临床同种活体部分小肠移植：附1例报告

目的：探讨临床同种活体小肠移植治疗短肠综合征的效果。方法：对1例因小肠扭转而切除大部分小肠和右半结肠，残留小肠仅20cm的超短肠综合征男性患者，行亲属活体同种部分小肠移植。供体为患者之母。受体术前行供体特异性输血，50mL/周，共8周。供受体巨细胞病毒感染状态均为阴性。移植肠长约160cm。移植肠的回结肠动静脉分别与受体肾下腹主动脉和下腔静脉端侧吻合，移植肠末端造口。术后给予抗排斥、抗感染、抗凝及营养支持治疗。结果：供体术后恢复顺利，无并发症。受体已健康存活31周，无感染和排斥反应。术后8周脱离肠外营养治疗，口服低脂饮食，D－木糖吸收试验结果接近正常。结论：同种活体部分小肠移植是治疗短肠综合征的有效措施。     

亲体小肠移植血管重建与二期肠吻合手术方式探讨

目的 探讨亲体小肠移植的手术技术和方式。方法 对1例短肠综合征患者分两期实施亲体小肠移植手术，一期手术采用患者母亲120cm回肠作为供体，动脉与受体乙状结肠动脉吻合、静脉与肠系膜下静脉属支吻合、移植肠襻两端腹壁造口；二期手术于首次术后188d将受体残留小肠横断，分别与移植肠襻的近、远端作端一侧吻合，保留原腹壁造瘘口。结果 两期手术顺利，先后发生的急性排斥反应和巨细胞病毒感染均得到有效控制，未发生消化道漏。受体已生存213d，二期手术后25d，体重增加4．5kg，进半流质饮食，生活能自理。结论 术前完善的检查和处理，术前设计多套方案对手术中的应变非常重要；采用门静脉回流方式是较为理想的术式；对移植肠襻采用二期吻合的方式降低了肠瘘的发生率。     

活体部分小肠移植一例报告

目的 对临床活体部分小肠移植进行总结。方法 为1例患超短肠综合的18岁男必患者施行父亲供肠的活体部分小肠移植术,移植肠段为150cm长之回肠,以UW液灌洗。移植肠动、静脉分别与受者的腹主动脉及下腔静脉端侧吻合,移植肠近端与受者的空肠近端行端端吻合,远端与受者的空肠远端行侧端吻合,末端造口。术后给予抗排斥、抗感染、抗凝及营养支持等治疗。结果 术后曾出现贫血、单纯疱疹病毒感染和 急性排斥反应,经积极处理行到控制目前患者已健康存活14月余。结论 活体部分小肠移植是治疗短肠综合征的一理想方法。     

血缘性活体部分小肠移植术二例

目的 探讨血缘性活性小肠移植治疗短肠综合征的效果。方法 对2例短肠综合征患者切取有血缘关系的供肠行部分小肠移植术,1例18岁,男性,供体为患者的父亲,供肠150cm。另1例15岁,男性供体为患者的母亲,供肠160cm。移植肠动、静脉分别与受者的腹主动脉及下腔静脉行端侧吻合,移植肠一期消化道重建,末端造口,术后给予抗排异、抗感染、抗凝血及营养支持等治疗。结果 第1例患者术后曾出现贫血、急性排异反应,经积极处理得到控制,目前已存活26个月,肠道吸收功能正常,自由经口进食,能参加日常工作,第2例患者术后26d发生排异反应,顷冲击治疗好转,术后80d再次发生重度排异反应,经甲基强的松龙冲击无效,改为单克隆抗淋巴细胞抗体、抗胸腺细胞球蛋白冲击治疗,排异反应虽有好转,但发生不可控制的感染。抢救无效死亡。生存5个月。结论 具有血缘关系的活体部分小肠移植是治疗短肠综合征的一种方法。     

同种异体非整块肝脏-小肠联合移植

目的 报告国内首例同种异体非整块肝肠联合移植,重点讨论外科技术,并与整块肝肠联合移植技术进行比较。方法 患者因短肠综合征和全肠外营养(TPN)肝病接受非整块肝肠联合移植,植入小肠380cm。肠系膜上动脉、门静脉分别与受体腹主动脉、下腔静脉端侧吻合;供肝行改良背驮式肝移植。供体热缺血时间为2min 30s,移植肠冷缺血6h 40min,移植肝冷缺血8h 7min．术后免疫抑制方案采用FK506 激素 骁悉 赛尼哌。结果 患者恢复顺利,未发生排斥反应,至今仍存活,已恢复完全肠道营养。结论 非整块肝肠联合移植技术适合于成年受体、特别是既往曾有腹腔感染或接受多次腹部手术的患者。     

