not seen (4/31, 13% vs. 5/205, 2%), p=0.02. CONCLUSIONS: We observed a low frequency (8%) of upper gastrointestinal tract complications after renal transplantation. There was no difference in the frequency of complications between patients on tacrolimus and those on cyclosporin based immunosuppression. Furthermore, the complication rates were similar in those that received omeprazole and those that received ranitidine as antiulcer prophylaxis, indicating the equivalence of these two agents in this setting.     

Severance of a ventriculoperitoneal shunt catheter implanted between the cerebral ventricle and peritoneal cavity, resulting in protrusion from the anus

One rare complication of a ventriculoperitoneal (VP) shunt is perforation of the gastrointestinal tract by the catheter. We report a case in which the catheter severed spontaneously inside the peritoneal cavity, creating a communication between the intestinal tract and the peritoneal cavity. The patient was a 41-year-old man who presented with a VP shunt catheter protruding from the anus. Computed tomography showed that the VP shunt catheter, which had been put in place 25 years earlier, had severed spontaneously. The distal end had then perforated and entered the intestinal tract. The patient was hospitalized and emergency surgery was performed to repair the intestinal tract perforation caused by the end of the VP shunt catheter. Laparotomy revealed that the catheter had perforated the sigmoid colon. The VP shunt catheter was removed, and the perforation in the intestinal tract was closed by suturing. The patient was discharged on postoperative day 20.     

Acute diverticulitis with colon perforation in renal transplantation

INTRODUCTION: Acute diverticulitis with colon perforation is a serious condition in transplant recipients. The aim of this study was to analyze our experience with colon perforations among 875 renal transplant recipients between January 1986 and September 2004. METHODS: Patients were analyzed by age, gender, steroid dosage, time interval from the transplantation, delay between symptoms and surgery, clinical presentation, surgical procedure, graft and patient outcomes. RESULTS: We identified 8 patients with colon perforation. The incidence of perforation was 0.9%. Mean age at the the time of perforation was 58.5 years. Fever, abdominal pain, localized or diffuse signs of peritonitis, and leukocytosis were present in 7 patients (87.5%). Three patients (37.5%) were on steroid-free immunosuppression, whereas in 2 cases (25%) the steroid dosage was >20 mg/d. The mean interval between transplantation and perforation was 4.1 years. Two episodes (25%) occurred within 1 month following transplantation and the other 6 (75%) between 1 and 15 years. The interval between the onset of symptoms and surgery was longer than 48 hours in 1 patient (12.5%). In 5 cases (62.5%), a Hartmann procedure was performed; in 2 patients (25%), a resection with primary anastomosis was preferred. The last patient had a direct suture of the colon. Mortality rate was 12.5%. At a median follow-up of 6.1 years, 6 patients (75%) are alive with 5 functioning grafts. CONCLUSIONS: Colon perforations in renal transplant recipients remain a challenging surgical problem. An aggressive diagnostic attitude and an immediate surgical treatment may contribute to significantly decrease the incidence and the mortality of this complication.     

Long-term complications following bladder augmentations in patients with spina bifida: bladder calculi,perforation of the augmented bladder and upper tract deterioration

Background

We desire to review our experience with bladder augmentation in spina bifida patients followed in a transitional and adult urologic practice. This paper will specifically focus on three major complications: bladder calculi, the most frequent complication found following bladder augmentation, perforation of the augmentation, its most lethal complication and finally we will address loss of renal function as a direct result of our surgical reconstructive procedures.

Methods

We reviewed a prospective data base maintained on patients with spina bifida followed in our transitional and adult urology clinic from 1986 to date. Specific attention was given to patients who had developed bladder calculi, sustained a spontaneous perforation of the augmented bladder or had developed new onset of renal scarring or renal insufficiency (≥ stage 3 renal failure) during prolonged follow-up.

Results

The development of renal stones (P<0.05) and symptomatic urinary tract infections (P<0.0001) were found to be significantly reduced by the use of high volume (≥240 mL) daily bladder wash outs. Individuals who still developed bladder calculi recalcitrant to high volume wash outs were not benefited by the correction of underlying metabolic abnormalities or mucolytic agents. Spontaneous bladder perforations in the adult patient population with spina bifida were found to be directly correlated to substance abuse and noncompliance with intermittent catheterization, P<0.005. Deterioration of the upper tracts as defined by the new onset of renal scars occurred in 40% (32/80) of the patients managed by a ileocystoplasty and simultaneous bladder neck outlet procedure during a median follow-up interval 14 years (range, 8–45 years). Development of ≥ stage 3 chronic renal failure occurred within 38% (12/32) of the patients with scarring i.e., 15% (12/80) of the total patient population. Prior to the development of the renal scarring, 69% (22/32) of the patients had been noncompliant with intermittent catheterization. The onset of upper tract deterioration (i.e., new scar formation, hydronephrosis, calculus development, decrease in renal function) was silent, that is, clinically asymptomatic in one third (10/32 pts).

Conclusions

This paper documents the need for high volume bladder irrigations to both prevent the most common complication following bladder augmentation, which is the development of bladder calculi and to reduce the incidence of symptomatic urinary tract infections. It provides a unique perspective regarding the impact of substance abuse and patient non-compliance with medical directives as being both the most common cause for both spontaneous bladder rupture following augmentation cystoplasty and for deterioration of the upper tracts. These findings should cause the surgeon to reflect on his/her assessment of a patient prior to performing a bladder augmentation procedure and stress the need for close follow-up.     

