Abu-Elmagd K, Todo S, Tzakis A, Reyes J, Nour B, Furukawa H, Fung J J, Demetris A, Starzl T E
Pittsburgh Transplant Institute, University of Pittsburgh Medical Center, PA 15213.
J Am Coll Surg. 1994 Oct;179(4):385-400.
After the successful evolution of hepatic transplantation during the last decade, small bowel and multivisceral transplantation remains the sole elusive achievement for the next era of transplant surgeons. Until recently, and for the last thirty years, the results of the sporadic attempts of intestinal transplantation worldwide were discouraging because of unsatisfactory graft and patient survival. The experimental and clinical demonstration of the superior therapeutic efficacy of FK 506, a new immunosuppressive drug, ushered in the current era of small bowel and multivisceral transplantation with initial promising results.
Forty-three consecutive patients with short bowel syndrome, intestinal insufficiency, or malignant tumors with or without associated liver disease, were given intestinal (n = 15), hepatic and intestinal (n = 21), or multivisceral allografts that contained four or more organs (n = 7). Treatment was with FK 506 based immunosuppression. The ascending and right transverse colon were included with the small intestine in 13 of the 43 grafts, almost evenly distributed between the three groups.
After six to 39 months, 30 of the 43 patients are alive, 29 bearing grafts. The most rapid convalescence and resumption of diet, as well as the highest three month patient survival (100 percent) and graft survival (88 percent) were with the isolated intestinal procedure. However, this advantage was slowly eroded during the first two postoperative years, in part because the isolated intestine was more prone to rejection. By the end of this time, the best survival rate (86 percent) was with the multivisceral procedure. With all three operations, most of the patients were able to resume diet and discontinue parenteral alimentation, and in the best instances, the quality of life approached normal. However, the surveillance and intensity of care required for these patients for the first year, and in most instances thereafter, was very high, being far more than required for patients having transplants of the liver, kidney or heart.
Although intestinal transplantation has gone through the feasibility phase, strategies will be required to increase its practicality. One possibility is to combine intestinal transplantation with contemporaneous autologous bone marrow transplantation.
在过去十年肝脏移植成功发展之后，小肠和多脏器移植仍是移植外科医生在下一个时代唯一难以实现的目标。直到最近，在过去三十年里，全球范围内零星的小肠移植尝试结果令人沮丧，因为移植物和患者存活率都不尽人意。一种新型免疫抑制药物FK 506卓越治疗效果的实验和临床证明，开启了当前小肠和多脏器移植时代，并取得了初步的喜人成果。
连续43例患有短肠综合征、肠道功能不全或伴有或不伴有相关肝脏疾病的恶性肿瘤患者，接受了肠移植（n = 15）、肝肠联合移植（n = 21）或包含四个或更多器官的多脏器同种异体移植（n = 7）。治疗采用基于FK 506的免疫抑制方案。43例移植物中有13例将升结肠和右横结肠与小肠一起移植，几乎均匀分布在三组之间。
6至39个月后，43例患者中有30例存活，29例带有移植物。单纯肠移植术后恢复最快，饮食恢复也最快，三个月时患者存活率最高（100%），移植物存活率也最高（88%）。然而，这种优势在术后头两年逐渐消失，部分原因是单纯肠移植更容易发生排斥反应。到这个阶段结束时，多脏器移植的存活率最高（86%）。三种手术方式下，大多数患者都能够恢复饮食并停止肠外营养，在最佳情况下，生活质量接近正常。然而，这些患者在第一年以及此后的大多数情况下所需的监测和护理强度非常高，远远超过肝、肾或心脏移植患者的需求。
尽管小肠移植已度过可行性阶段，但仍需要采取策略来提高其实用性。一种可能的方法是将小肠移植与同期自体骨髓移植相结合。
