GHP CC TNG TRONG BNG

GS BS Vn Tn Ch nhim B Mn Ngoi i Hc Y Khoa Phm Ngc Thch, TP H Ch Minh (Phng theo Sabiston Textbook of Surgery, Chapter 27, pp 699-755, Edit 17th) Ghp tng bt u t thp k u ca th k 20. Ban u ghp cho sinh vt, ngi c cng u tin l Alexis Carrel, c gii thng Nobel nm 1912. Gn 40 nm sau, Medawar m t s thi ghp sinh vt, c gii thng Nobel nm 1950. Murray, ghp cho 1 b sinh i thnh cng nm 1954 v c gii thng Nobel nm 1990. Thuc chng thi ghp, ch to nm 1960, lm cho tng ghp cho ngi khc c gi lu. S tin b nh ngi cho tng ghp cng nhm m, dng thuc chng thi ghp, cch gi cc tng cho v cch m lm cho tng ghp gi c lu, chng nhng thn m c nhng tng khc. Sau y l ghp thn, ghp gan, ghp ty v ghp rut.
GHP THN Ch nh: 3 bnh lm cho thn b suy, phi ghp thn l suy thn khng ph thuc vo Insulin trong tiu ng, vim cu thn v cao huyt p chim gn 60% trng hp. Cc nguyn nhn quan trng khc l thn a nang, bnh Alport, immunoglobulin, lupus , x thn, vim thn m k v nght thn. chu Phi, suy thn do cao huyt p dn u. Ngi i c ghp thn ngy cng nhiu hn ngi cho. Chun b ngi nhn: Mu ngi nhn v ngi cho phi ph hp: Nhm mu ABO: T bo lympho phi ph hp: Khuynh hng x l trng hp khng ph hp: Mu truyn: nm 1973, Opelz, truyn mu cho ngi ghp thn trc, thn ly ghp sng 1015% hn ngi khng truyn, t ngi ta mi truyn mu trc ghp. V nguy c ly lan HIV, Hepatitis v lm cho ngi nhn nhy cm hn i vi tng cho, nn truyn mu trc khi ghp b b. iu kin ty xng: Cn bn ci. Trc ghp: Chn ngi cho: M ph hp: HLA phi ph hp. Nguy c ca ngi cho: T vong 0,05%. Ngi cho khng lin h: Ly thn ngi cho: Ni soi ly thn: ly c. Chn ngi cht no cho: iu tr ngi cho: tui t 3 n 65 b chn thng no hoc b tai bin mch mu no. iu tr ngi cho: Cho thuc chng min nhim. HLA ngi cht no cho: cn HLA ph hp.

