摘要
目的 探讨异体肢体移植重建肢体缺失的可行性。方法 筛选两例右手外伤性缺如病人,与供者行ABO、Rh血型、人类白细胞抗原(HLA)配型、群体反应性抗体(PRA)检测及淋巴细胞毒性交叉试验,以确定合适的两例脑死亡者作供者。供体上肢切取后用4℃UW器官保存液灌注、冰桶内保存、运输,随机选择其中一个肢体在再植前经8Cy X射线照射。移植手术包括桡骨、尺骨固定,吻合尺、桡动脉、尺、正中神经、头、贵要静脉,缝合除指浅屈肌腱外所有肌腱及皮肤。术后常规应用抗感染、抗凝、解痉药物,联合应用抗免疫排斥反应药物:(1)全身用药:抗胸腺细胞球蛋白(ATG)、FK506、霉酚酸、强的松;(2)局部用药:肤轻松软膏涂手。术后密切观察生命体征、移植手血循环、免疫学指标以及皮肤活检。术后进行心理治疗以及在康复理疗师指导下进行功能锻炼。结果 术后移植手血循环同自体离断再植术。其中一个患者血糖升高,应用胰岛素对症治疗得以控制。皮肤切口顺利愈合。Tinel征检查显示神经生长速度较快。术后7周移植手皮肤发生红色丘疹,系局部使用过多肤轻松软膏所致,经停用肤轻松软膏并用炉甘石洗剂擦洗后治愈。术后4个月移植手功能较好,感觉已恢复至手指末节,可以持物,肌电图显示鱼际肌已见动作电位。术后定期取活检证实无任何排斥反应迹象。
Objective To study the feasibility of reconstruction of amputation by hand allograft in human
being. Methods Two male recepients, with traumatic right wrist amputation of 2 years, were matched respectively to two ABO-and Rh-compatible, HLA- half compatible brain-dead donors, and direct crossmatch were performed to confirm the absence of prior sensitization to alloantigens. After amputation the donor's arm was irrigated with UW organ preservation solution at 4℃, and transported in a box with ice. One of the two donor arms was randomly selected and irradiated by 8Gy X-ray before transplantation. The transplantation involved radial and ulnar bone fixation, anastomoses of radial and ulnar artery, sutures of median and ulnar and radial nerves, joining of tendons except flexors digitorium superficials, and skin closure. After surgery the patients were given wide-spectrum antibiotics, anticoagulation and antispasm agents, and immunosuppressants, which included antithymocyte globins, FK506, mycophenolic acid, prednisone systematically and fluocinolone acetonide ointment locally. Clinical observations included vital signs and circulation of the hands. Immune state was monitored by assaying of C-reactive protein, Igs and PRA in the blood. Skin biopsy was done to exclude the dermal rejection. After the surgery the patients received psychotherapy and hand rehabilitation. Results The circulation of the transplanted hands was similar to that of replanted ones. One of the patients developed hyperglycaemia. which required insulin administration. The skin healed naturally. The nerve regeneration were found more rapid by Titiel' s sign. At 7 weeks erythema papulatum occurred on the skin, which was cured by withdrawing of fluocinolone acetonide ointment and applying of calamine lotion. At 4 months the function of grafted hands recovered well. which could hold a drinking cup. The nerves had grown to the end of fingers and electromyograph showed regenerative action potentials ol thenal muscles. Skin biopsy confirmed no rejection happened. Conclusion Ideal histocompatability and combined usage of currently available immunosupres-sants can prevent hyperacute and accelerating rejection of human hand allograft. The tissues heal and the early-function recover similarly to those in autologous replantation.
