胰肾联合移植手术方式的选择

目的：探讨胰肾联合移植的手术方式及移植疗效。方法：10例I型糖尿病合并尿毒症患者施行了胰肾联合移植,最初2例为胰液膀胱引流（BD）术式,另8例为改进的胰液空肠引流（ED）术式。BD术式为移植物十二指肠的侧面与膀胱右侧壁作双层吻合;ED术式为移植物十二指肠的侧面与受者空肠作侧－侧吻合（不作Roux-en-Y)。术后早期采用皮质激素＋霉酚酸酯（MMF）＋他克莫司（FK506）＋抗淋巴细胞球蛋白（ALG）或赛尼哌四联诱导治疗,以后改为三联维持。结果：10例胰肾联合移植手术均获得成功,移植胰和移植肾功能术后1－5d恢复正常,停用胰岛素。术后未发生排斥反应和血栓形成,1例死于消化道出血和败血症,死亡时胰肾功能良好,其余9例均无其它外科并发症。随访3－27个月,目前移植胰和移植肾功能均正常,一般情况良好。2例BD术式患者术后长期伴有镜下血尿,其中1例发生2次反流性移植物胰腺炎和肉眼血尿,经保守治疗好转。结论：BD术式与改进的ED术式（不作Roux-en-Y吻合）均安全、可行,是治疗I型糖尿病并发尿毒症的有效方法;ED术式更符合患者生理功能,远期并发症,优于BD术式,可作为首选术式。

Selection of surgical procedure of combined kidney-pancreatic transplantation

OBJECTIVE: To evaluate simultaneous kidney-pancreatic transplantation (SKPT) with bladder drainage and enteric drainage for its efficacy and safety. METHOD: SKPT was performed in 10 patients from Jan. 2000 to Feb. 2002. All patients had long-standing insulin-dependent diabetes mellitus and subsequent renal failure. Bladder drainage (BD) of exocrine secretion was used in the first 2 cases and enteric drainage (ED) in last 8 patients. In BD, a two-layer hand sewn duodenocystostomy was performed. In ED, a two-layered side-to-side anastomosis was fashioned between the donor duodenal segment and the recipient jejunum. No Roux-en-Y limb was used. Quadruple immunosuppressive therapy with antithymocyte globulin, tacrolimus, mycophenolate mofetil and steroids was standard treatment in all patients. The patients were treated with quadruple therapy, which included antilymphocyte globulin (ALG) or anti-CD25 monoclonal antibody (Zenapax) induction therapy, prednisone, Cyclosporine A/tacrolimus, and mycophenolat-mofetil (MMF). RESULTS: SPK was successfully applied to all cases without complication referable to the technique. All patients have achieved excellent renal function and euglycemia, and no further insulin treatment was needed between 1 and 5 days posttransplant. One patient with ED died due to sepsis and upper gastrointestinal hemorrhage 5 weeks after operation. The death occurred with functioning grafts. Until now no rejection episode and thrombosis were observed and all the grafts from nine patients are functioning well. The first 2 patients with BD underwent slight metabolic complications and microscopic hematuria with entire follow-up time. Two episodes of reflux graft pancreatitis followed by macroscopic hematuria occurred in one patient with BD. CONCLUSION: Compared with SPK with BD, ED without Roux-en-Y anastomosis might be a more physiological and prior procedure for type I diabetes mellitus with uremia.