Miyagi S, Sekiguchi S, Kawagishi N, Akamatsu Y, Satoh K, Takeda I, Fujimori K, Satomi S
Division of Transplantation, Reconstruction, and Endoscopic Surgery, Tohoku University, Sendai, Japan.
Transplant Proc. 2011 Nov;43(9):3292-5. doi: 10.1016/j.transproceed.2011.09.094.
Pancreas transplantation has been associated with the highest surgical complication rate among routinely performed organ transplant procedures. Complications can be caused not only from the pancreas itself but also from the simultaneously transplanted duodenum: gastrointestinal bleeding, duodenal ulcer, pseudoaneurysm, arterioenteric fistula, and severe rejection. Herein we report a patient who underwent simultaneous pancreas-kidney transplantation (SPKT) and experienced a duodenal perforation because of rejection.
The 60-year-old man with insulin-dependent diabetes underwent SPKT with enteric drainage. At 15 days there after he displayed melena.
We suspected it to be caused by rejection and ischemic changes. We slightly increased the doses, of tacrolimus and methylprednisolone. But 17 days after SPKT, the ulcer perforated, requiring a repair operation and increased dose of mycophenolate mofetil. However, the ulcers perforated repeatedly, requiring 4 repair operations. Unfortunately the patient developed pneumonia that mitigated continues repairs or rejection therapies, so we expated the duodenum and pancreas but saved the kidney. The pathologic findings showed the ulcer to have been caused by severe rejection. Despite those episodes, the patient was weaned from hemodialysis.
Perforation of the transplanted duodenum is one of the most difficult complications among SPKT patients. This potentially lethal complication may be caused by mucosal rejection, ischemic changes, and the exocrine output from the pancreatic graft.
在常规进行的器官移植手术中，胰腺移植的手术并发症发生率最高。并发症不仅可由胰腺本身引起，还可由同时移植的十二指肠引发，包括胃肠道出血、十二指肠溃疡、假性动脉瘤、动脉肠瘘以及严重排斥反应。在此，我们报告一例接受胰肾联合移植（SPKT）的患者，因排斥反应发生十二指肠穿孔。
这位60岁的胰岛素依赖型糖尿病男性患者接受了采用肠内引流的SPKT。术后15天，他出现了黑便。
我们怀疑这是由排斥反应和缺血性改变所致。我们略微增加了他克莫司和甲泼尼龙的剂量。但在SPKT术后17天，溃疡穿孔，需要进行修复手术并增加霉酚酸酯的剂量。然而，溃疡反复穿孔，需要进行4次修复手术。不幸的是，患者并发了肺炎，这使得持续的修复或抗排斥治疗受到影响，因此我们切除了十二指肠和胰腺，但保留了肾脏。病理检查结果显示溃疡是由严重排斥反应引起的。尽管经历了这些情况，患者还是摆脱了血液透析。
移植十二指肠穿孔是SPKT患者中最难处理的并发症之一。这种潜在致命的并发症可能是由黏膜排斥反应、缺血性改变以及胰腺移植物的外分泌所致。
