Starzl T E, Todo S, Tzakis A, Alessiani M, Casavilla A, Abu-Elmagd K, Fung J J
Department of Surgery, University of Pittsburgh, Pennsylvania 15213.
Surg Gynecol Obstet. 1991 May;172(5):335-44.
The transplantation of multiple abdominal viscera, including liver-duodenum-pancreas, liver-stomach-duodenum-pancreas and liver-intestine, is being performed with increasing frequency and success. These procedures and other variations are derived from a seldom used multivisceral operation in which all of the foregoing organs are transplanted en bloc. It is described herein how the full multivisceral transplantation and its less extensive derivatives are based on the same principles of procurement, preservation and postoperative management. With all of these multiple organ permutations and with intestinal transplantation alone, management is complicated by inclusion in the grafts of a large lymphoreticular component that is capable of causing graft versus host disease (GVHD). Because of a systematic error in therapeutic philosophy, past efforts have been directed at altering or damaging the lymphoreticular cells by pretreatment of the donor or of the organs with drugs, irradiation or other means. From recent observations, the alternative approach is suggested of keeping these lymphoid depots intact, which then become the site of two way cell traffic after transplantation. With the use of powerful immunosuppression, such as that provided with FK 506, the donor lymphoreticular cells can circulate in the recipient without causing clinical GVHD, and the lymphoreticular cells in the graft become those of the recipient (local chimerism) without causing rejection. Even with avoidance of rejection and GVHD, metabolic interrelations between the grafted organs, and also between the graft organs and retained recipient viscera can affect the fate of the individual transplanted organs or retained recipient organs. The best delineated of these metabolic influences are mediated by the endogenous splanchnic hepatotrophic factors, of which insulin has been the most completely studied. An understanding of these various immunologic and nonimmunologic factors combined with more potent immunosuppression that is now available is sure to stimulate efforts at transplantation of abdominal organs and particularly of the hollow viscera that have resisted such clinical efforts.
包括肝 - 十二指肠 - 胰腺、肝 - 胃 - 十二指肠 - 胰腺和肝 - 肠在内的多种腹部脏器移植，正在越来越频繁地开展且成功率不断提高。这些手术及其他变体源自一种很少使用的多脏器手术，即上述所有器官整块移植。本文描述了全多脏器移植及其范围较小的衍生手术如何基于相同的获取、保存及术后管理原则。对于所有这些多器官组合以及单独的肠道移植，由于移植物中包含大量能够引发移植物抗宿主病（GVHD）的淋巴网状成分，管理变得复杂。由于治疗理念上的系统性错误，过去的努力一直致力于通过药物、辐射或其他手段对供体或器官进行预处理，以改变或损伤淋巴网状细胞。从最近的观察结果来看，建议采用另一种方法，即保持这些淋巴库完整，这样在移植后它们就成为双向细胞流通的场所。通过使用强效免疫抑制，如FK 506所提供的免疫抑制，供体淋巴网状细胞可以在受体中循环而不引起临床GVHD，并且移植物中的淋巴网状细胞会变成受体的细胞（局部嵌合）而不引起排斥反应。即使避免了排斥反应和GVHD，移植器官之间以及移植器官与保留的受体脏器之间代谢的相互关系仍可能影响单个移植器官或保留的受体器官的命运。这些代谢影响中最明确的是由内源性内脏肝营养因子介导的，其中胰岛素是研究最为全面的。对这些各种免疫和非免疫因素的理解，再加上现有的更强效免疫抑制，肯定会刺激腹部器官移植的努力，特别是对那些此前临床尝试中难以成功移植的中空脏器的移植努力。
