The many faces of multivisceral transplantation.
The many faces of multivisceral transplantation.
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发表时间：
1991-05
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通讯作者：
T. Starzl;S. Todo;A. Tzakis;M. Alessiani;A. Casavilla;K. Abu-Elmagd;J. Fung
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作者：
T. Starzl;S. Todo;A. Tzakis;M. Alessiani;A. Casavilla;K. Abu-Elmagd;J. Fung
肝-十二指肠-胰腺、肝-胃-十二指肠-胰腺、肝-肠等腹部多脏器的移植越来越多，成功率也越来越高。这些程序和其他变化源于很少使用的多内脏手术，其中所有上述器官全部移植。本文描述了完整的多脏器移植及其不太广泛的衍生品如何基于相同的获取、保存和术后管理原则。对于所有这些多器官排列和单独的肠道移植，由于移植物中包含能够引起移植物抗宿主病（GVHD）的大淋巴网状成分，治疗变得复杂。由于治疗理念的系统性错误，过去的努力一直是通过药物、照射或其他手段对供体或器官进行预处理来改变或破坏淋巴网状细胞。根据最近的观察，建议的替代方法是保持这些淋巴库完整，然后在移植后成为双向细胞运输的场所。使用强大的免疫抑制，如FK 506，供体淋巴网状细胞可以在受体体内循环而不引起临床GVHD，移植物中的淋巴网状细胞变成受体的淋巴网状细胞（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的代谢相互关系也会影响单个移植器官或保留的受体器官的命运。这些代谢影响的最佳描述是由内源性内脏肝营养因子介导的，其中胰岛素已被研究得最彻底。对这些不同的免疫和非免疫因素的理解，加上现在可用的更有效的免疫抑制，肯定会刺激腹部器官移植的努力，特别是空心内脏的移植，这些移植一直抵制这种临床努力。
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.