Basic And Clinical Study Of Abdominal Multiorgan Combined Transplantation

Part Ⅰ The Study on Rejection-associated Cytokines of CombinedLiver-kidney Transplantation in RatsObjective: (1) To establish a new model of liver-kidney transplantation combined (SLKT); (2)To study the correlation between rejection and cytokines of combined liver-kidney transplantation was performed.Method: The liver and kidney of donor were simultaneous ablated . The graft portal vein (PV) and inferorenal inferior vena cava (IVC) were anastomosised by the means of double cuff methods, The supraliver IVC were anastomosised end to side to suprahepatic caval. The graft ureter and bile duct was anastomosised by simple inside bracket. SD rats were used as syngeneic donors and allogeneic donors. Wistar rats were used as allogeneic recipients. All recipients were randomly divided as follows : Group Ⅰ : Syngeneic control ( SD→SD) ; Group Ⅱ : Treated with CsA 2mg/kg/d by subcutaneous (Wistar→SD); Group Ⅲ: Acute rejection group (Wistar →SD ) . All groups were subdivided into day 1, 3, 5, 7 posttransplantation respectively for sample harvesting. The extracted blood sample was used to examine serum ALT and Cr and to monitor the peripheral blood cytokines by Enzyme-linkedimmunoadsordent assay (ELJSA).Results: 1. The general results of operation: The donor operation time was 38 + 5min, recipient no-liver time 18±3min; recipient operation 81±13min , the successful rate was 80.0% , 70.0% , 80.0% respectively . serum Cr and ALT were both enhanced postoperatively except group I (P<0.05) There was a significant difference in the group HI with other groups (P<0.01) . 2. Histopathologic examination: The pathological evidences of rejection were not detected in all rats on the day 1, 3 after operation. There episodes of I and II rejection in group HI on the day 5 and 7 after operation respectively . On the day 7 after operation, the mild rejection occurred in the group II . 3. The expression of cytokines in peripheral blood : ?The expression of INF- y was not observed in syngeneic group in any period of. Slight expression was detected in CsA treated group on the 1, 3, 5and 7th day. The highest expression was observed for rejection group, which was dramatically higher than of the other groups from the third day, (P<0.05 or P<0.01) compared in any periods of . ? The expression of IL-2 in rejection group was significantly enhanced on the third day posttransplantation , and exhibited increasing expression trend , it was significant higher than that of CsA treated group and syngeneic group at the same time ( P<0.05 or P<0.01 ) . Lower expression of IL-2 was observed in syngeneic group. The expression level in CsA treated group was significant higher than that in syngeneic group (P<0.001). (3) The expression of IL-6 in rejection group was significant higher than that in syngeneic group and CsA treated group on the 5 and 7th day. The expression of IL-6 of CsA treated group had no difference compared with that of the syngeneic group. ? The expression of IL-10 in CsA treated group had significant difference compared with syngeneic group and rejection group (P<0.05 or P<0.01). The expression of IL-10 in rejection group was no significant difference compared with syngeneic group.Conclusion: 1. This method to establish the model of simultaneous liver-kidney transplantation in rats is simple and feasible; 2. The acute rejection grade of renal graft was similar to that of liver graft after rat liver-kidney combined transplantation. 3. The expression of IL-2 and INF- Y in peripheral blood was increase with rejection grade , which could be used as excellent parameter reflecting the immune state of rejection . 4. The increasing of IL-6 expression was observed in rejection group early post transplantation, which might be related to rejection episode. 5. IL-10 in peripheral blood of CsA group had increasing trend at the early time, then-higher expression might be related to long-term acceptance.PartH Clinical Study of En Bloc Harvesting ofAbdominal Multipl VisceraObjective: To explore the best method of en bloc harvesting of abdominal viscera with no pollution and no injury.Method: 1. Rapid in situ perfusion of multiviscera . Our modification of the rapid perfusion technique begins with a midline skin incision made from the sternal notch to the symphysis pubsis, and transverse extension is added bilaterally just below the umbilicus to maximize the exposure of the surgical field. Rapid inspection of the peritoneal to excluded for unexpected intraabdominal neoplasia and other significant pathology, and conforms the gross suitability of the organ to be procured. The retro-peritoneum is opened, and the anterior surface of the infrahepatic vena cave anddieted aorta are exposed. The aorta is encircled and taped just above the bifurcation of the iliac arteries. The distal aorta is ligated and a Foley catheters used as on aorta cannula is inserted for 15cm. The Foley catheter was blocked by pledget at the anterior extremity and opened 3~4 windows behind of the air-pocket. The air-pocket is enlarged by infusion 15ml water to block the upper segment of abdominal aorta. Another cannula as a drainage-tube is inserted in the infrahapatic vena cave on the same way to drain the effluent fluid. The superior mesenteric vein (SMV) is exposed between the duodenum and the transverse mesentery, and a cannula is inserted to SMV for perfusion of the portal system. After the cannulation is finished, the viscera are perfused through both the aortic and portal vein cannulas with cold preservation solution (HC-A solution and University of Wisconsin solution sequentially). The gall- bladder is opened and flushed, and the viscera are packed in crushed ice to achieve surface cooling. 