小鼠异位小肠移植模型的建立

目的 探讨稳定的小鼠异位小肠移植模型制作方法,为小肠移植排斥反应的研究提供良好的实验工具.方法 选用C57BL/6小鼠作供体和BALB/c小鼠作受体进行同种异基因型异位节段性小肠移植.采用小肠供体的门静脉与受体下腔静脉端侧吻合,供体带主动脉片的肠系膜上动脉与受体腹主动脉端侧吻合,供体近端肠管结扎,远端与受体空肠端侧吻合的方式建立异位小肠移植.术后禁食3天,不禁饮,每天分两次经皮下分别给予5%葡萄糖生理盐水2 mL,术后不使用抗生素和免疫抑制剂.小鼠存活超过5 d视为手术成功.结果 共行小肠节段性移植30例,术后5 d存活率达70%(21/30).供体手术时间(41±5.5)min,热缺血时间约0.5 min,供体肠段肠系膜上动脉组织片修整时间约为3 min,供体冷保存时间为(30±7.5)min,受体手术时间(90±7.5)min,其中腹主动脉及下腔静脉阻断时间为(40±3.0)min,静脉吻合时间(10±2.0)min,动脉吻合时间(15±2.5)min,成活小鼠受体手术平均出血量约0.2 mL.手术失败的9例小鼠的死亡原因为动脉吻合口部位狭窄及吻合口处血栓形成(6例),吻合口出血导致出血性休克(2例)和术后腹腔内感染(1例).结论 良好的供体肠段的获取、高质量的血管吻合和肠道吻合及供、受体补液是提高小鼠小肠移植手术成功率的关键.     

亲缘性活体部分小肠移植术

目的 介绍我国首例亲缘性活体部分小肠移植术的临床处理体会。方法 受体为男性,18岁,因短肠综合征而接受小肠移植。供体,男性,44岁,为受体之父。取供体回肠末段150cm,移植给患者,术后给予抗免疫排斥、抗感染、抗凝及营养支持等治疗。结果 目前,患者已健康生存19个月,移植肠功能恢复良好。结论 亲缘性活体部分小肠移植术是治疗短肠综合征的有效手段,良好的术后管理是确保活体小肠移植手术成功的关键。     

亲体小肠移植供肠获取与修整技术

目的探讨亲体小肠移植中供体小肠的获取和修整技术。方法根据亲体小肠移植供体的标准在父母中筛选合适供体,设计手术方案。选择回肠作为移植肠袢,采用保留回盲瓣及远端20cm回肠给供体,获取回肠120cm,总结手术中测量肠管长度的方法;综合采用透光、触摸法判断肠系膜上动脉分支,暂时阻断血流判断供肠和残留肠管血运;总结获取移植肠管中供体血管的选择和处理方法。结果供、受体手术顺利,移植肠袢功能良好。供体除短期轻度腹泻外,无肠系膜血栓、肠瘘等并发症。供体术后14d完全康复出院,随访8个月,无排便习惯改变;体重维持术前水平;食欲良好,无饮食习惯和进食量改变;未出现生活、工作习惯改变或心理改变。结论选择回肠作为移植肠袢,保留回盲瓣及远端20cm回肠给供体是理想的供肠获取方法,标准细致的操作方法对供体造成的近期和远期风险较小,并为获得优良的移植效果奠定基础。     

活体部分小肠移植治疗短肠综合征并肠瘘1例的临床经验

目的 总结活体部分小肠移植在治疗短肠综合征合并肠瘘中的临床经验.方法 1例短肠综合征合并肠瘘患者接受其子的150 cm 回肠,供肠动、静脉分别与受体的腹主动脉和下腔静脉行端侧吻合,受体残余空肠与供体回肠近端行端端吻合,受体结肠与供肠远端行端侧吻合,供肠远端造瘘作为观察窗,术后给予免疫抑制等治疗. 结果患者小肠移植术后恢复顺利,肠道功能恢复,血管吻合口通畅,正常生活110 d后因心脏意外死亡.结论 短肠综合征合并肠瘘患者实施活体部分小肠移植是可行的,植入肠管的血管植入技术对小肠移植成功非常重要.     

