胰腺移植现状

据国际胰腺移植登记处资料，从1987年10月1日至1994年8月31日，总计有4360例胰腺移植报告，其中85．9％为胰肾联合移植（SPK），6．8％为肾移植后胰腺移植（PAK），5．5％为单纯胰腺移植（PfA）。1996年全球移植中心名录报道，到1995年底全世界已开展8382例胰腺移植。现将其近况综述如下。1移植方式及其评价SPK是应用最广且效果最好的移植方式，适用于IDDM并发终末期肾病者。Bruce等[1]报道100例SPK患者及其胰、肾的1年存活率分别为肥％、81％和92％；5年存活率分别为81％、61％和71％。行SPK的胰腺1年存活率显著高于PTA（45％）…     

临床胰肾联合移植进展

胰肾联合移植（SPK）是治疗胰岛素依赖型糖尿病并发尿毒症及尿毒症合并有糖尿病的有效方法，胰腺移植之后可获得正常的糖代谢，不需要外源性胰岛素并可逆转糖尿病的并发症和提高生活质量，采用外源性胰岛素的替代疗法并不能防止糖尿病并发症的发生，肾脏移植之后使尿毒症得到纠正，自1966年首例临床胰腺十二指肠移植成功以来，到1994年底，全球单一胰腺移植1600例。有131个移植中心施行胰肾联合移植5628例，移植患者1年与5年存活率分别为91％和78％目前，胰肾联合移植仅次于肾，肝、心移植，居第4位，现将胰肾联合移植进展分述如下：一、…     

单独的胰腺同种移植:经皮活检的作用和排斥的标准组织学分级

胰岛素依赖性糖尿病和终末期肾病者施行胰一肾同种移植（SPK）的1年生存率达1000／0而单独胰腺移植（PTA）和肾移植后再行胰移植（PAK）的移植胰1年存活率分别为54％和52％，明显低干SPK的刀％，三者移植排斥率分别为280%、32%和8%，以SPK为最低。设想经皮活检的标准组织学排斥分级或可改善单独胰移植体的生存。作者分析30例PAK和5例PTK的结果。移植胰包括脾、十二指肠和近端空肠、置于受体的右髂窝，其脾动脉及肠系膜上动脉连接至供体的骼总动脉分叉，切除受体的脾脏。门静脉吻合至受体的骼外静脉，供体的Y型血管移植体的部总动脉…     

胰、肾联合移植术式的选择

由于胰腺外分泌液的引流方式和移植胰腺排斥反应难以诊断的特殊性,胰、肾联合移植的总数和效果都远远落后于其它器官移植。直到最近十年,胰、肾联合移植的手术方式才趋向定型,成为治疗 1 型糖尿病合并尿毒症的最佳选择。在我国,胰、肾联合移植的经验积累十分有限,手术方式尚无统一标准,多数中心仅仅实施单一术式。因此,本文结合我们的经验,对胰腺与胰、肾联合移植手术选择的有关问题作一综述。一、胰、肾同期移植与肾移植后的胰腺移植胰、肾联合移植分为胰、肾同期移植(SPK)和肾移植后的胰腺移植(PAK),SPK的免疫学特点是胰腺和肾脏…     

同期胰肾联合移植12例报告--德国埃森大学的经验

目的总结同期胰肾联合移植(SPK)术的治疗效果和经验。方法自2002年1月至2003年9月,以SPK术治疗胰岛素依赖型糖尿病(IDDM)合并终末期肾病(ESRD)患者12例。每例受者接受来自同一供者的胰腺和肾脏,移植肾以经典方法植入左侧盆腔,胰腺植于右下腹。1例移植胰腺静脉与受者门静脉系统吻合,11例与体静脉系统吻合。胰腺外分泌引流方法为:3例移植物十二指肠段与受者十二指肠吻合,9例与空肠上段吻合。术前应用甲泼尼龙及抗胸腺细胞球蛋白作为免疫诱导,术后以他克莫司、霉酚酸酯和泼尼松三联抗排斥药物维持。结果术后平均随访时间23个月,受者、移植胰腺和移植肾的存活率分别为100%、91.7%和91.7%。1例再次行SPK术的受者,术后出现了超急性排斥反应,且未能逆转,于术后13d切除移植物;其余11例首次行SPK术的受者中,3例(28.3%)出现急性排斥,均获成功纠治。2例受者术后移植肾功能延迟恢复,行过渡性透析。11例首次行SPK术的移植胰腺术后立即发挥了功能,分别于术后1~5d内停用胰岛素。结论同期胰肾联合移植是胰岛素依赖型糖尿病合并终末期肾病患者的一种安全而有效的治疗方法。     