2. En bloc harvested of multiviscera . After the in situ perfusion is established, the colon is separated firstly. Care is taken to free and section the ureters as far down towards the bladder as possible and to avoid dissection with renal hilus. The duodenum is transected at the pylorus proximally and the ligament of Treitz distally between ligatures. The left triangular ligament is dissected. The lesser omentum is dissected to the level above the diaphragm between the lesser curvature and the caudate lobe of the liver. The right diaphragm is dissected above the right triangular ligament. It is necessary to divide the tip of the right triangular ligament to prevent tear of the liver. The suprahepatil cava is transected at right auricle. The descending thoracic aorta is divided and cross-clamped and transected proximally above the diaphragm. The aorta and the cave are mobilized from vertebral bodies by dividing the diaphragm and lifting the entire tissue block anteriorly. The aorta and the vena cava are transected just below the position of annulation. The en bloc specimen consisting of liver,pancreatoduodenum, spleen, both kidneys and ureters, aorta and inferior vena eave can be lifted out of the abdomen and placed immediately into a basin of cooled perfusion solution. The iliac vessels are harvested for the vascular graft. The en bloc specimen is then placed in a sterile plastic jar holding iced-cold preservation solution. The container is wrapped in three layers of sterile barriers and packed in ice for storage and shipping.Results: From 1998 to 2002 , an improved surgical technique of en bloc harvesting of abdominal multiple viscera had been carried out for 120 times ,The procedure of establishing perfusion of abdominal aorta and portal vein took 1.0 ± 0.3 and 1.0 ± 0.7 minutes respectively. The time of multiple organs harvesting and warm ischemic was 10.0 ± 3.0 and 2.0 ±1.2 minutes respectively. liver transplantation (LT) and combined liver-kidney transplantation was performed in 65 patients and 12 patients in our center respectively .The functions of grafted liver recovered normally within 3 weeks. We also have successfully finished 238 cases of kidney transplantation (KT) and 6 cases simultaneous pancreas-kidney transplantation ( SPKT ) .The patients performed SPKT escaped hemodialysis and insulin therapy within 2 weeks .In KT group , normalization time of renal function was 4.28 ± 3.73 days and incidence rate of acute tubular necrosis (ATN) was 3.4% .Conclusion: l.The en bloc harvesting of multiple viscera is reliable and simple technique and can obtain the high quality organs rapidly. 2. There is no influence of preceding perfusion of the aorta to cooling of the liver. 3. There is no influence of incubation of the superior mesenteric vein to perfusion of the liver and the pancreas. 4. The in situ perfusion is provided via the aorta, thus avoiding direct artery incubation and possibility of intimal injury. 5. The multiple renal arteries can be left on a cuff of the aorta, thereby using a single Carrel's patch to anastomosis easily. 6. During the procedure of en bloc harvesting of multiple viscera, unseparated of thesingle organ can avoid the injury of the organs and vessels.PartmClinical Study of Abdominal Multiplorgan Combined TransplantationObjective: To explore the surgical technique and preliminary experience of the treatment of perioperative period, prevention of complicationand, reasonable imunosuppression regimen in abdominal multiplorgan combined transplantation. Method: 1. The back-table procedure. ? To separate the donor organ from the entire tissue block. During the back-table procedure, the entire donor tissue block should be submerged in cold preservation solution to maintain a tissue temperature of 0°Cto 4°C. An incision is made longitudinally on the posterior wall of the aorta just blow the origin of both renal arteries. After the origin of the superior mesenteric artery (SMA), celiac axis and bilateral renal arteries are identified from the inside of the aorta, the anterior wall of aorta is transected between the origin of SMA and the bilateral renal arteries, dividing the connective tissue arounde these vessels. The infarhepatic vena cava is divided above the level of the renal vein. The hepatorenal ligament, the lienorenal ligament and other tissue between pancreas and both kidneys are transected, thereby separating the both kidneys and ureters from the tissue block. Care should be taken to dissect the first hepatic hilum, The common bile duct is transected just below the duodenum. The portal vein is transectedaccording to situation of the operation. The proper hepatic artery is transected from its origin of the common hepatic artery. The pancreas is then separated from the liver. (2) The back-table procedure for the liver. The diaphragmatic tissue is removed from the suprahepatic vena cava, ligating the phrenic reins. The right adrenal vein is ligated at the infrahepatic vena cava, and the adrenal gland is removed. Connective tissue around the portal vein is dissected to the level of bifurcation. The artery is dissected from the aorta the level of the common hepatic artery between the spleen artery and the gastroduodenal artery. An aberrant right replaced hepatic artery is usually arose from the SMA. So the SMA should be examined routinely. If the pancreas is not used to transplant, the aberrant right replaced hepatic artery can be anastomosed to the gastroduodenal artery. (3) The back-table procedure for thepancreas.