摘要
Clinical-nutritional autonomy is the ultimate goal of patients with intestinal failure(IF).Traditionally,patients with IF have been relegated to lifelong parenteral nutrition(PN)once surgical and medical rehabilitation attempts at intestinal adaptation have failed.Over the past two decades,however,outcome improvements in intestinal transplantation have added another dimension to the therapeutic armamentarium in the field of gut rehabilitation.This has become possible through relentless efforts in the standardization of surgical techniques,advancements in immunosuppressive therapies and induction protocols and improvement in postoperative patient care.Four types of intestinal transplants include isolated small bowel transplant,liver-small bowel transplant,multivisceral transplant and modified multivisceral transplant.Current guidelines restrict intestinal transplantation to patients who have had significant complications from PN including liver failure and repeated infections.From an experimental stage to the currently established therapeutic modality for patients with advanced IF,outcome improvements have also been possible due to the introduction of tacrolimus in the early 1990s.Studies have shown that intestinal transplant is cost-effective within 1–3 years of graft survival compared with PN.Improved survival and quality of life as well as resumption of an oral diet should enable intestinal transplantation to be an important option for patients with IF in addition to continued rehabilitation.Future research should focus on detecting biomarkers of early rejection,enhanced immunosuppression protocols,improved postoperative care and early referral to transplant centers.
临床营养自给是肠衰竭患者的最终目标。一般来说,对于肠衰竭患者,当旨在恢复肠道功能的各种外科和药物治疗努力都失败后,只能接受终身肠外营养。然而在过去20年中,肠道移植方面的研究进展为肠康复治疗体系增加了一个治疗选择。随着在外科技术的标准化、免疫抑制治疗和诱导方案的改进、术后处理措施的改善等方面的不懈努力,肠道移植现已成为可能。肠道移植分为小肠移植、肝-小肠联合移植、多脏器联合移植和改良多脏器联合移植四种方式。目前的指南将肠道移植对象限定于那些具有严重肠外营养并发症(如肝衰竭和反复感染)的患者。随着20世纪90年代他克莫司(一种免抑制药)的应用,无论是在实验研究阶段还是临床实践中,肠衰竭患者肠道移植的疗效都得到了显著改善。研究显示,与肠外营养相比,肠道移植后若能保持13年的肠道功能,其成本效应显著。鉴于肠道移植可延长生存期、改善生活质量、恢复经口进食,肠道移植理应成为肠衰竭患者的一项重要治疗选择。下一步有必要就早期排斥反应标志物的确立、免疫抑制治疗方案的强化、术后康复措施的改善以及是否需早期转移植中心进行治疗等方面展开研究。