Ly thn ngi cht no: cn h hp v tun hon c duy tr, chng ng mu cn cho. Ly thn, mt on ng mch ch, mt on tnh mch ch, niu qun ra cho vo dung dch lnh ngm thn (4 ), sau khi canul vo u di MC v TMC bm dung dch (4 ), u trn MC c ng li. Gi thn ngi cho: Bm dung dch 4-10 gm c K, Na, Cl, Citrate, PO4, SO4, Glucose., Sucrose, Mannitol, Bicarbonate v Magnesium. Dung dch ny dng trong thi gian di nht l 48 gi. Sinh vt cho thn: Kh, heo. M ghp: Bnh nhn gy m dng gin c atracurium. Ni M thn vi M chu trong (x m nhiu) hay M chu ngoi v TM thn vi TM chu ngoi. tr con, khi dng thn ngi ln cho, c th ni M, TM thn vi MC v TMC. iu tr sau ghp: Nu thn ghp khng b thiu mu, nc tiu ra nhiu 1000 ml/gi v 1- yu t osmotic sau khi ur huyt cao hay lng ng cao trong mu, 2- lng nc tng cng trong ngi d ngi ur mu cao, 3- ng thn b tn thng va. Sau ghp c khi b thiu niu, nht tr con cn cho thm plasma hay mu. Sau ghp, bnh nhn v niu, hyperkalimia l nguy c u tin, cn dng kayexalate. Trong HA cao thng xy ra , cn cho h HA. Cho khng sinh. Chng thi: Azathioprine: nga thi ghp, nm 1988, Gertrude Elion v George Hitchings c gii thng Nobel v cht ny. Corticosteroids: Chng thi ghp khi kt hp vi Azathioprine. Khng th chng lymphocyte: OK T3, CD3. Cyclosporine: nm 1980, c s dng lm cho ghp tng tt hn hn, nhng liu cao gy nhim c thn. N c tnh khng nhim v tnh khng thi. Tacrolimus (FK 506): c ng dng tt hn cyclosporine. Mycophenolate Mofetil: sau 2 nm ghp thn v ty, sng 86% v 95% v 83% v 95% s dng MMF (mycophenolate mofetil) thay v azathioprine. Sirolimus (Rapamycin): vi cyclosporine, n chng thi v khng c i vi thn ghp. Cc thuc khc: Thi ghp: C th rt cp, cp v kinh nin. Tnh trng ny kh phn bit r gia cc th. Bui hi tho Banff c th cho bit cc tiu chun mi v thi tng ghp v pht trin cch gi c bn. Thi rt cp: i mu thn, khng mu nui v ngng hot ng. - Thi cp: Thi bt u t t bo trong vi ngy hay vi tun sau khi ghp, cng c khi vi thng hay vi nm. Du hiu lm sng kinh in l au, st, thiu niu, tng huyt p v au thn ghp. Dng cyclosporine v tacrolimus dnh cho chc nng thn b suy l chnh, trong trng hp ny, scan thy r thn c th khng c mu n. Mun bit chc cn chp hnh khi cung thn b kt, niu qun nght hay d niu qun. Sinh thit thn s bit nhiu hn. Trong cng thc Banff, i thn, ng thn v mu nui thn l khng b (0), t b (1), b va (2) hay nng (3). iu tr thi ghp cp tnh: corticosteroids (0,5-1 g methylprednisolone), 65% p ng tt sau 3 n 5 liu. Nu khng chu th th dng tacrolimus hay MMF. - Thi ghp kinh nin: thi ghp t t, lm mt chc nng thn. Thi ghp kinh nin thng tip theo thi ghp cp tnh sau khi iu tr. nh bnh gm c tiu ra m, tiu mu vi th v chc nng thn suy t t. Cng thc Banff cho bit. Dng liu cao corticosteroids hay ALS, OK T3 c th cu vn. Suy thn ti pht sau ghp:

Vim i thn: L nguyn nhn th ba gy suy thn, khong 8,4%. Bnh collagen: Lupus . Bnh chuyn ha: Cystimosis, oxalosis, tiu ng. Bin chng: Do k thut: - Mch mu: CT scan hay chp hnh ng mch s cho bit. - Xut huyt: Do h ng khu. - Cao huyt p v thuyn tc mch mu thn ghp: Lacombe chp hnh cho bit 23% mch mu b hp. Nguyn nhn c th do khu ni, c tn thng intima, hay xon ch khu. - Bin chng niu qun: Do ly ht mch mu nui. - Hoi t cp ng thn. - Lymphoceles. Bin chng khng do k thut: - Nhim khun do: vi trng, nhim trng c hi, cytomegalovirus (CVM), suy thn pylomavirus. - Hyperglycemia. - Bin chng tiu ha. - Hyperparathyroidism. - U bu. Kt qu ghp thn: 65% ghp t xc cht sng 5 nm, 40% sng 10 nm. Thn ghp t cho thn sng hn thn cho t xc cht n 20%. Thn cho t ngi trn 60 tui, sng qua 5 nm s l 50%, t 6 n 18 tui sng 5 nm s l 72%. GHP GAN Ch nh: Gan cp hay mn, suy gan giai on cht, ung th gan cha di cn ra ngoi gan. im ChildTurcote-Pugh nh gi tnh trng nng ca chc nng gan cn li. t tnh trng trn, MELD (Statitical model for end-stage liver disease) v ESLD (End-stage liver disease) c dng nh gi gan suy s c nguy c t vong trong vng 3 thng. Ngi ln X gan khng mt - Vim gan B v C - Ung ru - Khng r Nght mt - X gan tin pht - Teo hp ng mt tin pht Bnh t min Ung th Bnh khc Ch nh ghp gan (Bng 1) Tr con 65 ng mt b teo Sanh ra b bnh chuyn ha Nght mt Teo ng mt tin pht 14 Hi chng Alagille Bnh t min Vim gan siu vi 5 Bnh khc 2 14