临床活体部分小肠移植术的血管处理技术

目的　报告我国首例活体小肠移植术的血管处理技术。方法　为 1例 18岁的男性超短肠综合症患者施行了活体部分小肠移植术 ,供肠来自患者的父亲 ,切取供体回肠 15 0cm ,UW液灌洗血管。将移植肠动、静脉分别与受体腹主动脉及下腔静脉端侧吻合。移植肠近端与受体空肠近端行端端吻合 ,移植肠远端与受体空肠远端行侧端吻合 ,末端造口。术后给予抗排斥 ,抗感染 ,抗凝及营养支持等治疗。结果　术后曾出现贫血 ,单纯疱疹感染和急性排斥反应 ,经积极处理得到控制 ,目前患者健康 ,生存 11月余。结论　活体小肠移植术中处理好供、受体的血管对手术成功至关重要。     

Treatment of short gut syndrome with early living related small bowel transplantation

AIM: To investigate the results of treating short bowel syndrome with an early living related small bowel transplantation (SBT). METHODS: A 17-year-old boy with a 20-cm-long residual intestine due to necrotic volvulus received an early living related SBT from his mother. Donor-specific blood transfusion was performed for 8 weeks before transplantation, each time for 50 mL every week. Cytomegalovirus status in both donor and recipient was negative. A 160-cm distal ileal segment was removed from the donor. The graft ilecolic artery and vein were anastomosed to the recipient's infrarenal aorta and caval vein. The proximal end of the graft was anastomosed end-to-end to the residual recipient jejunum; the distal anastomosis, between the distal end of the graft and transverse colon. An ileostomy was also performed. Immunosuppression, infection prophylaxis, and antithrombotic and nutrition support were given postoperatively. RESULTS: The donor had an uneventful recovery. No technical complications were observed. The recipient was alive and well at 31 weeks after the operation. No graft rejection or infection was observed. He was off TPN 8 weeks after the operation and took low-fat food. The D-xylose test in the recipient was almost normal. CONCLUSIONS: Early living related small intestine transplantation is a good treatment for short bowel syndrome.     

Vascular anastomosis and two-stage reconstruction of the gut in a living-related small bowel transplant recipient: a case report

AIM: We sought to discuss vascular anastomosis and gut reconstruction in a living-related small bowel transplantation recipient. METHODS: Living-related small bowel transplantation was performed successfully on a boy with short gut syndrome in two stages. In the first stage, 120 cm, of his mother's ileum was implanted into the recipient with the artery and vein anastomosed to the recipient's sigmoid artery and inferior mesenteric vein, respectively. The two ends of the implanted intestine were constructed as stomas. In the second stage, reconstruction of the continuity of the digestive tract was performed at 188 days after the initial transplantation. The residual small bowel was transected and both ends were anastomosed to the proximal and distal end of the graft in end-to-side fashion. The stomas were closed 30 and 43 days later. RESULTS: Both procedures were successful. Postoperative cytomegalovirus infection and acute rejection occurred successively and were controlled. No leakage of the reconstructed gut or other complications developed after the second procedure. The recipient is alive at 15 months with 8 kg an increase in weight. He is caring for himself independently and has a half-liquid diet, sometimes supplied with auxiliary enteral nutrition. A d-xylose test increased from 4.25% to 25% after the small bowel transplantation. CONCLUSIONS: Vascular anastomoses should be performed according to the state of graft and the recipient. The portal route is the first choice when possible. A two-stage gut reconstruction could decrease the incidence of complications, and offer a useful method in living-related small bowel transplantation.     

Segmental living related small bowel transplantation in adults

The advent of small bowel transplantation has provided selected patients with chronic intestinal irreversible failure with a physiologic alternative to total parenteral nutrition. Recently a standardized technique for living related small bowel transplantation (LR-SBTx) has been developed. Three patients with short bowel syndrome underwent LR-SBTx at our institution. All donors were ABO compatible with a good human leukocyte antigen match. A segment of 180 to 200 cm of ileum was harvested and transplanted with its vascular pedicle constituted by the ileocolic artery and vein. The grafts were transplanted with a short cold and warm ischemia time. The immunosuppression regimen consisted of oral FK-506, prednisone, and intravenous induction with atgam. Serial biopsies of the intestinal grafts were performed to evaluate rejection or viral infections. The postoperative course was uneventful for all donors. All of the recipients are currently alive and well. Two of three patients are off total parenteral nutrition and tolerating an oral diet with no limitations on daily activity. In the third patient, the graft was removed 6 weeks after transplantation. At the time of enterectomy, no technical or immunologic complications were documented. Absorption tests for D-xylose and fecal fat studies were performed showing functional adaptation of the segmental graft. All biopsies were negative for acute rejection. A well-matched segmentai ileal graft from a living donor can provide complete rehabilitation for patients with short bowel syndrome. Our initial experience suggests that the risk of acute rejection and infection is greatly reduced compared to cadaveric bowel transplantation. Further clinical application of this procedure is warranted. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 21–24, 2000.     

