Nakhleh R E, Benedetti E, Gruessner A, Troppmann C, Goswitz J J, Sutherland D E, Gruessner R W
Department of Pathology, Henry Ford Hospital, Detroit, Michigan, USA.
Transplantation. 1995 Sep 27;60(6):541-6. doi: 10.1097/00007890-199509270-00004.
Tissue diagnosis of pancreas graft dysfunction is desirable. Bladder-drained pancreaticoduodenal transplants allow tissue diagnosis by cytoscopic biopsy procedures of the pancreas and duodenum. To assess the diagnostic utility of duodenal biopsies, we reviewed all cystoscopically obtained pancreas and duodenal biopsy tissues at our institution (July 1, 1989 through September 30, 1993). Adequate tissue for histologic examination was obtained from 75 biopsies in 58 recipients. Indications for cytoscopic biopsies were relative hypoamylasuria in 85%, hematuria in 6%, hyperamylasemia in 3%, and other causes in 6%. Duodenal specimens were available from 52 biopsies (25 with, and 27 without, concurrent pancreas biopsies). Of the 27 duodenal biopsies alone, 3 were diagnostic of rejection, 15 had features consistent with rejection, 6 were normal, 1 showed fibrosis, 1 showed necrosis, and 1 was ulcerated. Thus, two-thirds of the duodenal biopsies alone yielded clinically relevant information resulting in antirejection treatment. In 25 of the duodenal biopsies, pancreas tissue was also available (11 simultaneous pancreas-kidney, 9 pancreas transplant alone, and 5 pancreas after kidney recipients). Findings in both organs completely agreed in 9 (36%) of the biopsies. In 7 (28%), rejection was suggested or diagnosed in both organs, although the organs were discrepant with regard to the presence of vascular rejection (6 pancreas, 1 duodenum). In 2 (11%), minor nonrejection discrepant findings were present. Therefore, in 18 of 25 (72%) pancreas-duodenal biopsies, treatment would not have been different if only one graft had been biopsied. But in the other 7 (28%), treatment would have been different if only the organ with negative findings had been biopsied. In 6 cases (4 duodenal, 2 pancreas), rejection was seen in one organ but not the other. In 1 case, cytomegalovirus (CMV) inclusions were present in the duodenum, but the pancreas was normal. We conclude that (1) the duodenum and pancreas can reject independently of each other, and a negative biopsy does not preclude rejection of the other organ; (2) duodenal biopsies determined therapeutic decisions one-fifth of the time when both tissues were available for examination, and two-thirds of the time when only duodenal tissue was available; and (3) since cystoscopy allows easy access to the duodenum, both the pancreas and duodenum should be biopsied whenever possible; tissue samples of one organ alone are sufficient only with positive findings.
胰腺移植功能障碍的组织诊断很有必要。膀胱引流式胰十二指肠移植可通过胰腺和十二指肠的膀胱镜活检程序进行组织诊断。为评估十二指肠活检的诊断效用，我们回顾了本机构（1989年7月1日至1993年9月30日）所有经膀胱镜获取的胰腺和十二指肠活检组织。58名受者的75次活检获取了足够用于组织学检查的组织。膀胱镜活检的指征为：85%为相对低淀粉酶尿症，6%为血尿，3%为高淀粉酶血症，6%为其他原因。52次活检获取了十二指肠标本（25次同时进行了胰腺活检，27次未同时进行胰腺活检）。仅27次十二指肠活检中，3次诊断为排斥反应，15次具有与排斥反应一致的特征，6次正常，1次显示纤维化，1次显示坏死，1次为溃疡。因此，仅十二指肠活检中有三分之二产生了具有临床意义的信息，从而导致了抗排斥治疗。在25次十二指肠活检中，也获取了胰腺组织（11次同时进行胰腺 - 肾脏移植，9次单独进行胰腺移植，5次为肾移植后进行胰腺移植）。9次活检（36%）中两个器官的检查结果完全一致。7次活检（28%）中，两个器官均提示或诊断为排斥反应，尽管在血管排斥反应的存在方面两个器官存在差异（6次胰腺，1次十二指肠）。2次活检（11%）存在轻微的非排斥性差异结果。因此，在25次胰腺 - 十二指肠活检中的18次（72%）中，如果仅对一个移植物进行活检，治疗方案不会有所不同。但在另外7次活检（28%）中，如果仅对检查结果为阴性的器官进行活检，治疗方案会有所不同。6例（4次十二指肠，2次胰腺）中，一个器官出现排斥反应而另一个器官未出现。1例中，十二指肠存在巨细胞病毒（CMV）包涵体，但胰腺正常。我们得出以下结论：（1）十二指肠和胰腺可相互独立发生排斥反应，一次活检结果为阴性并不排除另一个器官发生排斥反应；（2）当两个组织均可进行检查时，十二指肠活检在五分之一的情况下决定了治疗决策，当仅有十二指肠组织可进行检查时，三分之二的情况下决定了治疗决策；（3）由于膀胱镜检查可方便地获取十二指肠组织，只要有可能，胰腺和十二指肠均应进行活检；仅一个器官的组织样本在检查结果为阳性时才足够。