58 11 9 4 2 16

Hu ht ngi suy gan do ru b nhim siu vi C im Chil-Turcote-Pugh ca Suy gan nng im 1 2 3

au u Bng bng Bilirubin PBC/PSC Albumin (g/dl) PT (INR)

0 0 <2 <4 > 3,5 < 1,7

1-2 t 2-3 4-10 2,8-3,5 1,7-2,3

3-4 Va >5 > 10 < 2.8 > 2,3

Ph hp vi t vong trong vng 3 thng: MELD v CTP im Ph hp 95% khong trung thc MELD 0,88 0,85; 0,90 CTP 0,79 0,75; 0,85 Ghp gan iu tr: Vim gan B: hu ht b nhim vim gan siu vi B v 1 s b suy gan din tin gy hu qu xu. Rt may l phng nga vi immune globulin siu vi B hay lamivudine. Vim gan C: trong 1 nm thng tt 85-90%, nhng trong t 5 n 10 nm, gan s b suy. Cho nn tin lng km hn cc loi ghp khc. Suy gan do ru: Nu khng nhim thm siu vi C th tin lng nh cc loi ghp khc. PBC (primary bile cirrhosis) v PSC (Primary sclerosing cirrhosis): 90% s tt. Ung th gan tin pht: nhng ca chn lc v d nh histologic grading ca G1-2 v bu < 5 cm th sng 3 nm t 60-85%. Teo ng mt: phu thut Kasai tht bi th phi ghp gan. 1/10.000 tr s sanh mc phi. Ghp gan tht bi: thng xu hn ghp ln u. Chn bnh v chun b: Ngi b suy gan t t hay suy gan cp trn c a vim gan mn hay ngi bnh thng thnh lnh b suy gan ti cp cn phi a n trung tm ghp gan. Ngi b suy gan ti cp c au u, ri lon ng mu v lng ng mu thp v hn m cn ghp gan gp. Ngi cho gan: Ngi cht no hay ngi cho cn sng. M ly gan ngi cho: Ngm gan ly ra vo nc lnh ri cho vo dung dch gi gan, thng ti a khong 10 gi. Gi trong dung dch i hc Wisconsin ti a 24 gi, thng di 10 gi. M ngi nhn: Ct b gan, xem xt k cc cung mch mu, cha di ghp cho d. Cung M gan, cung TM ca, cung TM trn v di gan. Ghp: - Th tnh mch: ni tnh mch gan vi tnh mch ch; ni tnh mch ca. - Th ng mch v ng mt: ni ng mch ngi nhn vi ngi cho (ng mch thn tng v 1 s nhnh) v ng mt c hoc khng ng T, ni vi hng trng. M ly 1 phn gan ngi sng: ra vi nc lnh. Ghp: ging nh ghp c gan, tr ng mt th ni vi hng trng. M phc tp v bin chng: Bin chng xut huyt: Ngi tng p TM ca, dng tiu cu v huyt thanh ti lnh. Thuyn tc tnh mch ca: ly mu cc.

