Pirenne Jacques, Kawai Masaru
Abdominal Transplant Surgery, University Hospitals Leuven, Herestraat 49, Leuven B-3000, Belgium.
Curr Opin Organ Transplant. 2009 Jun;14(3):250-5. doi: 10.1097/MOT.0b013e32832b2eb7.
Intestinal transplantation is a treatment for patients with short bowel syndrome and associated severe complications. The intestine has long been seen as a 'forbidden' organ to transplant. This fact is because the first attempts at intestinal transplantation were rapidly defeated by rejection and sepsis.
Several factors have contributed to improve the results: tacrolimus-based immunosuppression, induction therapy (independent of the type), introduction of ganciclovir and rituximab and subsequent better control of cytomegalovirus and posttransplant lymphoma, better differential diagnosis between rejection versus infection and ischemia (avoiding unnecessary overimmunosuppression), better patient follow-up. Center experience is more important than a particular immunosuppressive protocol. M-TOR inhibitors, infliximab have been used. Mycophenolate mofetil is less frequently used because of its potential gastrointestinal toxicity. Of note, no significant improvement in short-term and long-term (>1 year) survival was observed since 2000 and 1985, respectively.
Intestinal transplantation remains a formidable clinical/immunological challenge. With newer immunosuppression and accumulated experience, intestinal transplantation results have improved and the procedure represents a life-saving option in patients with short bowel syndrome-related complications. Before intestinal transplantation becomes a 'quality of life-improving' procedure (offered to patients who are free of short bowel syndrome-related complications), new strategies focusing on facilitating graft acceptance and reducing the need for immunosuppression will have to be developed.
肠道移植是治疗短肠综合征及相关严重并发症患者的一种方法。长期以来,肠道一直被视为移植的“禁区”。这是因为早期的肠道移植尝试很快就因排斥反应和败血症而失败。
有几个因素促使结果得到改善:以他克莫司为基础的免疫抑制、诱导治疗(与类型无关)、更昔洛韦和利妥昔单抗的应用以及随后对巨细胞病毒和移植后淋巴瘤的更好控制、对排斥反应与感染及缺血之间更好的鉴别诊断(避免不必要的过度免疫抑制)、更好的患者随访。中心经验比特定的免疫抑制方案更重要。已使用m-TOR抑制剂、英夫利昔单抗。由于其潜在的胃肠道毒性,霉酚酸酯的使用频率较低。值得注意的是,自2000年和1985年以来,短期和长期(>1年)生存率均未观察到显著改善。
肠道移植仍然是一项艰巨的临床/免疫学挑战。随着更新的免疫抑制方法和积累的经验,肠道移植的结果有所改善,该手术是治疗短肠综合征相关并发症患者的一种挽救生命的选择。在肠道移植成为一种“改善生活质量”的手术(提供给没有短肠综合征相关并发症的患者)之前,必须制定新的策略,以促进移植物的接受并减少免疫抑制的需求。