Bueno J, Abu-Elmagd K, Mazariegos G, Madariaga J, Fung J, Reyes J
Thomas E. Starzl Transplantation Institute, University of Pittsburgh and Children's Hospital of Pittsburgh, PA 15213, USA.
J Pediatr Surg. 2000 Feb;35(2):291-5; discussion 295-6. doi: 10.1016/s0022-3468(00)90027-7.
BACKGROUND/PURPOSE: Liver and intestinal transplantation is commonly required for children with intestinal failure who suffer concomitant total parenteral nutrition (TPN)-induced liver failure. Retrieval of such composite allografts using previously described "standard techniques" mandates reconstruction of the biliary system with a defunctionalization loop of the proximal allograft jejunum. The occasional posttransplant biliary complications have been associated with significant morbidity and mortality. Also, size matching has limited the pool of donor organs for this patient population. To improve outcome and increase the donor pool the authors have utilized a duodenal-sparing composite liver small bowel allograft technique (DLSBTx) by preserving the head of the pancreas and the pancreatic-duodenal arteries. This precludes a biliary drainage procedure.
Nine children (5 girls, 4 boys), with a mean age of 1.4 years (range, 1 to 17.4 years) received a DLSBTx. In 2 patients the liver was reduced; 1 patient received the whole pancreas. The mean recipient weight at the time of transplantation was 17.4 kg (range, 6.6 to 49.8 kg). The mean age and mean weight for donors was 7.9 years (range, 3 days to 22 years) and 25 kg (range, 4 to 70 kg), respectively. All transplants were performed under tacrolimus and steroid immunosuppression.
With a mean follow-up of 419 days (range, 5 to 795 days), patient and graft survival rates are 78% and 67%, respectively. One patient underwent a combined retransplantation with the standard technique 31 days after the primary allograft was destroyed by a native pancreatic fistula. Currently, all surviving recipients are at home and off TPN. DLSBTx allowed the expansion of the donor pool by transplanting 6 patients with donor to recipient weight ratio > or =1 and utilizing 2 less than 5-kg donors, including a neonatal donor. In 55% of the patients, chemical pancreatitis was observed during the early postoperative period. None of the duodenal allografts experienced signs of ischemia or leak.
The technical advantages of this procedure include avoidance of a biliary reconstruction and simplification of the operative procedure. This, together with the feasibility of split or reduced liver grafting promises to increase the donor pool from neonates to adults.
背景/目的：对于患有肠衰竭并伴有全胃肠外营养（TPN）诱导的肝衰竭的儿童，通常需要进行肝肠移植。使用先前描述的“标准技术”获取此类复合移植物需要用移植的近端空肠的去功能化环重建胆道系统。术后偶尔出现的胆道并发症与显著的发病率和死亡率相关。此外，尺寸匹配限制了该患者群体的供体器官库。为了改善治疗效果并增加供体库，作者采用了保留胰头和胰十二指肠动脉的保留十二指肠的复合肝小肠移植技术（DLSBTx）。这避免了胆道引流手术。
9名儿童（5名女孩，4名男孩）接受了DLSBTx，平均年龄为1.4岁（范围1至17.4岁）。2例患者接受了减体积肝移植；1例患者接受了全胰腺移植。移植时受体的平均体重为17.4 kg（范围6.6至49.8 kg）。供体的平均年龄和平均体重分别为7.9岁（范围3天至22岁）和25 kg（范围4至70 kg）。所有移植均在他克莫司和类固醇免疫抑制下进行。
平均随访419天（范围5至795天），患者和移植物存活率分别为78%和67%。1例患者在原发性移植物被自身胰瘘破坏31天后，采用标准技术进行了联合再次移植。目前，所有存活的受体都已回家且停用TPN。DLSBTx通过移植6例供体与受体体重比≥1的患者并使用2例体重小于5 kg的供体（包括1例新生儿供体），扩大了供体库。55%的患者在术后早期出现化学性胰腺炎。所有十二指肠移植物均未出现缺血或渗漏迹象。
该手术的技术优势包括避免胆道重建和简化手术操作。这与劈裂或减体积肝移植的可行性一起，有望增加从新生儿到成人的供体库。