Khu li ng mch gan: cn thit. Sau ghp: Bin chng thng gp: - Gan khng hot ng: 2-3% ghp gan, t vong sm do nhim trng - Chy mu trong bng: cho tiu cu v mu - Tc mch: cn ghp li - D mt: m li - Nhim trng: dng khng sinh ph rng v chng nm. Vn min nhim: Thi cp: thng 10 ngy, c khi 3 thng, 6 thng. Lm sng gm st, au bng, SGOT, SGPT tng v mt tng. Biopsy s nh bnh. Cho corticosteroids liu cao. Nu corticosteroids khng hiu qu th dng khng th monoclonal hay polyclonal anti-T cell, 90% trng hp s n. Thi mn: thy nhiu thng, nm sau ghp, cn ghp li. au gan li: nhim siu vi B, cn cho lavimudine. Kt qu lu di: 30.000 ca ghp gan, ngi ghp v gan ghp sng 10 nm l 59 v 51% ngi ln. tr th 78 v 63%. Ghp cp cu v ghp bnh nhn suy a tng t vong cao. Ngoi ra cn tui cao, suy h hp, suy thn v ghp li t vong s cao. GHP TY Ch nh v chn bnh: T 1988 n 2000, M c 10,562 ca ghp ty, 83% ghp c ty ln thn, 12% ghp ty sau ghp thn, v 5% ch ghp ty. cc nc khc, 93% ghp c ty ln thn. Trn hu ht mi trung tm, ghp ty c s dng loi tr min nhim i vi ghp thn v suy thn do tiu ng. Ngi cho ty: tui tc, nhim khun, huyt ng hc khng n hay ung th th khng c. M ly ty: gan v ty-thn ly nguyn khi. Chun b ty ly ra: ly ty ln t trng, ngm trong dung dch lnh, ri ct bt t trng. Khu M mng treo chung vi M lch. Chun b ngi nhn, ghp ty: Ni M khu chung vi M chu, ni TM ca vi TM chu, ni t trng vi t trng hay ni t trng vi bng quang. Yu t sinh hc nh hng ti ghp ty: Yu t m hc: Yu t min nhim: Yu t thi: Nghim trng ca thi. Thng thn v ty cng b thi 1 ln. nh bnh thi: islet b thi u tin (hyperglycemia). Nu thn cng ghp th serum creatinine tng. Sinh thit thn s bit thi sm. iu tr: dng corticosteroid liu cao v khng th anti- T- cell. Min nhim ti pht: Bin chng ghp ty:

 Nght mch: Vim ty: D ty v p-xe: D trong thng u thng l do d ming ni, d sau l do d ng khu. Bin chng niu: C th b vim niu o, t niu o, tiu mu, nhim trng tiu. Kt qu: Kt qu iu tr tiu ng: Tr mt vi trng hp lng ng xung thp, tt c cn li lng ng thng tt. Tng ghp sng: t nm 1966 n nm 2002, M c 12.900 ca ghp ty, sng qua 1 nm trn 95%. Nhm ghp: tt n 95%. ng ghp: dn lu qua bng i (81%) hn qua rut (74%) sau 1 nm. nh hng min nhim: tacrolimus. nh hng ca vi mch ty ghp: au thn kinh: dn truyn thn kinh tt hn. au mt: 30% kh hn. au thn: kh hn. Kt lun: tt hn nhiu. Ghp Ty Islet: - K thut chun b Islet: truyn enzyme collagenase vo ng ty, tch islet khi acinar, ng, hch lymph v mch mu. - Ch ghp Islet: cho vo tnh mch ca. - Islet min nhim: ch c trn chut. - Min nhim: Kenyon dng CD154, cho khi thy lng ng gi c bnh thng kh lu. - Tolerance: khng c (Posselt). - Min nhim ch: tht kh. - Vt ghp khc loi: ngay c k thut ghp islet thc hin c, lm sao p ng c hng triu ngi ang i. Ngi ta ngh n heo, c islet ph hp vi ngi nhng kh l mu nui, lm sao cho islet sng c. - Lm sng: ghp Islet c th thay th c iu tr insulin v ghp c ty. - Phng php tch: thng ng dng k thut Ricordi. - Phu thut v bin chng: nght h thng ca hay xy ra. - nh hng ca chuyn ha: vi iu kin l phi gi cho lng ng trong mu bnh thng trong mt thi gian. - T ghp Islet: dng ty ngi b vim ty kinh nin, ngi ny ty ngoi tit b ph hy. - Islet bnh nhn b ung th ty: c nhng ung th ti pht. - Ghp Islet ngoi lai: c nhng kh, khng phi ngi cho b tiu ng type I. Phi dng k thut Edmonton. - T min ph hoi Islet: Kh bit. - Islet thai nhi ngi v sinh vt: lm, cn bn ci. - Thi ghp: rt kh bit, ch c o lng ng trong mu. GHP RUT

