小肠移植术后内镜引导下移植肠黏膜活检的时机及诊断价值  

Timing and diagnostic value of endoscopic biopsy of intestinal graft after small bowel transplantation

作　　者：李元新[1] 李宁[1] 李幼生[1] 汪志明[1] 吴波[2] 倪小冬[1] 王剑[1] 黎介寿[1] 

机构地区：[1]南京军区南京总医院普通外科研究所,210002 [2]南京军区南京总医院病理科,210002

出　　处：《中华器官移植杂志》2010年第10期584-588,共5页Chinese Journal of Organ Transplantation

基　　金：基金项目：国家科技支撑计划（2008BA160806）

摘　　要：目的 总结小肠移植术后内镜引导下移植肠黏膜活检的时机及该技术对急性排斥反应和感染的诊断价值.方法 根据免疫抑制方案的不同,将15例小肠移植受者分为3个阶段.1994-1995年为第1阶段（3例）,2003-2006年为第2阶段（7例）,2007年以后为第3阶段（5例）.第3阶段进行计划性内镜引导下移植肠黏膜活检的监测,既术后第3天进行首次内镜引导下移植肠黏膜活检,此后活检的频次在术后第1个月为2次/周,术后第2～3个月为1次/周,术后第4～6个月为1次/2周,术后7个月以后为1次/月,在受者出现排斥反应的临床症状和抗排斥反应治疗期间,也进行内镜引导下移植肠黏膜活检.结果 15例共进行内镜引导下移植肠黏膜活检255次,移植肠腹壁造口肉眼直视下取材活检21次.以上276份样本中,诊断排斥反应共51份（18.5%）,其中诊断不确定急性排斥反应至轻度排斥反应32份（11.6%）、中度排斥反应9份（3.3%）、重度排斥反应10份（3.6%）,巨细胞病毒（CMV）感染2份（0.7%）,细菌感染2份（0.7%）.15例共发生病理证实并需l临床治疗的排斥反应20次,其中不确定急性排斥反应至轻度排斥反应11次、中度5次、重度4次,发生细菌性和CMV肠炎各1次.结论 内镜引导下移植肠黏膜活检及其病理学检查是小肠移植术后诊断排斥反应和感染的重要手段,有计划的进行该检查对排斥反应有术后监测、早期诊断、鉴别诊断和指导治疗的价值.Objective To summarize the timing and diagnostic value of endoscopic biopsy of intestinal graft after small bowel transplantation （SBTx）.Methods Fifteen cases of SBTx were divided into 3 eras：era Ⅰ （1994-1995）-3 cases of SBTx treated with cyclosporine-based immunosuppression; era Ⅱ （2003-2006）-7 cases of SBTx treated with tacrolimus-based immunosuppression,and era Ⅲ （2007-present） than CVC group 5 cases of SBTx treated with Atemtuzumab induction therapy and maintenance tacrolimus monotherapy.The scheme of endoscopic surveillance was initially used in era Ⅲ, the first endoscopic biopsy was performed on postoperative day 3,2 times weekly during the first month, followed once weekly during months 2-3, once every other week during months 4-6 and once monthly thereafter.When clinical signs and symptoms of rejection were present, and during rejection episodes, the additional endoscopic biopsies were also performed.Results A total of 276 biopsies of these 15 SBTx recipients were obtained.Fifty-one biopsies （18.5%） were diagnosed as acute cellular rejection （ACR）, which included IND to mild （n = 32,11.6 %）, moderate （n = 9,3.3 %）, and severe （n = 1 0, 3.6 %）, two biopsies （0.7 %） were diagnosed as cytomegalovirus （CMV） enteritis and other 2 biopsies （0.7 %） bacteria enteritis.The ACR episodes verified by biopsy pathology and undergoing anti-rejection treatment were 20 （11 IND to mild,5 moderate,and 4 severe） ,and 1 episode of CMV enteritis and 1 episode of bacteria enteritis were observed.Conclusion Endoscopic surveillance and biopsy pathology is crucial diagnostic tool for ACR and sepsis.ACR surveillance after SBTx and early diagnosis of ACR could be made with scheming endoscopic biopsies.Endoscopic biopsy can be used to make differential diagnosis when clinical signs and symptoms were present, and to guide the treatment during anti-rejection episode.

关 键 词：小肠移植 排斥反应 活检 内镜监测 

分 类 号：R686[医药卫生—骨科学]