E-Book, Englisch, 152 Seiten, ePub
Reihe: Thieme
Sidhu / Baxter Ultrasound of Abdominal Transplantation
1. Auflage 2002
ISBN: 978-3-13-257864-7
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark
E-Book, Englisch, 152 Seiten, ePub
Reihe: Thieme
ISBN: 978-3-13-257864-7
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark
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Section 1: Introduction
Historical Introduction: The Impact of Imaging on Organ Transplantation
Section 2: Renal Transplantation
Chronic Renal Failure and Pretransplantation Assessment
Renal Transplant Surgery
Ultrasound Imaging in Renal Transplantation
Pediatric Renal Transplantation
Interventional Radiology and the Transplant Kidney
Section 3: Liver Transplantation
Indications and Assessment for Liver Transplantation
Liver Transplantation: Surgical Techniques
Ultrasound Assessment of the Liver Transplant Candidate
Early Postoperative Liver Transplant Ultrasound
Long-Term Ultrasound Follow-Up of Liver Transplantation
Interventional Radiology in Liver Transplantation
Section 4: Multivisceral Transplantation
Pancreas Transplantation
Small Bowel and Multivisceral Transplantation
Historical Introduction: The Impact of Imaging on Organ Transplantation
D. Hamilton
Only within our generation has rapid progress been made towards the ancient goal of replacement of human tissue with that from other persons or animals. In the early part of the twentieth century the first step was taken when the old myth that allografts (i.e., grafts from other persons, then called homografts) could succeed by chance was replaced by a realization that there was a consistent barrier to transplantation. Until that time many skin and organ fragment transplants had been attempted in the absence of any objective measurement of outcome, and the large and contradictory literature on such early grafting used subjective, fallible outcome criteria. When improved understanding of immunology emerged and biochemical and radiological assessments appeared in the 1930s, the approach to transplantation had a more rigorous basis. These aids were not, however, exploited until the modern continuous period of organ transplantation in the 1950s, when management became increasingly dependent not only on laboratory medicine, but also on a growing variety of imaging techniques and radiological interventions. There is debate on the importance of immunology in day-to-day transplantation. There is no doubting the value of modern imaging in transplant management.
The long road to the initial successes of the 1960s will be reviewed in this chapter.
Ancient Times
The tales of ancient civilizations record stories of magical repair and replacement of lost parts of the human body. Since it was believed that the inflicting of disease and illness and even the outcomes after injury were in the hands of the gods, it was also assumed that supernatural forces could replace lost tissue, and folklore in all parts of the world has remarkably similar tales of magical transplantation.1 Helpful attributes in the recipientnotably a state of grace or personal worth—were also thought to enable the treatment to succeed. In the Christian tradition, for example, there were numerous such incidents, and at the medieval shrines in Britain, notably Canterbury, miraculous restoration of lost tissues was often reported. The best-known legend was the miracle involving the posthumous intervention by the twins St. Cosmas and St. Damian, who replaced a cancerous leg with that of a recently dead donor.
Skin Grafting: Flaps and Other Methods
A limited amount of conventional plastic surgery had been carried out in India in ancient times, as recorded in the Hindu text Susruta of the third century BCE. It described sensible, practical, reconstruction procedures for cosmetic defects, particularly following the mutilating punishments of the time. But thereafter, the ancient texts are silent on such matters, and the illustrious Greek medical writers in particular accorded little place to surgery in general, and even less to plastic surgical operations.2
The Middle Ages
Belief in divine healing declined and conventional surgery improved in the Middle Ages. The first known revival of the ancient Indian restorative surgery came in Italy in the fourteenth century, when it was discovered in use by skilled surgical empirics in Sicily, and through them the methods came to the notice of the talented trained surgeons of the northern Italian towns and universities. Gaspare Tagliacozzi (1545-1599) is remembered for accepting these techniques into the academic canon, and in his great text on plastic surgery of the face he usually employed an upper arm flap to replace nose or lip defects.3 He taught that success with allografts was prevented by the “power and force of individuality.” But it was a method ahead of its time, and the first of the early English surgical texts, James Cooke's The Marrow of Surgery, largely ignored the subject of replacement of tissue. There was a remarkable discontinuity in the practice of plastic surgery, and European surgical texts ignored the earlier sensible plastic surgery of Tagliacozzi until 1800, although enthusiastic surgeons made occasional claims for successful reimplantation of large detached bits of skin or parts of the nose or fingers.