Rut ngn: 3 cch ghp rut non c thc hin: 1 - ghp rut non vi mt t i trng. 2 - ghp rut non chung vi gan. 3 - ghp rut non vi nhiu tng. Hin nay ghp rut non vi mt t i trng v ghp rut non vi gan c lm gn bng nhau, tuy nhin ghp rut non vi gan nguy him hn v rut non b thi th m ly ghp v nui dng qua tnh mch, ch gan b thi th ch c ghp li. Ch nh ca ghp rut non l rut ngn, nui dng qua tnh mch kh khn v tnh mch b h hi v suy gan do nui dng qua tnh mch. Ci kh ca ghp rut non l b thi qu cao, v d nh thn v gan, lng thi t 10% n 40%, cn rut non b thi t 90% n 100% trong vng 6 thng. Vn thi rut non kh bit, sinh thit cng khng th bit c, nhng chnh l mt nim mc rut lm mt chng nhim trng a n nhim trng huyt v t vong. Nguy him nht l th cc nhanh lm mt h thng lm mu. 90-100% b thi trong vng 6 thng, nh tnh cht thi kinh nin, cc bin php chng thi mnh, a s rut ghp vn cn hot ng. Kt qu: M (Pittsburg), c 165 ghp rut non, sng 1 nm l 75%, sng 5 nm l 54% v sng 10 nm l 42%. T nm 1994, ghp sng 1 nm l 78%, sng 5 nm l 63%, nh ci thin bin php chng thi, chng hn nh dng khng th cyclophosphamide ant-H2 receptor iu tr v cho ngi ghp t bo ty hay chiu tia on rut ghp. CH LI X HI V NGI C GHP Ghp tng kh t nhng nhng ca ghp tng l ca giai on cht ca bnh. N c gi tr hn c iu tr ung th. V d mi ca ghp thn tn khong 40.000 US Dollar (1998), v mi nm phi tn thm mt s tin na nhm theo di, bo tn v chng thi nhng tnh chung vn r hn chy thn nhn to. i vi ghp rut, ghp vn c li hn. Ghp ty th t hn l do insuline nhng n nga c m v suy thn. V vy, bo him ng ra nng . i vi ghp gan hay tim cng nh th. Tuy nhin, mt tng suy v cht sm, tnh li s r hn ghp nhng t ngi thch nh th v nu c phng php g cu c nh ghp tng chng hn th h li mong mun. V vy, nh nc M nm 1980, chp nhn ghp tng v khuyn khch ngi cho tng, c bit ngi cht no. t lu sau, ly tng ca ngi cn sng cng c khuyn khch. C iu t ra l ngi ngho bn tng, v d nh thn, vn ny khng thuc php l ca ngi M. Trung Quc ngi cho tng l ngi t b t hnh, mc d cam kt, iu ny cng khng c php lut M cng nhn. Vn ghp t bo hay mt nhm t bo, vic ny lm c bit l ty nhng hiu qu cha chc chn.