__The portal vein is dissected to the level of superior border of thepancreas. If the length of portal vein is short because of the liver is used to transplant. The iliac vein may be as a vessel graft to extension the portal vein. The SMA and the celiac axis are dissected leavening both origins within a Carrel's patch. The left gastric artery and the proper hepatic artery are ligated. The ganglion and lymphatic surrounding the pancreas are removed. The both stumps of the duodenum are processed followed by an over-and-over continuous suture in the first layer and an interrupted suture in the second layer. The spleen vessels between the tail of the pancreas and spleen are lighted and transected between ligatures. @The back-table procedure for the kidney. The left renal vein is carefully dissected toward and divided flush with the vena cava to preserve adequate length. After incision of the anterior wall of the aorta, the two kidneys are separated, leaving the right renal vein attached to the inferior vena cava to permit extension of a short renal vein if necessary. Excess adherent fat is dissected from the kidney surface, and care is taken to preserve the fibroadipose triangular wedge of tissue between the lower pole andureter. When a lower polar artery is present, the ureteral blood supply may arise from this lower polar vessel, which would be protected. It is very important to avoid two errors in the back-table procedure of kidney and ureter. The first error is striping the ureter of it connective and adventitial tissue, which may lead to necrosis of the lower ureter. The second error is dissecting too high into the renal hilum, which can compromise the ureteral branch of the renal artery on which the donor ureter will depend for its survival. 2. The procedure of organ transplant operation. (l)The liver transplantation. All of the liver transplantations are made with the fashion of orthotopic liver transplantation. The classic liver transplantations are proceeded in 8 cases without the pump-driven veuovenoas bypass and the piggyback technique is used in 4 patients. ?The pancreas transplantation. The pancreatic exocrine secretions of the pancreas transplantations are used enteric drainage technique. The pancreatic graft is implant to the right iliac fossa. The Carrel's patch consisting of the SMA and the celiac axis is anastomosed to the external iliac artery end-to-side. The portal vein is anastomosed to the external iliac rein end-to-side. The duodenum of donor is anastomosed to the jejunum of recipient side-to-side without a Roux-en-Y limb. ?The kidney transplantation. The renal graft is implanted to the right iliac fossa routinely. The renal vein is anastomosed to the external iliac rein end-to-side, and the renal artery is anastomosed to the external iliac artery end-to-side or the hypogastric artery end-to-end. The ureter is implanted to the anterior wall of the bladder with a submucosal tunnel. During the operation of the liver-kidney or the liver-pancreas combined transplantation, the transplantation of the liver is preceded, and then the kidney or the pancreas transplantation can be made under stable homodynamic circumstance. In the procedure of the kidney-pancreas transplantation, the kidney is implant proceding to the pancreas, because the back-table procedure of the pancreatic graft required a very long time.3. Immunosuppression regimen. All of the patients received a quadruple-drug regimen, including antithymocyte globulin (ATG) or interleukine 2 receptor blocker (anti-CD25 antibody: basiliximab and daclizumab) as prophylaxis and maintenance immunosuppresion therapy consisting of tacrolimus (TAC), mycophenolate mofetil (MMF) and prednisone (Pred).Results: Between October 2001 and January 2005, 19 abdominal multiorgan combined transplantation were performed. There were 6 cases of simultaneous pancreas-kidney transplants, 12 cases of combined liver-kidney transplantations and a case of combined liver-pancreas transplantation. Acute rejection occurred in 3 cases (15.8%) and reversed by intravenous bolus methylprednisolone. The Tac toxicity occurred in a patient (5.3%). The hemorrhage of digestive tract was in 2 recipients (10.5%) received simultaneous pancreas-kidney transplants, and the hemorrhage of peritoneal cavity was in a patient on the first day after transplantation. The pneumonia occurred in one case (5.3%). The survival rate of the perioperative period was 100%.Conclusion: 1. The abdominal multiple organs combined transplantation is the best option of patients with multiorgans failure. 2. In liver-kidney combined transplantation, the hepatic graft can protect the renal graft. 3. Pancreas transplantation is the reliable option of insulin independence for patients with diabetes mellitus. 4. The quadruple-drug regimen of immunosuppression is saft and effective.