小腸移植技術(shù)發(fā)展的創(chuàng)新之路

1、小腸移植技術(shù)發(fā)展的創(chuàng)新之路短腸綜合征 (Short Gut Syndrome, SGS) 胃腸外營(yíng)養(yǎng)（TPN） 小腸移植小腸移植的發(fā)展歷程免疫排斥反應(yīng)為什么小腸移植很困難？全身最大的淋巴器官?lài)?yán)重的免疫排斥反應(yīng)空腔有菌器官 16歲男性, 腸扭轉(zhuǎn)小腸廣泛切除術(shù)后病例1: 移植受者13cmHLA配型理想降低排斥反應(yīng)活體小腸移植的可行性全球僅6例報(bào)道缺乏足夠的經(jīng)驗(yàn)醫(yī)院條件有限供者安全性活體小腸移植的風(fēng)險(xiǎn) 46歲中年男性 血型B型/HLA半相合 交叉配型陰性病例1: 小腸供者(患者父親）姓名年齡移植時(shí)間移植腸病人/存活情況秦XX152001.016個(gè)月/死亡急性排斥反應(yīng)張X142002.1219天/死亡

2、急性排斥反應(yīng)龍X152003.028年/慢性排斥反應(yīng)等待再次移植西京醫(yī)院活體小腸移植Stockholm, SwedenDr. Carl GrothDr. Andreas G. TzakisUniversity of Miami Jackson Memorial HospitalECFMG CERTIFICATIONWith Dr. Kareem Abu-ElmagedWith Dr. Thomas StarzlDonor Specific Human Leukocyte Antigen Antibodies and Outcome of Small Bowel AllograftGuoshen

3、g Wu MD, John Lunz PhD, Guilherme Costa MD, Geoffrey Bond MD, Ruy Cruz MD, Kyle Soltys MD, Rakesh Sindhi MD, Adrianna Zeevi MD, Kareem Abu-Elmagd MDThomas E. Starzl Transplantation Institute University of Pittsburgh Medical CenterAm J Transplant 2010; 10(Suppl4):162Abu-Elmagd KM#, Wu G#, Costa G, Lu

4、nz J, Martin L, Koritsky DA et al. Am J Transplant 2012;12(11):3047-3060.Preformed and De Novo Donor Specific Antibodies in Visceral Transplantation: Long-Term Outcome with Special Reference to the LiverHypothesis: Antibody-Mediated Rejection (ABMR) Plays an Important Role in Intestinal Graft Outcom

5、e小腸移植慢性排斥反應(yīng)病例1：小腸內(nèi)鏡和病理結(jié)果 (治療前）慢性排斥反應(yīng)的傳統(tǒng)治療抗T淋巴細(xì)胞治療: ATG/Tacrolimus1-2年內(nèi)需要切除小腸/再次移植供體特異性抗體檢測(cè)結(jié)果C4d Staining 13 years after SBTx病例1：小腸移植術(shù)后血液他克莫司濃度和供體特異性抗體水平病例：小腸內(nèi)鏡結(jié)果 (治療前后）病例1：病理結(jié)果 （治療前后） 2015/04/182012/05/292015.05.20術(shù)后16年ABO血型不合小腸移植 16 歲, 女, 廣泛小腸壞死（腸系膜上動(dòng)脈血栓）病例3：移植受者病例3：手術(shù)探查十二指腸殘端4位可能供者血型受者：A供者 1：AB供者

6、2：B供者 3：AB供者 4：AB移植前肺部感染 新型免疫移植劑的問(wèn)世 血型不合肝腎移植的成功經(jīng)驗(yàn) 小腸移植的經(jīng)驗(yàn)積累血型不合小腸移植的可行性 46歲中年男性（患者父親） 血型AB; HLA半相同 CDC交叉配型陰性病例3：供者超急性排斥反應(yīng)的預(yù)防RituximabPPPPPPPTxIgG titer 1:8 1:16 病例3：移植手術(shù) 他克莫司+激素 急性排斥反應(yīng) 吻合口出血 胃癱 感染病例3：術(shù)后治療病例 2: 抗血型抗體B滴度和供體特異性抗體術(shù)后變化Am J Transplant 2015;15(5):1432-1435 二次小腸移植病例3：慢性排斥反應(yīng) 26歲男性，小腸移植術(shù)后10年慢

7、性排斥反應(yīng)二次小腸移植再次小腸移植 機(jī)理：吸收和處理抗體Wu GS#*, Cruz RJ. Liver inclusion improves outcomes of intestinal retransplantation in adults. Transplantation 2014;11(PMID: 2542 7167)肝臟對(duì)移植小腸具有保護(hù)作用小腸移植+輔助性部分肝移植活體部分小腸移植 國(guó)內(nèi)首例非親緣性小腸移植亞洲首例同卵雙生小腸移植小結(jié)與展望減輕供體創(chuàng)傷 (da Vinci Surgery)誘導(dǎo)小腸移植免疫耐受（Tolerance）異種小腸移植 （Xenotransplant）da V

8、inci 機(jī)器人手術(shù)世界首例機(jī)器人活體供腸切取手術(shù)視頻Produce_new.avi小腸自體移植腫瘤包繞腹腔大血管自體小腸移植技術(shù)1. In vitro Perfusion2. Vascular Reconstruction3. Reperfusion4. Drainage自體小腸移植技術(shù)Table 1. Characteristics of patients and surgical outcomesCaseAgeSexDiagnosisInvolved organs/lengths of bowel graftSite of vascular anastomosisBLT (Units)C

9、IT (hr)WIT (hr)ComplicationsStatus of patients/follow-up (mos)163MMesenteric desmoid tumorDuodenum, head of pancreas, small bowel and transverse colon/150cmAorta/vena cava43.50.9Arterial thrombosis/ graft necrosisAlive, TPN dependent/51.1256FSolid pseudopapillary tumor of the pancreasDuodenum, head

10、of pancreas, and small bowel/250cmSMA/portal vein33.00.35NoneAlive/32.8367FSerous cystadenocarcinoma of the pancreasDuodenum, head of pancreas, small bowel, and transverse colon/280cmSMA/GDA; portal vein/splenic vein44.10.38NoneAlive/17.3453MMesenteric desmoid tumorDuodenum, head of pancreas, and sm

11、all bowel /300cmAorta/vena cava64.50.50NoneAlive/16.7524MGiant retroperitoneal ganglioneuromaDuodenum, head of pancreas, celiac artery, SMA, and small bowel /350cmSMA/GDA/splenic artery; portal vein, splenic vein105.50.6Pancreatitis/intra-abdominal bleedingDead/21days658MPancreatic neuroendocrine tumor Duo