腹部器官簇移植治疗终末期肝病合并胰岛素依赖的2型糖尿病五例

Modified upper abdominal cluster transplantation in patients with end-stage liver diseases associated with insulin dependent type 2 diabetes mellitus

目的总结了改良的腹部器官簇移植（MCT）治疗终末期肝病合并胰岛素依赖的2型糖尿病（T2DM）患者的经验。方法回顾性分析了单中心连续实施的5例MCT的资料。5例全部为男性，原发病为乙型肝炎后肝硬化合并T2DM3例，乙型肝炎后肝硬化合并T2DM1例，原发性肝癌（HCC）合并T2DM1例。受者切除患肝后，原位植入包括肝脏、胰腺、部分十二指肠的器官簇，器官簇来源于同一个供者。胆道和胰腺外引流采用供者十二指肠与受者上段空肠Roux-ewY吻合或者侧侧吻合方式。术后采用巴利昔单抗诱导，他克莫司（Tac）＋吗替麦考酚酯（MMF）＋皮质激素联合应用预防排斥反应，之后过渡至单用Tac维持治疗。结果5例手术均顺利，患者于术后早期（8～27d）完全脱离胰岛素治疗，并且血糖水平维持正常。其中3例术前C肽水平严重降低，术后早期明显升高，并维持于正常水平。1例术后发生移植物抗宿主病，并死亡，其他4例顺利恢复，术后分别随访22、15、5和4个月，均存活，并已恢复正常生活，移植物功能正常，血糖水平正常。结论腹部器官簇移植是治疗终末期肝病合并胰岛素依赖的2型糖尿病的有效手段。

Objective Modified upper abdominal cluster transplantation （MCT）, which was inspired by the classical cluster transplant technique, has been proven more effective and feasible in the treatment of patients with end stage liver diseases associated with insulin-dependent diabetes mellitus （DM） than orthotopic liver transplantation （OLT） alone. In this study, we summarized our experience with MCT in 5 consecutive patients suffering from end stage liver diseases associated with insulin-dependent type 2 DM in our single center. Methods Five patients with hepatitis B-related chronic liver cirrhosis and insulin dependent type 2 DM received MCT in our single center. The biliary and exocrine pancreatic drainage reconstructions were achieved by a Roux en-Y duodenojejunostomy or a side-to-side duodenojejunostomy. A quadruple immunosuppressive regimen based on tacrolimus including Basiliximab induction, mycophenolate mofetil （MMF） and steroids was used in the early stage post-transplant, and then converted to tacrolimus monotherapy. Results All of the patients experienced an uneventful post-operative recovery. They were rendered independent from insulin therapy shortly after transplantation. The fasting glucose and glycosylated hemoglobin levels were within normal range. In addition, the fasting C-peptide value was increased from much lower than the normal range pre-transplant to within normal range post-transplant and maintained stable since then. However, the third patient suffered from graft verse host disease （GVHD） 20 days post-operatively and died from severe infection on the post-operative 47 days. The other 4 patients had returned to work and a normal lifestyle over 22, 15, 5 and 4 months of follow-up. Conclusion MCT is an effective method in treating patients suffering from end stage liver diseases combined with insulin-dependent type 2 D1VL Whether a cluster graft would increase the risk of GVHD needs further investigation.