Catastrophic visceral involvement secondary to de novo systemic vasculitis in a renal transplant recipient

De novo systemic vasculitis after renal transplant is a rare complication. We report a patient who developed rapid, catastrophic necrotizing vasculitis of the gastrointestinal tract 11 months after renal transplant. A 60-year-old man was admitted for persistent pain in the right abdomen and mild intestinal hemorrhage. After some days the patient presented partial intestinal occlusion, severe hypoproteinemia and acute renal insufficiency. The patient was urgently operated with resection of a tract of the jejunum where there was a venous infarct. Laboratory tests were not significant and the search for hepatitis B, C viruses and ANCA was negative. After some days of irrepressible intestinal hemorrhage, total gastrectomy, splenectomy and resection of the duodenum and pancreas were performed. Histological pictures showed vascular lesions pathognomonic of systemic polyarteritis nodosa (PAN). After thirty days the patient died. The autopsy confirmed atypical systemic PAN with involvement of the pulmonary arteries besides the gastrointestinal tract and pancreas. Gastrointestinal (GI) complications are not frequent in renal transplant recipients, but 30% of patients with such lesions die as a direct consequence of visceral vascular damage. To the best of our knowledge, de novo PAN has been reported as the cause of catastrophic gastrointestinal involvement in only one renal transplant recipient. This case therefore raises the number of reports of PAN in kidney transplantation recipients who had no history of underlying connective tissue disease.     

Gastrointestinal Disease following Heart Transplantation

With advances in heart transplantation, a growing number of recipients are at risk of developing gastrointestinal disease. We reviewed our experience with gastrointestinal disease in 92 patients undergoing 93 heart transplants. All had follow-up, with the median time 4.8 years (range 0.5–9.6 years). During the period of the study we progressively adopted a policy of low immunosuppression aiming toward monotherapy with cyclosporine. Nineteen patients (20.6%) developed 28 diseases related to the gastrointestinal tract. Thirteen patients required 18 surgical interventions, five as emergencies: closure of a duodenal ulcer, five cholecystectomies (one with biliary tract drainage), a sigmoid resection for a diverticulitis with a colovesical fistula, a colostomy followed by a colostomy takedown for an iatrogenic colon perforation, appendectomy, two anorectal procedures, and six abdominal wall herniorrhaphies. At the onset of gastrointestinal disease, 8 patients were on standard triple-drug immunosuppression, all of them within 6 months of transplantation; 13 were on double-drug immunosuppression; and 7 were on cyclosporine alone. All the patients with perforations/fistulas were on steroids. Among the 11 infectious or potentially infectious diseases, 10 were on triple- or double-drug immunosuppression. One death, a patient who was on triple-drug immunosuppression, had a postmortem diagnosis of necrotic and hemorrhagic pancreatitis. Except for an incisional hernia following a laparoscopic cholecystectomy, there was no morbidity and, importantly, no septic complications. We concluded that a low immunosuppression policy is likely to be responsible for the low morbidity and mortality of posttransplant gastrointestinal disease, with a lower incidence of viscous perforation/fistula and infectious gastrointestinal disease.     

An atypical course of Caroli's disease in a renal transplant patient--case report and review of the literature

This is a rare case of Caroli's disease, diagnosed following renal transplantation in a patient with autosomal recessive polycystic kidneys. Despite advanced cystic transformation of the biliary tree with striking architectural changes, there was no evidence of portal hypertension or hepatic fibrosis. Moreover, the patient did not suffer a single episode of cholangitis, a most interesting feature of this case. Her clinical course was punctuated by repeated episodes of gastrointestinal and urinary tract infections with resistant organisms; but fortunately, she had no evidence of septicemia. Recurrent Salmonella gastroenteritis indicated a chronic carrier state with the dilated bile ducts possibly acting as a potential reservoir. This has significant implications considering the immune suppression associated with renal transplantation. In general, Caroli's disease is rare. Therefore, a high index of suspicion for the diagnosis of Caroli's disease is warranted especially in patients with ARPKD or ADPKD. Once confirmed, affected patients with end-stage renal disease such as our patient, should ideally undergo combined liver-kidney transplantation.     

Autosomal Dominant Polycystic Kidney Disease Transplant Recipients After Kidney Transplantation: A Single-center Experience

Kidney transplantation is indicated for end-stage renal disease. Autosomal dominant polycystic kidney disease (ADPKD) causes structural degeneration of the kidney and eventually becomes end-stage renal disease. ADPKD patients usually have several renal and nonrenal complications. We analyzed our kidney transplantation activities between 1991 and 2010 regarding ADPKD. We followed up with patients to December 31, 2016. Data were collected as patient and graft survival rates, the prevalence of polycystic manifestation of the gastrointestinal tract and other organs, and the attendance of urinary tract infection. Among the 734 kidney transplantations, 10.9% (n = 80) had an ADPKD. Four patients (5%) had diverticulum perforation. The prevalence of post-transplantation urinary tract infection was higher in ADPKD patients (55.9%) compared to non-ADPKD patients (44.1%). The 1-, 3-, and 5-year overall survival rates in ADPKD recipients versus non-ADPKD patients are 77.5%, 70.0%, and 67.5% versus 86.4%, 83.0%, and 80.1%, respectively. Patients with ADPKD were transplanted at an elder age compared to others (median: 47.5 years vs. 39.9 years). Female patients had longer graft survival times than males. ADPKD implies multiple cystic degeneration of the kidneys; however, it can cause structural degeneration in other organs. It is typical for ADPKD patients to have an acute abdominal-like syndrome. Immunosuppressive drugs can hide the clinical picture, which makes early diagnosis difficult.