原位肝胰十二指肠联合移植:附2例报告

Simultaneous liver-pancreas-duodenum transplantation:two cases report

目的探讨肝胰十二指肠联合移植的适应证和治疗效果。方法总结分析本中心近两年实施的肝胰十二指肠联合移植2例,1例为酒精性肝硬化伴2型糖尿病,1例为乙肝肝硬化伴2型糖尿病肾病。2例患者均采用原位整块的肝脏、十二指肠、胰腺联合移植。供者器官切取和修整简单,移植时依次吻合肝上、肝下下腔静脉;供者肠系膜上静脉与受者肠系膜上静脉吻合;供者腹腔干动脉与受者肝总动脉吻合。术后采用巴利昔单抗诱导治疗;采用他克莫司(FK506)+霉酚酸酯(MMF)+泼尼松(Pred)三联免疫抑制治疗。结果患者1实施肝胰十二指肠联合移植,术后出现肠瘘,未发生弥漫性腹膜炎和严重感染,经充分引流后,肠瘘逐渐愈合。患者2实施肝胰十二指肠移植联合肾移植,术后出现胰腺周围积液和切口愈合不良,予以充分引流和换药处理后痊愈;2例患者术后移植肝和移植胰腺功能恢复正常,完全脱离胰岛素治疗。患者1由于术后1年7个月发生急性排斥反应,应用甲泼尼龙冲击治疗,出现胃肠穿孔继发腹膜炎而死亡;患者2术后6个月出现血丙氨酸转氨酶(ALT)升至150 U/L,转换为低剂量他克莫司联合西罗莫司治疗,患者肝功能改善,ALT维持在80 U/L。患者存活至今,移植物功能良好。结论对于终末期肝病伴有血糖难以控制的糖尿病患者实施肝胰十二指肠联合移植治疗,可以取得良好的治疗效果。

Objective To investigate the indications and effects of treatment on end-stage liver disease and diabetes mellitus with simultaneous liver-pancreas-duodenum transplantation. Methods In recent 2 years, 2 simultaneous liver-pancreas-duodenum transplantations have been carried out in two patients,one with alcoholic liver cirrhosis and type 2 diabetes mellitus,another one with chronic hepatitis B related liver cirrhosis and type 2 diabetes mellitus. Both of the two patients underwent in situ en bloc liver,duodenum and pancreas transplantation. Organ harvesting and trimming were simple. We anastomosed the suprahepatic inferior vena cava and infrahepatic inferior vena cava of liver graft to the eponymous vessels of recipient,superior mesenteric vein of liver graft was anastomosed to superior mesenteric vein of the recipient; celiac artery of the liver graft was anastomosed to hepatic artery of recipient. Basiliximab was used for induction therapy,tacrolimus(FK506),mycophenolate mofetil(MMF) and prednisone(Pred)were used for immunosuppressive therapy. Results Patient 1 underwent liver-pancreas- <br> duodenum transplantation and suffered post-operative intestinal fistula, which was healed with adequate drainage without diffuse peritonitis and severe infection. Patient 2 underwent combined liver-pancreas-duodenum and kidney transplantation and suffered peripancreatic effusion and surgical wound bad healing which were successfully treated by adequate drainage and changing of wound dressing. The functions of pancreas and liver allograft of these 2 patients were recovered immediately and both patients became insulin-independence postoperatively. Patient 1 suffered an acute rejection episode treated by intravenous bolus methylpredisolone 1 year 7 months after operation, and died of acute peritonitis secondary to gastrointestinal perforation. The level of alanine aminotransferase(ALT)of patient 2 increased to 150 U/L 6 months after transplantation,and immunosuppressive regimen were shifted to low dose tacrolimus and sirolimus therapy,then the ALT level decreased to 80 U/L. Patient 2 is alive with good grafts function. Conclusion It is effective to implement simultaneous liver-pancreas-duodenum transplantation for patients with end-stage liver disease and difficult-to-control diabetes mellitus.