Low infectious complications in segmental living related small bowel transplantation in adults

Clinical small bowel transplantation (SBTx) has been associated with a high rate of infectious complications. Laparotomy, preservation injury, abnormal motility, lymphatic disruption, aberrant systemic venous drainage, rejection and antibiotic therapy could all be implicated in the etiology of these complications. In addition to the underlying disease, total parental nutrition could determine infections and liver impairment. Recently, standardized techniques for segmental living related SBTx (LR-SBTx) have been developed. This technique allows reduction of some of these factors, thus resulting in a reduced incidence of infections. We report the infectious complications observed in 3 patients with short bowel syndrome treated with LR-SBTx at our institution. A segment of 180-200 cm of ileum was transplanted with a neglectably short cold ischemia time (CIT). The donor bowel was decontaminated. Oral tacrolimus, prednisone and IV induction with ATG were used for immunosuppression. Blood, stool, urine, sputum and peritoneal fluids were collected and cultured as a routine surveillance. All recipients are alive with a current follow-up time up to 21 months. No bacterial infections were observed during the post-transplant period. One patient developed cytomegalovirus (CMV) enteritis 4 months after LR-SBTx and was treated successfully with IV ganciclovir. In our limited experience, LR-SBTx is associated with a low infection rate. This could be due to optimal graft decontamination, short CIT and to the reduced incidence of rejection and lower immunosuppression used in this immunologically well-matched combination.     

尸体供肠的获取、保存及临床应用

目的　研究尸体供肠的获取与保存方法。方法　采用原位灌洗、整块切取的方法自 6具尸体获取供肠 ,Euro Collins液保存 ,光镜和电镜下观察供肠的组织学变化 ,其中 2例供肠分别移植至 2例短肠综合征患者。结果　 6例尸体供肠完整切取的时间为 (10 .8± 1.4)min ,热缺血时间为(5 .6± 1.2 )min ;光镜及电镜检查证实保存 10h内的供肠组织损伤轻微 ;第 1例移植的小肠运动和吸收功能逐渐恢复 ,后因肠道和肺部感染死亡 ,第 2例患者恢复无脂饮食。结论　该法实用、有效 ,所获小肠可用于临床移植。     

Living-related small bowel transplantation: two cases experiences

We have recently performed living-related small bowel transplantation for 2 patients. The first patient was a 14-year-old boy with total parenteral nutrition (TPN)-dependent short-bowel syndrome associated with hypoganglionosis of the entire intestine. He received a bowel graft from his 43-year-old mother. The second patient was a 27-year-old woman, who had massive enterectomy due to volvulus and developed vitamin deficiencies and severe metabolic disorders as a result of long-term TPN. She underwent living-related bowel transplantation from her 57-year-old mother. Blood types were ABO identical, cytotoxic cross matches were negative, and cytomegalovirus statuses were positive-to-positive in both cases. Up to one third of the donor bowel was harvested from the donor distal ileum more than 30 cm away from the ileocecal valve. The graft vessels were connected to infrarenal aorta, and inferior vena cava. The immunosuppressive regimen consisted of daclizumab, tacrolimus, and steroid. The graft surveillance was accomplished using zoom endoscopy and mucosal biopsy. The first patient developed progressive acute cellular rejection (ACR) on the 9th postoperative day (POD)-9 requiring OKT-3 therapy, which was effective. Two months after transplantation, he was weaned from TPN, tolerating oral intake with a fully functioning graft. The second patient experienced no episode of ACR and was weaned off TPN on POD-29 with a functioning graft. Her metabolic disorder dramatically improved after bowel transplantation. Both donors had no complication and were discharged from the hospital on POD-10. Living-related bowel transplantation is an extreme option of treatment for patients with short-bowel syndrome.