他克莫司在胰、肾同期联合移植中的应用体会

目的回顾性总结他克莫司（FK506）在胰、肾同期联合移植（SPK）中的应用经验。方法37例SPK受者，术后早期采用抗淋巴细胞球蛋白（最初3例）或抗白细胞介素2受体单克隆抗体（34例）诱导治疗，采用FK506、霉酚酸酯（MMF）和皮质激素维持治疗。FK506于术后第3～4天开始口服，起始剂量为0．05～0．08mg·kg^-1·d^-1，3～5d后根据血药浓度调整用量，血FK506的浓度谷值，术后1个月内维持在10～12μg／L，2～3个月为6～10μg／L，3个月后为4～8μg／L。结果37例术后均停用胰岛素，仅1例（2．7％，1／37）术后6个月死于急性心肌梗死，受者、移植胰和移植肾1年存活率均为97％。空腹血糖恢复正常的时间为（13．4±8．9）d。28例1型糖尿病患者术后空腹血糖恢复正常的时间为（9．7±3．2）d，9例2型糖尿病患者术后空腹血糖恢复正常的时间显著延长，为（23．0±11．7）d。1年内急性排斥反应发生率为13．5％（5／37），其中4例为单纯移植肾排斥反应，1例同时累及移植胰腺和肾脏；2例经激素冲击治疗后逆转，1例经激素和抗淋巴细胞球蛋白治疗逆转，另2例经激素冲击治疗后，血肌酐一度下降，但2～3个月后因再次发生排斥反应，血肌酐逐渐上升，恢复血液透析，但移植胰功能良好，其后行再次肾移植。结论以FK506为基础的免疫抑制能安全、有效地预防SPK后的排斥反应。     

改良肠引流式胰肾联合移植的外科技术及临床应用

目的报道改良胰液空肠引流式胰肾联合移植的外科技术和其治疗糖尿病合并尿毒症的近期效果。方法2000年6月至2006年8月,共有38例糖尿病合并尿毒症患者在华中科技大学同济医学院附属同济医院接受胰肾联合移植,移植胰腺的外分泌液用空肠内引流,不作Roux-en-Y吻合。移植胰腺及肾脏的平均冷缺血时间分别为（10±2．0）h和（7±2．0）h。除1例外,术后早期均采用他克莫司、霉酚酸酯及皮质激素预防排斥反应,同时以抗淋巴细胞球蛋白或抗CD25单克隆抗体诱导治疗。结果受者、移植肾脏和胰腺的6个月存活率均为97．4％,平均停用胰岛素时间为（7±6．9）d,空腹血糖恢复正常的平均时间为（14±9．1）d。术后3周口服糖耐量试验、胰岛素和C肽释放试验显示移植胰腺功能完全正常。血淀粉酶恢复正常的平均时间为（10±7．7）d。肾功能延迟恢复8例,其血肌酐恢复正常的平均时间为（53±20．0）d;其余30例血肌酐恢复正常的平均时间为（8±7．4）d。术后主要外科并发症为移植胰腺伤口感染、胰十二指肠-空肠吻合口出血和移植肾脏周围出血,3例（7．9％）因并发症再次手术,未发生与胰液引流术式相关的并发症如胰漏、肠漏、腹腔脓肿及肠梗阻等。结论胰肾联合移植是治疗1型和部分2型糖尿病合并尿毒症的有效方法;改进的胰液空肠引流术式（不作Roux-en-Y吻合）有助于降低胰液空肠引流术式的术后早期并发症发生率,提高受者和移植物的存活率。     

美国产胰岛细胞移植专用设备COBE-2991细胞分离机介绍

胰岛、肾联合移植（SIK）及肾移植后胰岛移植（IAK）治疗1型糖尿病合并晚期肾病患者，其临床效果与胰、肾联合移植（SPK）一样，除可以使患者完全或大部份脱离胰岛素、糖代谢稳定，并能有效控制并发症的发生和发展外，还可以改善患者的心脏功能，增强移植肾的存活率和功能等，同时也避免了胰腺移植带来的术后风险和外分泌液可能泄漏的致命性副作用。     

美国产胰岛细胞移植专用设备COBE-2991细胞分离机介绍

胰岛、肾联合移植（SIK）及肾移植后胰岛移植（IAK）治疗1型糖尿病合并晚期肾病患者，其临床效果与胰、肾联合移植（SPK）一样，除可以使患者完全或大部份脱离胰岛素、糖代谢稳定，并能有效控制并发症的发生和发展外，还可以改善患者的心脏功能，增强移植肾的存活率和功能等，同时也避免了胰腺移植带来的术后风险和外分泌液可能泄漏的致命性副作用。亦不会额外增加患者术后免疫抑制剂的使用成本。本技术也适应单纯胰岛移植治疗（同种或异种）1型糖尿病患者。     

美国产胰岛细胞移植专用设备COBE-2991细胞分离机介绍

胰岛、肾联合移植（SIK）及肾移植后胰岛移植（IAK）治疗1型糖尿病合并晚期肾病患者，其临床效果与胰、肾联合移植（SPK）一样，除可以使患者完全或大部份脱离胰岛素、糖代谢稳定，并能有效控制并发症的发生和发展外，还可以改善患者的心脏功能，增强移植肾的存活率和功能等，同时也避免了胰腺移植带来的术后风险和外分泌液可能泄漏的致命性副作用。亦不会额外增加患者术后免疫抑制剂的使用成本。本技术也适应单纯胰岛移植治疗（同种或异种）1型糖尿病患者。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.