Gaber A O, Shokouh-Amiri M H, Hathaway D K, Hammontree L, Kitabchi A E, Gaber L W, Saad M F, Britt L G
Department of Surgery, College of Medicine, University of Tennessee, Memphis, USA.
Ann Surg. 1995 Jun;221(6):613-22; discussion 622-4. doi: 10.1097/00000658-199506000-00001.
The standard method for pancreatic transplantation involves drainage of exocrine secretions into the urinary bladder with venous outflow into the systemic circulation. Despite the high success rate associated with this approach, it often leads to complications, including chemical cystitis, reflux pancreatitis, metabolic acidosis, and hyperinsulinemia. The authors developed a new technique of pancreatic transplantation with portal drainage of endocrine secretions and enteric drainage of exocrine secretions (PE), which theoretically should be more physiologic.
All patients were insulin-dependent diabetics with end-stage renal disease who underwent combined kidney-pancreas transplantation. Between 1990 and 1994, 19 patients have been transplanted using intraperitoneal placement of the pancreas allograft with exocrine drainage into a Roux-en Y loop and venous drainage into the portal circulations (PE). A comparison group of all patients undergoing standard systemic-bladder (SB) transplantation between April 1989 and March 1993 (n = 28) also was studied. Patient follow-up ranges from 6 months to 5 years for the SB patients (mean = 2.5 years) and 6 months to 4 years for the PE patients (mean = 1.6 years). Routine follow-up includes documentation of the clinical course and detailed endocrine studies.
Patient and graft actuarial survival at 1 and 3 years is no different for SB and PE patients. Urinary tract infections occurred in 89.3% of the SB patients (2.8/patient) versus 26.3% of the PE patients (0.25/patient, p < or = 0.0001). None of the PE patients experienced hematuria compared with 53.6% of the SB patients (p < or = 0.0001); however, two PE patients had melanotic episodes. The incidence of urinary retention and reflux pancreatitis was 32.1% versus 5.3% (p < or = 0.028) for SB and PE groups, respectively. Patients in the SB group required sodium bicarbonate therapy (mean = 55 mEq/day) although no PE patient required routine therapy; despite this, SB patients experienced more episodes of acidosis (44 vs. 5). Endocrine studies indicate no difference in glycosylated hemoglobin or fasting and stimulated glucose values throughout the follow-up period. In contrast, hyperinsulinemia was evident in both fasting and stimulated tests for the SB patients, with values consistently two- to fivefold higher than those of the PE group.
These results indicate that PE and SB pancreas transplantation are equivalent in terms of patient and graft survival and suggest that the PE approach is associated with a decreased incidence of metabolic and bladder-related complications. In addition, the PE approach eliminates the state of peripheral hyperinsulinemia that characterizes the SB procedure. Continued follow-up will be necessary to determine if long-term outcomes will differ for patients with PE and SB grafts.
胰腺移植的标准方法是将外分泌液引流至膀胱，同时将静脉血回流入体循环。尽管这种方法成功率较高，但常引发并发症，包括化学性膀胱炎、反流性胰腺炎、代谢性酸中毒和高胰岛素血症。作者研发了一种新的胰腺移植技术，即内分泌液经门静脉引流、外分泌液经肠道引流（PE），理论上该方法更符合生理状态。
所有患者均为依赖胰岛素的终末期肾病糖尿病患者，接受了肾胰腺联合移植。1990年至1994年间，19例患者接受了胰腺移植，采用将胰腺移植物腹腔内植入，外分泌液引流至Roux-en Y肠袢，静脉血回流入门静脉循环（PE）的方法。还对1989年4月至1993年3月期间接受标准体循环-膀胱（SB）移植的所有患者（n = 28）组成的对照组进行了研究。SB组患者的随访时间为6个月至5年（平均 = 2.5年），PE组患者的随访时间为6个月至4年（平均 = 1.6年）。常规随访包括记录临床病程和进行详细的内分泌学研究。
SB组和PE组患者及移植物的1年和3年实际生存率无差异。SB组患者中89.3%发生尿路感染（每位患者2.8次），而PE组患者中这一比例为26.3%（每位患者0.25次，p≤0.0001）。与53.6%的SB组患者相比，PE组患者均未出现血尿（p≤0.0001）；然而，有2例PE组患者出现黑变病发作。SB组和PE组尿潴留和反流性胰腺炎的发生率分别为32.1%和5.3%（p≤0.028）。SB组患者需要碳酸氢钠治疗（平均 = 55 mEq/天），而PE组患者均无需常规治疗；尽管如此，SB组患者发生酸中毒的次数更多（44次对5次）。内分泌学研究表明，在整个随访期间，糖化血红蛋白、空腹及刺激后血糖值在两组间无差异。相比之下，SB组患者在空腹和刺激试验中均出现明显的高胰岛素血症，其值始终比PE组高2至5倍。
这些结果表明，PE和SB胰腺移植在患者及移植物生存率方面相当，提示PE方法可降低代谢及膀胱相关并发症的发生率。此外，PE方法消除了SB手术所特有的外周高胰岛素血症状态。需要持续随访以确定PE和SB移植物患者的长期预后是否存在差异。
