Gruessner R W, Sutherland D E, Troppmann C, Benedetti E, Hakim N, Dunn D L, Gruessner A C
Department of Surgery, University of Minnesota, Minneapolis 55455, USA.
J Am Coll Surg. 1997 Aug;185(2):128-44. doi: 10.1016/s1072-7515(01)00895-x.
Pancreas transplants are still associated with the highest surgical complication rate of all routinely performed solid organ transplants. To date, the impact of serious surgical complications in the cyclosporine era on perioperative patient morbidity, graft and patient survival, and hospital costs has not been analyzed in detail.
We retrospectively studied surgical complications after 445 consecutive pancreas transplants (45% simultaneous pancreas-kidney [SPK], 24% pancreas after kidney [PAK], and 31% pancreas transplant alone [PTA]). Of these, 80% were primary transplants, 20% were retransplants. Cadaver donors were used in 92%, living related donors in 8%. To develop guidelines for their prevention and management, we studied the impact of significant surgical complications (intra-abdominal infections, vascular graft thrombosis, and anastomotic leak) requiring relaparotomy on graft and patient survival.
Relaparotomy was required after 32% of all pancreas transplants (SPK: 36%, PAK: 25%, PTA: 16% [p = 0.04]). Perioperative mortality was 9%. Graft and patient survival rates were significantly lower for recipients with (versus without) relaparotomy. The most common procedures were drainage of intra-abdominal abscess with graft necrosectomy (50% of all relaparotomies) and transplant pancreatectomy (34%). The most common causes of relaparotomy were intra-abdominal infection, vascular graft thrombosis, and anastomotic leak. Intra-abdominal infection occurred in 20% (SPK: 18%, PAK: 24%, PTA: 20% [p = NS]). The rate was significantly higher for living related donor (42%) versus cadaver donor (18%) recipients and for those with enteric-drained (39%) versus bladder-drained (18%) transplants. Graft and patient survival rates were significantly lower for recipients with (versus without) intra-abdominal infection. Outcome was better after bacterial (versus fungal) infections. For SPK recipients, those not on dialysis before the transplant had significantly higher graft survival than those on dialysis. Vascular graft thrombosis occurred in 12% of all recipients. The rate was significantly higher for PAK (21%) than for PTA (10%) and SPK (9%) recipients. It was significantly lower for recipients of grafts with donor iliac Y-graft reconstruction (versus all other types of arterial reconstruction) and with right-sided (versus left-sided) graft placement. Of note, patient survival was not different for recipients with versus without vascular graft thrombosis. The incidence of anastomotic or duodenal stump leaks was 10%; of these recipients, 70% required relaparotomy. Patient and graft survival rates were no different for recipients with versus without leaks.
Serious surgical complications occurred in 35% of pancreas recipients and had a significant impact on patient and graft survival. Based on multivariate risk factor analyses, we recommend the following: donors over 45 years and those dying of cerebrocardiovascular disease should not be used; recipients over 45 years and those with a history of cardiac disease should be considered for a kidney transplant alone (KTA); surgical technique for graft procurement, preparation, and implantation should be meticulous; right-sided implantation and arterial Y-graft reconstruction should be performed when possible, since they had the highest success rates; when complications require relaparotomy, the focus must switch from graft salvage to life preservation; and the threshold for pancreatectomy should be low. Diagnosis should be timely, and treatment and relaparotomy expeditious. These cornerstones of success should help decrease the risk of surgical complications and mortality after pancreas transplants.
胰腺移植仍是所有常规实施的实体器官移植中手术并发症发生率最高的。迄今为止，在环孢素时代，严重手术并发症对围手术期患者发病率、移植物和患者生存率以及医院成本的影响尚未得到详细分析。
我们回顾性研究了连续445例胰腺移植后的手术并发症（45%为胰肾联合移植[SPK]，24%为肾后胰腺移植[PAK]，31%为单纯胰腺移植[PTA]）。其中，80%为初次移植，20%为再次移植。92%使用尸体供体，8%使用活体亲属供体。为制定预防和管理指南，我们研究了需要再次剖腹手术的重大手术并发症（腹腔内感染、血管移植物血栓形成和吻合口漏）对移植物和患者生存率的影响。
所有胰腺移植中有32%需要再次剖腹手术（SPK：36%，PAK：25%，PTA：16%[p = 0.04]）。围手术期死亡率为9%。接受再次剖腹手术的受者的移植物和患者生存率显著低于未接受再次剖腹手术的受者。最常见的手术是腹腔内脓肿引流并切除坏死移植物（占所有再次剖腹手术的50%）和移植胰腺切除术（34%）。再次剖腹手术最常见的原因是腹腔内感染、血管移植物血栓形成和吻合口漏。腹腔内感染发生率为20%（SPK：18%，PAK：24%，PTA：20%[p = 无显著性差异]）。活体亲属供体受者（42%）的发生率显著高于尸体供体受者（18%），肠内引流移植受者（39%）的发生率显著高于膀胱引流移植受者（18%）。有（对比无）腹腔内感染的受者的移植物和患者生存率显著较低。细菌感染（对比真菌感染）后的结局更好。对于SPK受者，移植前未接受透析的受者的移植物生存率显著高于接受透析的受者。所有受者中有12%发生血管移植物血栓形成。PAK受者（21%）的发生率显著高于PTA受者（10%）和SPK受者（9%）。采用供体髂Y形移植物重建的移植物受者（对比所有其他类型的动脉重建）以及右侧（对比左侧）移植物植入的受者的发生率显著较低。值得注意的是，有（对比无）血管移植物血栓形成的受者的患者生存率没有差异。吻合口或十二指肠残端漏的发生率为10%；这些受者中，70%需要再次剖腹手术。有（对比无）漏的受者的患者和移植物生存率没有差异。
35%的胰腺移植受者发生了严重手术并发症，对患者和移植物生存率有显著影响。基于多变量危险因素分析，我们建议如下：不应使用45岁以上的供体以及死于心血管疾病的供体；45岁以上且有心脏病史的受者应考虑单纯肾移植（KTA）；移植物获取、准备和植入的手术技术应精细；应尽可能进行右侧植入和动脉Y形移植物重建，因为它们的成功率最高；当并发症需要再次剖腹手术时，重点必须从挽救移植物转向保全生命；胰腺切除术的阈值应较低。诊断应及时，治疗和再次剖腹手术应迅速。这些成功的基石应有助于降低胰腺移植后手术并发症和死亡率的风险。
