會田 直弘

膵移植は1型糖尿病の唯一の現時点で確立された根治療法である。本稿では膵移植手術に関して、術式の分類、摘出から移植までの手技、そして最近の術式のUp-to-Dateを紹介する。膵移植の分類として腎移植との関係から膵腎同時移植(simultaneous pancreas and kidney transplantation:SPK)、腎移植後膵臓移植(pancreas after kidney transplantation:PAK)、膵単独移植(pancreas transplantation alone:PTA)の三つに分類される。また膵液ドレナージの方法から腸管ドレナージと膀胱ドレナージの二つに分類される。摘出手技は肝グラフトとの血管のシェアリングがポイントとなる。一方、移植手技は血栓症の予防が最大の課題であり、静脈吻合部狭窄とならないように細心の注意を要する。最近の術式のUp-to-Dateとして、GDA-CHA I-graft再建の必要性、portal drainageの是非、robotic pancreas transplantationなどについて解説する。(著者抄録)

<p>The aim of the present study was to reveal the long-term outcomes of pancreas transplantation and to elucidate the risk factors that affect pancreatic graft survival in Japan.<br/>We retrospectively analyzed a total of 246 cases of pancreas transplantation. After the exclusion of cases involving graft loss resulting from perioperative complications, the cases of 233 patients who underwent pancreas transplantation were divided into two groups: the simultaneous pancreas and kidney transplantation (SPK) group (n=188) and the pancreas transplantation after kidney and pancreas transplantation alone (PT) group (n=45) ; each group was analyzed to determine the factors associated with pancreatic graft survival.<br/>The pancreatic graft survival rates at 1, 5, and 10 years after transplantation were 86.8%, 82.9%, and 74.9%, respectively, in the cases of SPK; and 85.1%, 42.2%, and 31.7%, respectively, in the cases of pancreas transplantation after kidney and pancreas transplantation alone, which amounted to a significant difference （P=4.81×10^‐5）. Episodes of rejection made pancreatic survival significantly lower in both groups. A multivariate analysis using Cox proportional hazards regression revealed that the preoperative period of diabetes （hazard ratio, 1.065; 95%CI, 1.009-1.125; P=0.02341） was significantly associated with pancreatic graft survival in the SPK group. HLA-A mismatch （hazard ratio, 2.153; 95%CI, 1.073-4.321; P= 0.03101） was the only factor associated with pancreatic graft survival in the PT group. Although the difference did not reach statistical significance, it was suggested that induction therapy with a T-cell depleting antibody would improve the rate of pancreatic graft survival in both groups.<br/>In spite of the severe shortage of donors in Japan, simultaneous pancreas and kidney transplantation should be performed for type 1 diabetes patients with end-stage renal failure in the earlier stage, and HLA-A matching should be considered when selecting recipients to improve the rate of pancreatic graft survival in the PT group.</p>