Stratta Robert J, Shokouh-Amiri M H, Egidi M Francesca, Grewal Hani P, Lo Agnes, Kizilisik A Tarik, Nezakatgoo Nosratollah, Gaber Lillian W, Gaber A Osama
Departments of Surgery-Transplant, University of Tennessee, Memphis, TN, USA. rstratta@ wfubmc.edu
Clin Transplant. 2003;17 Suppl 9:69-77. doi: 10.1034/j.1399-0012.17.s9.13.x.
Refinements in surgical techniques and advances in clinical immunosuppression have led to steadily improving results in pancreas transplantation (PTX). Although there is renewed interest in enteric exocrine drainage, most PTXs are performed with systemic venous delivery of insulin. To improve the physiology of PTX, we developed a novel technique of portal venous delivery of insulin and enteric drainage of the exocrine secretions (portal-enteric [P-E]). The purpose of the study was to analyse outcomes in patients undergoing PTX with P-E drainage and contemporary immunosuppression.
From January 1997 through September 2002, we performed 67 primary simultaneous kidney-PTXs (SKPT) with P-E drainage. Maintenance immunosuppression consisted of tacrolimus (TAC), mycophenolate mofetil (MMF) and steroids. No antibody induction therapy occurred in 33 patients (49%) with the remainder receiving daclizumab (n = 15), basiliximab (n = 2), or thymoglobulin (n = 14) induction therapy. The patient group included 38 males and 29 females with a mean age of 39.7 year (range 23-58) and a mean duration of pretransplant diabetes of 24.5 year (9-46). Fourteen patients (21%) were African-American.
The mean waiting time for SKPT was 3.3 months (range 0.1-10). Mean kidney and pancreas cold ischaemia times were 15.1 and 15.4 h, respectively. Patient, kidney and pancreas graft survival rates were 97%, 92.5% and 82%, respectively, with a mean follow-up of 20 months (range 1-56). Two deaths (one sepsis, one cardiac event) occurred at 1 month after SKPT; both patients died with functioning grafts (DWFG). Three patients (4.5%) had delayed renal allograft function and received temporary dialysis after SKPT. Five kidney graft losses occurred (two DWFG, one thrombosis, two chronic rejection). All but four patients (6%) had immediate PTX function. A total of 12 pancreas graft losses occurred (two DWFG, five thrombosis, five chronic rejection). The incidence of acute rejection was 28%, but no grafts were lost due to isolated acute rejection. The incidence of major infection was 51%, but only five patients (7.5%) developed cytomegalovirus infection. A total of 19 patients (28%) underwent early relaparotomy within 3 months of SKPT. The composite endpoint of no rejection, graft loss, or mortality was attained by 63% of patients. At present, 58 patients (87%) are both dialysis and insulin-independent (including four retransplants).
These findings suggest that SKPT with P-E drainage and contemporary immunosuppression may result in excellent intermediate-term outcomes.
手术技术的改进和临床免疫抑制的进展使得胰腺移植（PTX）的结果不断改善。尽管对肠内外分泌引流重新产生了兴趣，但大多数PTX手术采用胰岛素的全身静脉输注。为了改善PTX的生理功能，我们开发了一种新的胰岛素门静脉输注和外分泌分泌物肠内引流（门静脉-肠内[P-E]）技术。本研究的目的是分析接受P-E引流和当代免疫抑制的PTX患者的预后。
从1997年1月至2002年9月，我们进行了67例原发性同期肾-胰腺移植（SKPT），采用P-E引流。维持免疫抑制包括他克莫司（TAC）、霉酚酸酯（MMF）和类固醇。33例患者（49%）未接受抗体诱导治疗，其余患者接受达利珠单抗（n = 15）、巴利昔单抗（n = 2）或抗胸腺细胞球蛋白（n = 14）诱导治疗。患者组包括38名男性和29名女性，平均年龄39.7岁（范围23-58岁），移植前糖尿病平均病程24.5年（9-46年）。14例患者（21%）为非裔美国人。
SKPT的平均等待时间为3.3个月（范围0.1-10个月）。肾脏和胰腺的平均冷缺血时间分别为15.1小时和15.4小时。患者、肾脏和胰腺移植物的存活率分别为97%、92.5%和82%，平均随访20个月（范围1-56个月）。SKPT术后1个月发生2例死亡（1例败血症，1例心脏事件）；两名患者均死于移植物功能良好（DWFG）。3例患者（4.5%）出现移植肾延迟功能，SKPT术后接受临时透析。发生5例肾脏移植物丢失（2例DWFG，1例血栓形成，2例慢性排斥）。除4例患者（6%）外，所有患者的PTX均立即发挥功能。共发生12例胰腺移植物丢失（2例DWFG，5例血栓形成，5例慢性排斥）。急性排斥反应的发生率为28%，但没有移植物因单纯急性排斥反应而丢失。主要感染的发生率为51%，但只有5例患者（7.5%）发生巨细胞病毒感染。共有19例患者（28%）在SKPT术后3个月内接受了早期再次剖腹手术。63%的患者达到了无排斥、移植物丢失或死亡的复合终点。目前，58例患者（87%）不再依赖透析和胰岛素（包括4例再次移植患者）。
这些发现表明，采用P-E引流和当代免疫抑制的SKPT可能会带来优异的中期预后。
