摘要
背景 联合应用最新免疫抑制剂治疗下的动物异体肢体移植的长期存活以及自体肢体再植令人鼓舞的结果使我们相信人体异体手移植将会成活。方法 1998年9月,我们将一位脑死亡的男性的手和前臂远端移植到一位因创伤致前臂远端1/3截肢的48岁男性患者。供者的手臂用4℃ UW器官保存液灌注后,肘上5cm截肢并置于冰箱中运输。同时解剖供体和受者的手臂,辨别各自的解剖结构,使有活力的结构准确相配。移植过程中包括骨的固定、动静脉的吻合(缺血时间12.5小时)、神经吻合、肌肉和肌腱的缝合和皮肤的覆盖。免疫抑制剂包括抗胸腺细胞蛋白、FK506、霉酚酸和强的松。维持治疗包括FK506、霉酚酸以及强的松。随访包括常规移植后的实验室检测、皮肤活检、增强理疗和心理支持治疗。结果 术后早期过程十分平静,未发生外科并发症。患者能很好地耐受免疫抑制剂。术后8～9月发现有轻度的皮肤排斥反应的临床和组织学表现。加大强的松的剂量(20mg/天至40mg/天)以及局部免疫抑制剂霜剂应用后临床和组织学表现消失。增强理疗使运动功能获得令人满意的进展。感觉的恢复(Tinel征)十分理想,已达到腕横纹(20cm)。术后100天时正中神经和尺神经的感觉已恢复到手掌,至少24cm。手掌的深压觉存在而无触觉。结论 异体手移植技术上是可行的。现有?
Background Long-term survival of animal limb allografts with new immunosuppressant combinations and encouraging results of autologous limb replantations led us to believe that clinical application of hand transplantation in human beings was viable. Methods On Sept 23, 1998, we transplanted the right distal forearm and hand of a brain - dead man aged 41 year's on to a man aged 48 years who had had traumatic amputation of the distal third of his right forearm. The donor's arm was irrigated with UW organ preservation solution at 4°, amputated 5 cm above the elbow, and transported in a cool container. We dissected the donor limb and the recipient's arm simultaneously to identify anatomical structures. Appropriate lengths of viable structures were matched. Transplantation involved bone fixation, arterial and venous anastomoses(ischaemic time 12.5 h), nerve sutures, joining of muscles and tendons, and skin closure. Immunosuppression included antithymocyte globulins, tacrolimus, mycophenolic acid, and prednisone. Maintenance therapy included tarcrolimus, mycophenolic acid, and prednisone. Follow-up included routine post - transplant laboratory tests, skin biopsies, intensive physiotherapy, and psychologicl support. Results The initial postoperative course was uneventful. No surgical complications were seen. Immunossupperssion was well tolerated. Mild clinical and histological signs of cutaneous rejection were seen at weeks 8 ~ 9 after surgery. These signs disappeared after prednisone dose was increased (from 20 mg/day to 40 mg/day) and topical application of immunosupressive creams (tacrolimus, clobetasol) . Intensive physiotherapy led to satisfactory progress of motor function. Sensory progress(Tinel' s sign) was excellent and reached the wrist crease (20 cm) on day 100 for the median and ulnar nerves, and at leasst 24 cm to the palm by 6 months when deep pressure, but not light touch sensation, could be felt at the mid palm. Conclusion Hand allotransplantation is technically feasibel. Currently available immunosuppression seems to prevent acute rejection. If no further episode of rejection occurs the functional prognosis of this graft should be similar to if not better than that reported in large series of autoreconstruction.
