Fishbein Thomas M, Matsumoto Cal S
Small Bowel & Pediatric Liver Transplantation, Georgetown University Hospital, Washington, DC 20007, USA.
Gastroenterology. 2006 Feb;130(2 Suppl 1):S147-51. doi: 10.1053/j.gastro.2005.12.004.
Current treatment options for patients suffering from intestinal insufficiency include all forms of intestinal replacement therapy (IRT). Parenteral nutrition has achieved extended success for the majority of patients requiring interval treatment, however, complications leading to failure of this treatment increases with the duration of therapy. There is currently no consensus as to the appropriate timing for transplantation of the intestine or the timing of referral for evaluation at a center experienced with this therapy. Certain patient characteristics warrant evaluation. Those patients with no jejunoileum who have guaranteed lifelong parenteral dependence, both adult and pediatric, should be immediately referred to a transplant center due to the high likelihood of the development of liver disease. Patients with metastatic infectious complications from catheter sepsis, patients with cholestasis seen intermittently with sepsis episodes, patients who are not successfully weaning and who demonstrate progressive thrombocytopenia, and patients with motility disorder experiencing deterioration should also warrant early referral to an intestinal rehabilitation and transplant program. The objective of evaluation is to maximize the opportunities for rehabilitation while not missing the critical window of opportunity for successful transplantation when needed. We favor an aggressive directed approach to rehabilitation, coupled with psychological preparation for both transplantations and other options. Early referral requires trust between the patient, referring physician, and the transplant team to assure that a rush to judgment will not lead to a premature transplant. The current wait list mortality is high, mandating early referral and listing with an approach aimed at maximizing both the success of gastrointestinal support, as well as of transplantation when necessary.
对于患有肠道功能不全的患者，目前的治疗选择包括各种形式的肠道替代疗法（IRT）。肠外营养已在大多数需要间歇性治疗的患者中取得了广泛成功，然而，随着治疗时间的延长，导致这种治疗失败的并发症会增加。目前对于肠道移植的合适时机或在有该疗法经验的中心进行评估的转诊时机尚无共识。某些患者特征值得评估。那些没有空肠回肠且保证终身依赖肠外营养的患者，无论成人还是儿童，由于发生肝病的可能性很高，应立即转诊至移植中心。患有导管败血症转移性感染并发症的患者、间歇性出现败血症发作伴胆汁淤积的患者、无法成功撤机且出现进行性血小板减少的患者，以及患有运动障碍且病情恶化的患者，也应尽早转诊至肠道康复和移植项目。评估的目的是在不错过必要时成功移植的关键时机的同时，最大限度地增加康复机会。我们倾向于积极的定向康复方法，同时为移植和其他选择做好心理准备。早期转诊需要患者、转诊医生和移植团队之间的信任，以确保匆忙判断不会导致过早移植。目前等待名单上的死亡率很高，这就要求尽早转诊并登记，采取旨在最大限度提高胃肠支持成功率以及必要时移植成功率的方法。
