胰肾同期移植术式选择与并发症分析

【目的】总结胰液膀胱引流(BD)与肠道引流(ED)两种胰肾一期移植(SPK)手术方式，分析术后并发症发生情况、原因和处理方式。【方法】12例Ⅰ型糖尿病(IDDM)合并尿毒症患者施行了SPK，最初2例为BD术式，另10例为改进的ED术式。术后早期采用他克莫司(FK506)／环孢素A(CsA) 霉酚酸酯(MMF) 皮质激素 抗淋巴细胞球蛋白(ALG)或抗CD25单抗四联诱导治疗．以后改为三联维持。抗凝治疗使用肝素、低分子右旋糖酐。【结果】12倒手术均获得成功，术后移植胰、移植肾功能恢复良好，停用外源性胰岛素。4例出现移植肾急性排斥，其中3例治疗后逆转，1例移植肾功能丧失。手术并发症包括：腹腔感染3例，切口感染2例。分别经引流换药治疗后二期愈合；肾周血肿2例．经手术探查清理后好转。多与抗凝剂短期应用过量有关。远期并发症：2例BD术式患者长期存在化学性膀胱炎．其中1例发生2次反流性移植物胰腺炎．经保守治疗好转。所有病例术后均未发生吻合口漏和移植物血管栓塞等严重并发症。【结论】改进的ED—SPK术式安全、简单，远期并发症少，是治疗IDDM合并尿毒症的理想方法；但应积极预防术后早期出血、感染并发症。

Surgical Consideration on Simultaneous Pancreas Kidney Transplantation and Analysis of Postoperative Complications

Objective To summarize the surgical consideration on modes of pancreatic exocrine secretions and analyses the complications after simultaneous pancreas kidney transplantation (SPK).Twelve patients suffered from insulin dependent diabetes mellitus (IDDM) with uremia were involved in the study. They received SPK between Jan. 2000 and July 2003. Bladder drainage(BD) of pancreatic allograft exocrine secretion was used in the initial two cases and enteric drainage (ED) in the other ten patients. Quadruple immunosuppressive regimes consisted of tacrolimus/cyclosporine, mycophenolate mofetil (MMF), steroid and antilymphocyte globulin (ALG) or anti-CD25 monoclonal antibody. Fraxiparine and dextran 40 were used as anticoagulant agents.SPK was applied to all patients without serious surgical complications such as graft thrombosis and pancreatic fistula. The patients achieved immediate kidney allograft function and euglycemia. Episodes of acute kidney graft rejection were seen in four patients with three cases reversed successfully. Early surgical complications included peritoneal infection (3/12), wound infection (2/12) and bleeding (2/12). Late complications including persistent hemauria were only observed in the initial 2 patients with BD and two episodes of reflux graft pancreatitis were seen in one of them.Conclusion]SPK with ED shown less incidence of late complications is preferable to IDDM patients with secondary uremia. Prevention of hemorrhage and infection during peri-operative period should be taken into consideration at first.