Some nonclinical interest in tissue grafting was kept up by the protobiologists of the day, and the new pragmatic Royal Society in mid-seventeenth century London took some interest in transplantation of skin, teeth, and blood, but their experiments and results were inconclusive, leaving them to concentrate, with success, on the physical sciences instead. In Holland, shortly after, Trembley worked with the tiny pond polyps and showed their remarkable powers of fusion from divided parts of each other. This success encouraged uncritical allografting later.
John Hunter made a number of valuable observations in tissue transfer in the later 1700s.4 He judged graft success by successful adhesion of donor tissue and noted importantly that donor tissue must be grafted quickly after removal, otherwise the “life principle” in the graft, as he called it, would be lost. His grafts, notably of testis, deceptively appeared vascularized and viable, but he wisely claimed only tissue survival rather than functional replacement. He also taught that separated tissues would unite by the host and donor blood vessels rejoining in continuity, rather than ingrowth of new vessels from the host rescuing the graft. This faulty theoretical background, as seen in Hunter's writings, came from a familiar source, horticulture, where the trunks of one species then and now are routinely merged with desirable roots from another to give an improved hybrid. He noted that “as the transplanting of teeth is very similar to the ingrafting of trees, I thought the term ‘scion' for the graft might be transferred from gardening to surgery.” He also coined the word “transplant” for his procedure. But he misled surgery for a while with his claims for successful human tooth transplantation. Using human donor teeth, Hunter obtained a reputation for tooth transplants, but the practice revealed for the first time the danger of introducing disease from a graft, when he found that syphilis had been transferred along with a tooth grafted from an apparently normal donor. The first ethical concerns with transplantation also arose at this time, since paid tooth donation was in use, and Joseph Fox complained for the first time that this “involved a defect of the moral principle.”
Plastic Surgery Revives
In London, in 1812, closely following the ancient Indian methods, Carpue treated two patients whose noses were damaged by syphilis or trauma. It was an ancient treatment, observed by some colonists, that had mysteriously returned to favor.5 Surgical repair by plastic surgery was rapidly being taken up in the increasingly specialized clinics of Germany and France, though Britain lagged behind. Modern methods of plastic surgery were further encouraged in the mid-nineteenth century when Jacques-Louis Reverdin in Paris, aided by the teachings of Paul Bert and others in Claude Bernard's circle at the Collége de France, finally put free skin grafting on a sound basis and into regular use. Reverdin used multiple, thin, small “lambeaux cutanes”6 rather than single full-thickness grafts—and his grafts succeeded because new vessels grew in quickly. Bert also noted that that animal donor tissue vitality is temperature-dependent. He made the first demonstration that grafts would survive better if cooled, and explained this as retention of Hunter's “life principle.”
This new simple method of split skin grafting spread rapidly from Paris, and enthusiasts in London and Boston adaptedit and publishedon the method. These new “pinch” grafts met a need for covering the many unhealed ulcers, burns, and open wounds of the time. Ironically, the success with thin skin autografts seemed to encourage the uncritical use of skin grafts from unrelated human donors and even the use of xenografts, and a confused scientific literature emerged in the late 1800s describing the treatment of many human ills by the use of fragments of spleen, pancreas, nerve, thyroid, and ovary taken from other humans or animals.7
Vascular Surgery
Attempts at organ grafting progressed when the first attempts at human and experimental vascular surgery started in 1900. Crude suturing with the stitching materials then available without the support of anti-coagulation gave dismal results, but Payr's intravascular metal stents allowed occasional restoration of vessel flow, and successful experimental organ transplants were reported by a number of distinguished surgical scientists in Vienna.
The modern era of vascular surgery commenced when members of the Department of Surgery in Lyon, headed by Mathieu Jaboulay, devised better methods and materials for vascular anastomosis. Jaboulay carried out the first ever attempt at a human kidney transplant in 1906, but the xenografts placed in the arm of patients in chronic renal failure never functioned.8 Attached to Jaboulay's department in Lyon was the young Alexis Carrel, and he improved the departmental vascular surgical methods by adding triangulation and the use of finer nonpenetrating stitches. Carrel, out of favor in France, emigrated to Chicago and with Charles Guthrie published a remarkable series of technical papers on organ transplantation and preservation. He later moved to the Rockefeller Institute and established routine success with autografting of the dog kidney, but showed a consistent barrier to kidney allografting with this model. For this work he become...
