Laftavi M R, Gruessner A C, Bland B J, Foshager M, Walsh J W, Sutherland D E, Gruessner R W
Department of Surgery, University of Minnesota, Minneapolis 55455, USA.
Transplantation. 1998 Feb 27;65(4):528-32. doi: 10.1097/00007890-199802270-00013.
The most common cause of graft failure after technically successful pancreas transplants is rejection. Laboratory parameters for detecting pancreas graft rejection are not consistently reliable and can lead to unnecessary antirejection treatment. Histopathologic evaluation is the gold standard in the differential diagnosis of pancreas graft dysfunction. Four biopsy techniques have been described: cystoscopic transduodenal (CB), percutaneous computed tomography scan-guided (PB), open, and laparoscopic biopsy.
We studied the two most common techniques, CB and PB, in pancreas transplant recipients with presumed rejection. Group 1 comprised 103 attempts at CB in 82 recipients (53 men, 29 women) with bladder-drained (BD) pancreas transplants, at 1 to 80 (median, 14) months after transplant. Group 2 comprised 93 attempts at PB in 68 recipients (41 men, 27 women), at 0.5 to 64 (median, 14) months after transplant.
In group 1, of 103 attempts at CB, adequate tissue was obtained in 90 (87%): pancreas alone in 23 (22%), pancreas + duodenum in 35 (34%), duodenum alone in 32 (31%). Of the 58 pancreas biopsies, 23 (40%) showed acute rejection. Of the 67 duodenal biopsies, 16 (24%) showed acute rejection. Complications of CB included macrohematuria in 4 recipients (4%) and microhematuria in 32 (31%). We noted no biopsy-related pancreatitis. The mean cost of CB was $2561+/-246. In group 2, of 93 attempts at PB, adequate tissue (all pancreas) was obtained in 67 (72%); of these, 29 (43%) showed acute rejection. Of 23 inaccessible pancreases, 9 (39%) underwent CB; pancreatic tissue was obtained in four (45%), and results were consistent with rejection in all four. Complications of PB included biopsy-related pancreatitis (serum amylase > or = 25%) in five (7%) recipients, macrohematuria in one (1%), and abdominal hemorrhage in two (3%). The mean cost of PB was $1038+/-78. (1) CB and PB prevented unnecessary antirejection treatment in 44% of our recipients with successful biopsies; (2) CB had a higher success rate for obtaining tissue (including duodenal specimens) and a lower rate of major complications; (3) PB was easier and cheaper, did not require general anesthesia, and was performed as an outpatient procedure.
We conclude that PB should become the biopsy technique of choice in recipients with presumed pancreas graft rejection. If PB fails, recipients with bladder-drained pancreas transplants should undergo CB. If CB fails, or in recipients with enteric-drained or duct-injected pancreas transplants, a laparoscopic or open biopsy should be considered.
在技术上成功的胰腺移植后，移植失败的最常见原因是排斥反应。用于检测胰腺移植排斥反应的实验室参数并非始终可靠，可能导致不必要的抗排斥治疗。组织病理学评估是胰腺移植功能障碍鉴别诊断的金标准。已描述了四种活检技术：膀胱镜经十二指肠活检（CB）、经皮计算机断层扫描引导活检（PB）、开放活检和腹腔镜活检。
我们研究了胰腺移植受者中两种最常用的技术，即CB和PB，这些受者被推测发生了排斥反应。第1组包括对82例膀胱引流（BD）胰腺移植受者（53例男性，29例女性）进行的103次CB尝试，时间为移植后1至80个月（中位数为14个月）。第2组包括对68例受者（41例男性，27例女性）进行的93次PB尝试，时间为移植后0.5至64个月（中位数为14个月）。
在第1组中，103次CB尝试中有90次（87%）获得了足够的组织：仅胰腺组织23例（22%），胰腺+十二指肠组织35例（34%），仅十二指肠组织32例（31%）。在58例胰腺活检中，23例（40%）显示急性排斥反应。在67例十二指肠活检中，16例（24%）显示急性排斥反应。CB的并发症包括4例受者（4%）出现肉眼血尿，32例（31%）出现镜下血尿。我们未发现与活检相关的胰腺炎。CB的平均费用为2561美元±246美元。在第2组中，93次PB尝试中有67次（72%）获得了足够的组织（均为胰腺组织）；其中，29例（43%）显示急性排斥反应。在23例无法获取胰腺组织的受者中，9例（39%）接受了CB；4例（45%）获得了胰腺组织，且所有4例的结果均与排斥反应一致。PB的并发症包括5例（7%）受者出现与活检相关的胰腺炎（血清淀粉酶≥25%），1例（1%）出现肉眼血尿，2例（3%）出现腹腔内出血。PB的平均费用为1038美元±78美元。（1）CB和PB在44%活检成功的受者中避免了不必要的抗排斥治疗；（2）CB获取组织（包括十二指肠标本）的成功率更高，主要并发症发生率更低；（3）PB更简便、更便宜，无需全身麻醉，可作为门诊手术进行。
我们得出结论，对于推测发生胰腺移植排斥反应的受者，PB应成为首选的活检技术。如果PB失败，膀胱引流胰腺移植受者应接受CB。如果CB失败，或对于肠道引流或导管注入式胰腺移植受者，应考虑进行腹腔镜或开放活检。
