肾移植术后并发肠穿孔的诊断和治疗体会

目的 总结肾移植术后并发肠穿孔的诊断和治疗体会.方法 回顾性分析8例肾移植术后并发生肠穿孔患者的资料.8例均为首次肾移植,术后采用环孢素A(或他克莫司)、霉酚酸酯及甲泼尼龙预防排斥反应.8例患者中,1例肾移植术前有胃大部切除手术史,其余7例术前无胃肠道病变.1例于肾移植术中切除了双侧多囊肾.1例在发生肠穿孔前因急性排斥反应而接受甲泼尼龙冲击治疗.8例患者均接受了剖腹探查术,同时减少免疫抑制剂的用量.结果 肠穿孔发生于肾移植术后3～18 d.5例患者表现为突发性腹部绞痛,不同程度的急性腹膜炎体征;3例急性腹膜炎体征不明显.患者体温为36.5～38.4℃.腹部X线检查显示,5例右侧或双侧膈下出现游离气体,3例出现肠管扩张及肠梗阻征象.诊断肠穿孔后3～96 h患者接受了剖腹探查.术中证实,7例为同肠穿孔,1例为降结肠穿孔.剖腹探查的同时,3例接受了小肠穿孔修补术,4例接受了部分小肠切除吻合术,1例接受了部分结肠切除吻合术.经手术治疗,5例患者痊愈出院.随访0.5～3.5年,肾功能良好,未再发生肠穿孔;3例患者分别于肾移植术后30～108 d因肠穿孔并发症死亡.结论 肠穿孔是肾移植术后少见而严重的并发症,其临床症状不典型,腹部X线检查结果对早期诊断具有较大意义,早期诊断和手术治疗是改善患者预后的关键.

Diagnosis and treatment of intestinal perforation after kidney transplantation

Objective To summarize the diagnosis and treatment of intestinal perforation after kidney transplantation. Methods The clinical data of 8 kidney allograft recipients with intestinal perforation were retrospectively analyzed. All the 8 cases were subjected to primary transplantation,and received cyclosporine A (or tacrolimus), mycophenolate mofetil and methylprednisolone to prevent rejection. Of the 8 cases of kidney transplantation, 1 recipient had a history of subtotal gastrectomy,and the remaining 7 recipients had no gastrointestinal lesions. One case received bilateral polycystic kidney resection during kidney transplantation. One case accepted pulse methylprednisolone therapy for acute rejection prior to intestinal perforation. All 8 patients received laparotomy, and at the same time the dosage of immunosuppressive agents was reduced. Results Intestinal perforation occurred in 3-18 days after kidney transplantation. Five eases had sudden abdominal cramps and some degrees of signs of acute peritonitis. Three cases had no obvious signs of acute peritonitis. The body temperature of the patients was 36. 5-38. 4 ℃. Abdominal X-ray examination demonstrated the right or bilateral pneumoperitoneum in 5 patients. Three cases showed the signs of intestinal dilation and intestinal obstruction. All the patients received exploratory laparotomy 3-96 h after the diagnosis of intestinal perforation. The sites of perforation included colon (n = 1) and ileum (n = 7). During exploratory laparotomy, 3 cases of intestinal perforation accepted repair, 4 cases underwent a partial small bowel resection and anastomosis, and one case of colon perforation received a partial colon resection and anastomosis. After surgery, 5 patients were cured and discharged. During a follow-up period of 0. 5-3. 5 years, the kidney function was normal, and no intestinal perforation reoccurred. Three patients died of complications due to intestinal perforation after kidney transplantation in 30-108 days.Conclusions Intestinal perforation after kidney transplantation is a rare but serious complications.The clinical symptoms are not typical. Abdominal X-ray examination results have the greater significance for early diagnosis. Early diagnosis and surgical treatment is the key to improve the