Troppmann C, Gruessner A C, Dunn D L, Sutherland D E, Gruessner R W
Department of Surgery, University of Minnesota, Minneapolis 55455, USA.
Ann Surg. 1998 Feb;227(2):255-68. doi: 10.1097/00000658-199802000-00016.
To study significant surgical complications requiring early (< or = 3 months posttransplant) relaparotomy (relap) after pancreas transplants, and to develop clinically relevant surgical and peritransplant decision-making guidelines for preventing and managing such complications.
Pancreas grafts are still associated with the highest surgical complication rate of all routinely transplanted solid organs. However, the impact of surgical complications on morbidity, hospital costs, and graft and patient survival rates has not been analyzed in detail to date.
We retrospectively studied surgical complications requiring relap in 441 consecutive cadaver, bladder-drained pancreas transplants (54% simultaneous pancreas and kidney [SPK]; 22% pancreas after kidney [PAK]; 24% pancreas transplant alone [PTA]; 37% retransplant). Outcome and hospital charges were analyzed separately for recipients with versus without reoperation.
The overall relap rate was 32% (SPK, 36%; PAK, 25%; PTA, 16%; p = 0.04). The most common causes were intraabdominal infection and graft pancreatitis (38%), pancreas graft thrombosis (27%), and anastomotic leak (15%). Perioperative relap mortality was 9%; transplant pancreatectomy was necessary in 57% of all recipients with one or more relaps. The pancreas graft was lost in 80% of recipients with versus 41% without relap (p < 0.0001). Patient survival rates were significantly lower (p < 0.05) for recipients with versus without relap. By multivariate analysis, significant risk factors for graft loss included older donor age (SPK, PAK), retransplant (PAK), relap for infection (SPK, PAK), and relap for leak or bleeding (PAK). For death, risk factors included older recipient age (SPK, PAK),retransplant (SPK, PAK), relap for thrombosis (PAK), relap for infection or leak (SPK), and relap for bleeding (PTA).
Posttransplant surgical complications requiring relap were frequent, resulted in a high rate of pancreas (SPK, PAK, PTA) and kidney (SPK, PAK) graft loss, and had a major economic impact (p = 0.0001). Complications were associated with substantial perioperative mortality and decreased patient survival rates. The focus must therefore shift from graft salvage to preservation of the recipient's life once a pancreas graft-related complication requiring relap occurs. Thus, the threshold for pancreatectomy should be low. In this context, acceptance of older donors and recipients must be reconsidered.
研究胰腺移植后需要早期（移植后≤3个月）再次剖腹手术（再次手术）的严重手术并发症，并制定具有临床相关性的手术及移植围手术期决策指南，以预防和处理此类并发症。
胰腺移植物仍是所有常规移植实体器官中手术并发症发生率最高的。然而，迄今为止，手术并发症对发病率、医院费用以及移植物和患者生存率的影响尚未得到详细分析。
我们回顾性研究了441例连续的尸体供体膀胱引流式胰腺移植中需要再次手术的手术并发症（54%为胰肾联合移植[SPK]；22%为肾移植后胰腺移植[PAK]；24%为单纯胰腺移植[PTA]；37%为再次移植）。分别分析了再次手术和未再次手术受者的结局及住院费用。
总体再次手术率为32%（SPK为36%；PAK为25%；PTA为16%；p = 0.04）。最常见的原因是腹腔内感染和移植胰腺胰腺炎（38%）、胰腺移植物血栓形成（27%）以及吻合口漏（15%）。围手术期再次手术死亡率为9%；在所有有一次或多次再次手术的受者中，57%需要进行移植胰腺切除术。有再次手术的受者中80%的胰腺移植物丢失，而未再次手术的受者中这一比例为41%（p < 0.0001）。有再次手术的受者的患者生存率显著低于未再次手术的受者（p < 0.05）。多因素分析显示，移植物丢失的显著危险因素包括供体年龄较大（SPK、PAK）、再次移植（PAK）、因感染进行再次手术（SPK、PAK）以及因漏血进行再次手术（PAK）。对于死亡，危险因素包括受者年龄较大（SPK）、再次移植（SPK、PAK）、因血栓形成进行再次手术（PAK）、因感染或漏进行再次手术（SPK）以及因出血进行再次手术（PTA）。
移植后需要再次手术的手术并发症很常见，导致胰腺（SPK、PAK、PTA）和肾脏（SPK、PAK）移植物丢失率很高，并产生重大经济影响（p = 0.0001）。并发症与围手术期高死亡率及患者生存率降低相关。因此，一旦发生需要再次手术的胰腺移植物相关并发症，重点必须从挽救移植物转向挽救受者生命。所以，胰腺切除术的阈值应较低。在此背景下,必须重新考虑对老年供体和受者的接受问题。
