臺灣博碩士論文加值系統

將微創手術運用於血管摘取是現今進行冠狀動脈繞道手術的趨勢，其除了能縮小手術傷口外，更顯著的減少術後的傷口疼痛、縮短住院時間、縮短臥床的時間、使病患進行早期復建，同時提升了病患滿意度。自2001年迄今，我已為超過1,700名冠心病患進行冠狀動脈繞道手術，其中300多名病患進行微創的冠狀動脈繞道手術，在這些案例中，因為一些臨床的經驗與觀察，我們針對使用內視鏡時常用以輔助的二氧化碳充氣來探討二氧化碳造成栓塞的發生率、嚴重度及其與壓力大小之關連，並研究使用內視鏡摘取大隱靜脈對內皮細胞造成的影響。
第一部分，我們以經食道超音波探討二氧化碳造成栓塞的發生率與嚴重度，結果發現在403位病患中，共有17.1%位病患發生二氧化碳栓塞，程度可分為少量（13.1%）、中量（3.5%）、及多量（0.5%）氣泡，中量至多量好發於清除大隱靜脈分枝的當下，但在統計上並沒有找到直接相關控制變因，整體而言，明顯發生二氧化碳栓塞的約有4％，而持續以經食道超音波監控下腔靜脈有助於早期發現及預防嚴重二氧化碳栓塞，而這也是這項手術技術首次被報導的重要的合併症。
接著我們探討二氧化碳栓塞的發生是否會隨著二氧化碳充氣壓力的降低而減少，在498個進行心臟不停跳冠狀動脈繞道手術的病患中，隨機分為高壓（15 mmHg）與低壓組（12 mmHg），並以經食道超音波來監控下腔靜脈氣泡的出現，結果發現，高壓組受試者的二氧化碳栓塞率（13.3%）明顯高於低壓組（6.5%，p<0.05），由此推論，二氧化碳栓塞可因二氧化碳充氣壓力的降低而減少；再次證明術中持續使用經食道超音波監控能幫助減少大量二氧化碳栓塞的發生風險，這兩項研究中二氧化碳栓塞的發生率，也有明顯的下降，這也說明了手術的經驗和技術的累積可以降低這種合併症。
第二部分的研究，是希望了解內視鏡大隱靜脈摘取手術對內皮細胞的影響，因為到目前為此，並沒有此項手術長期暢通率的報告，我們希望藉由研究內皮細胞型態與功能性分析，間接得知可能對長期暢通率的影響，我們先以20對大隱靜脈的標本進行內皮細胞上CD31表現量之評估，CD31是內皮細胞上一個重要的標誌，CD31的存在與否代表內皮細胞的健在，結果顯示CD31在傳統大隱靜脈摘取手術的這一個族群與微創手術的族群相比有顯著的減少的趨勢，這給我們很大的鼓勵，代表新的微創的手術可以保存更多內皮細胞的完整性；此外，我們進行內皮細胞功能的研究，針對蛋白質分析，共有22對大隱靜脈的標本進行endothelial nitric oxide synthase（eNOS）、endothelin-1（ET-1）、和cyclooxygenase-2（COX-2）三種蛋白質的定量，這三種蛋白質是一般認為對內皮細胞的功能、血小板的凝聚、血管的舒張與收縮扮演相當重要的角色，傳統手術組的濃度分別為302.87±128.8、1.84±0.1、0.59±0.0 pg/mg protein而內視鏡組的濃度則是286.94±111.0、4.48±0.3、0.30±0.0 pg/mg protein，研究結果顯示這三種分子之蛋白質含量在不同手術方式所摘取的大隱靜脈並沒有明顯的差別，針對這項結果我們的想法是，蛋白質的形成，從訊號傳遞到基因的表現需要一定的時間，甚至長過我們手術的時間，於是我們更深入針對上游RNA層次作探討，共有26對大隱靜脈的標本進行eNOS、ET-1、COX-2 RNA的定量，結果顯示eNOS和COX-2的RNA在兩種不同手術所得到的大隱靜脈的標本的表現量並沒有差異（eNOS、COX-2在傳統手術分別是15.4±7.5、12.6±6.9；在內視鏡手術分別是與17.1±19.5、10.9±6.9），但ET-1 RNA在傳統手術方式的表現量卻高於內視鏡手術的表現量（16.3±6.7與8.79±4.1），且具有統計學上顯著的意義（p=0.00035）。從形態及功能性研究，我們可以說，利用微創手術摘取大隱靜脈與傳統方式並沒有差別。然而，在未來，除了透過臨床診斷的方法外，我們也預計進行大隱靜脈在短期承受動脈壓力之後所產生變化的相關研究，期望能應用於預測血管的長期暢通率，以提供更直接明確的佐證。
微創心臟手術是一條艱辛又遙遠的路，我期望藉由這些年的經驗與大家分享，並提供後學者一個較清楚的方向，以期造福更多病患。

第一章 中文摘要 1
第二章 緒論 3
第一節 冠狀動脈繞道的微創手術 5
第二節 不停跳的冠狀動脈繞道手術 7
第三節 內視鏡輔助微創冠狀動脈繞道手術 10
第四節 使用內視鏡摘取橈動脈進行冠狀動脈繞道手術 13
第五節 內視鏡大隱靜脈摘取術 18
第六節 內視鏡大隱靜脈摘取手術於臨床上的優缺點 22
第三章 研究方法與材料 24
第一節 如何減少二氧化碳栓塞 24
（一） 二氧化碳栓塞在進行內視鏡摘取大隱靜脈手術時的影響及嚴重性 24
（二） 二氧化碳栓塞與充氣壓力之關連 27
第二節 內視鏡大隱靜脈摘取手術對內皮細胞的影響 28
（一） 以CD31進行血管內皮形態的研究 30
（二） 以血管內皮中endothelial nitric oxide synthase（eNOS）、endothelin-1（ET-1）、和cyclooxygenase-2（COX-2）進行血管內皮功能的研究 31
（三） 儀器設備 49
第四章 結果 50
第一節 如何減少二氧化碳栓塞 50
（一） 二氧化碳栓塞在進行內視鏡摘取大隱靜脈手術時的影響及嚴重性 50
（二） 二氧化碳栓塞與充氣壓力之關連 53
第二節 內視鏡大隱靜脈摘取手術對內皮細胞的影響 54
（一） 以CD31進行血管內皮形態的研究 54
（二） 以血管內皮中endothelial nitric oxide synthase（eNOS）、endothelin-1（ET-1）、和cyclooxygenase-2（COX-2）進行血管內皮功能的研究 56
第五章 討論 59
第一節 如何減少二氧化碳栓塞 59
（一） 二氧化碳栓塞在進行內視鏡摘取大隱靜脈手術時的影響及嚴重性 59
（二） 二氧化碳栓塞與充氣壓力之關連 61
第二節 內視鏡大隱靜脈摘取手術對內皮細胞的影響 63
第六章 展望 67
第七章 論文英文簡述 71
第八章 參考文獻 78
第九章 附錄 85

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