allogeneic adrenal transplantation

In order to avoid the replacement of Nelson in the Cushing syndrome after adrenal total resection, the prevention of Nelson is caused by the implementation of autologous adrenal tissue transplantation (Hardy Drucker Franksson, 1985) since 1960. This technique has been administered to a small number of cases. However, this method can only be used in the surgical resection process for adrenal gland proliferation, and the adrenal gland tissue selected for cutting must be a normal cell morphology structure, and the scope, time limit, and conditions are strictly limited. For many patients with complete loss of adrenal function due to lesions, such as Addison disease, or early adrenalectomy, or recurrence of symptoms after subtotal resection, there is no condition for autologous implantation. To this end, since the early 1980s, China began to use allogeneic adrenal transplantation to expand surgical indications. After long-term curative effect observation on a group of recipients, it proved that the transplanted gland survived and had physiological functions, and the curative effect was positive. The application value of adrenal allograft was preliminarily established from this clinical practice. At present, adrenal gland transplantation can be divided into two types: one is true allograft transplantation with vascular anastomosis (homotransplantation), the other is also called transplantation, but it is actually autologous adrenal tissue implantation. Autoimplantation. Recently, although autologous transplantation of adrenal tissue with blood vessels has been tried, its clinical value has yet to be further explored and verified. In order to make up for the defects of adrenal autologous tissue implantation, to develop indications for adrenal transplantation, and to improve the curative effect, since the early 1980s, China has first used allogeneic adrenal gland transplantation to treat bilateral resection of the adrenal gland. After the patient with Addison disease. At the same time as the cadaver was taken for kidney (or donor liver), the intact adrenal gland was transplanted to the above two types of patients. The early and mid-term clinical observations of several hospital case groups were more reliable and stable than autologous tissue implantation. Later, there were reports of the use of fetal adrenal gland for allogeneic transplantation. This new technology has been gradually accepted by clinicians and has attracted the attention of foreign scholars. Curing disease: Indication 1, Cushing syndrome has undergone bilateral adrenal total resection. 2, bilateral adrenal hyperplasia in the implementation of bilateral adrenal total resection, the glandular "normal" gland tissue can be used for tissue implantation or autologous transplantation, waiting for allograft surgery. 3. Adrenal cortical failure caused by various causes. 4, for all kinds of congenital adrenal dysfunction abnormalities of hydroxylase function, the use of allogeneic adrenal transplantation may be exempted from long-term hormone replacement therapy, may be a relative indication, but this is only a theoretical pre-cut, there is no clinical Experience. Contraindications There are no absolute contraindications within the scope of the indication, unless the patient already has a malignant cancer. Preoperative preparation 1. For the recipients to fight for the same blood type, and some also transplant the adrenal gland of the O-type blood donor to the A and B receptors. No other histocompatibility matches have been made in the past. 2. Maintain adequate amount of hormone therapy before surgery. Oral dexamethasone 4.5 mg or hydrocortisone 150-300 mg/d was given 1 day before surgery to give large doses of broad-spectrum antibiotics. 3. Hydrogen cortisone, 200mg/d, intravenous antibiotics during the transplant operation. Surgical procedure 1. Take the brain dead body, intubate through the laparotomy and abdominal aorta to the diaphragmatic plane. 4 to 8 ° C Collin solution perfusion. The bilateral adrenal gland, kidney, abdominal aorta, and inferior vena cava were cut out from the following. The cut organ was bathed in a Collin liquid reservoir at 4-8 ° C for refrigeration. The warm ischemia time is 6-10 min. 2. When cleaning the adipose tissue around the adrenal gland, pay attention to preserve a complete adrenal artery and adrenal vein to protect the glandular capsule intact. If the superior adrenal artery is used, a thicker branch of the infraorbital artery must be worn. If the middle or lower adrenal artery is used, it is best to have an elliptical wall flap with the center of the abdominal aorta or the opening of the renal artery. The extracorporeal section of the adrenal vein should be kept long enough to fit. The gland should be intact, not torn, and not contusive. 3. The Collin solution was infused with 4 to 8 °C through the selected adrenal artery. The perfusate can be gently infused by hand, until the gland is completely pale and bloodless, and the adrenal venous fluid is clear. About 30 to 40 ml of perfusate is required. 4. The irrigated adrenal gland is bathed in Collin with antibiotics and heparin to be transplanted. The anatomy, re-irrigation, and completion of the transplanted adrenal gland take about 4 to 6 hours, which is the warm ischemia time of the gland severance cycle. If you need to wait for transplant or long-distance transportation, you can refrigerate in 4°C Collin solution for 24~30h. After rebuilding the cycle, the vitality and function will not be affected. 5, the transplant site can choose the inguinal or lower abdominal wall. If the former is selected, the saphenous vein, the deep femoral artery and its branches are first revealed, and the external rotation is preferred. The proximal end of the great saphenous vein and the adrenal vein end-to-end anastomosis. Intermittent sutures with 5-0 or 6-0 non-invasive needles can be done under direct vision. The deep femoral artery is ligated to the distal end of the heart, and the proximal end of the heart and the superior adrenal artery and the associated infraorbital artery are end-to-end anastomosis. The diameter of the blood vessel is between 0, 8 and 0, and 3 mm. The anastomosis often needs to be completed successfully by means of a surgical microscope. Sutures were interrupted with 8-0 or 11-0 non-invasive needles. 6. If the adrenal middle artery or the adrenal inferior artery with the abdominal aortic wall flap or the renal artery wall flap is selected, the diameter of the tube can be increased to about 2 mm. The diameter of the adrenal vein is about 4, 0 mm. Therefore, the anastomosis of the artery and the vein can be completed under the naked eye without the aid of a surgical magnifying glass. 7. If the lower abdomen is selected for the transplant site, the inferior epigastric artery and vein can be dissected first, and the adrenal gland and vein are matched with the above method. There is a rich vascular communication branch in the adrenal gland. As long as one artery is completed, it can supply the blood supply of the whole gland. After the blood circulation was reconstructed, the whole gland was observed. If the color was immediately rosy and the vein filling was good, it indicated that the transplantation was completed satisfactorily. The gland and the surrounding tissue were properly fixed, and the anastomotic vessels were observed to be free of distortion. After the topical antibiotic solution was washed, the incision of each layer of the graft was sutured. The procedure and technical points of the human recipient transplantation using the neonatal adrenal gland are substantially the same as those described above. complication Preventing infection in the transplanted area is the key to whether the transplanted gland can survive and restore function. The prevention and treatment measures must be carried out to every detail of the operation. The dose of corticosteroids should be appropriate. If the dose is large and the time is too long, the recovery of the transplant gland function can be inhibited. In general, the dose should be small and not too large, and the time should be short and not too long. However, the dose is small, the time is too short, and the cortical crisis is feared. It can only be adjusted according to the clinical observation and according to the specific conditions of each patient. At present, there is no scientific routine to follow.