台大醫院的肺臟置換療法

Abstract

肺臟置換療法是解決末期肺臟功能障礙的根本方法，肺臟置換療法包括肺臟移植以及人工肺臟，肺臟移植是目前肺臟置換療法中較為可行的方法，但是肺臟移植受限於肺臟捐贈的短缺，長期性人工肺臟在未來的實際使用，將是根本的解決辦法。在本論文中，根據台大醫院的十二例肺臟移植經驗，藉以了解肺臟置換療法的要點，並且檢視台大醫院肺臟置換療法的有效性，進而對未來長期性人工肺臟的實際運作與執行做可行性評估。 台大醫院的肺臟置換療法，其適應症包括有慢性阻塞性肺病，原發性肺動脈高壓和守宮木所致的閉鎖性細支氣管炎。從肺臟移植的實際案例經驗予以探索反證，冀望能由了解台大醫院肺臟移植案例成功的關鍵因素，包括術後的感染控制、排斥反應的免疫抑制、以及血管接合術的技能改進等等，將有助於人工肺臟的成功表現。 人工肺臟的氣體交換發生於人造通透膜處，這人造通透膜也是體外肺膜氧合器（葉克膜）的前身。葉克膜和血管內氧合器只容許數天到數週的使用時間，但是隨身型人工肺臟能提供比葉克膜或血管內氧合器更長的使用時間。隨身型人工肺臟的結構類型包括有肺動脈至左心房型，肺動脈至肺動脈型，右心房至肺動脈型，以及雙腔靜脈幫浦型。 長期性人工肺臟的需求背景來自葉克膜受限於較短的使用時間，而其技術需求則主要是在於克服葉克膜的人造通透膜的生物相容性問題，這技術需求也因此導致了幹細胞的引進應用。由於對自身肺臟幹細胞無排斥反應的特性，使得以肺臟幹細胞覆蓋於具生物相容性的人工肺臟支架時，將表現出完全相容的長期性人工肺臟。這種生物醫學科技將結合肺臟移植的手術技能和幹細胞的增殖技術與生物相容性人工肺臟支架，如此以肺臟幹細胞再生技術做為人工肺臟的肺臟置換療法，將是未來完美的長期性人工肺臟。

Lung replacement therapy is the radical way to solve the problem of the end-stage pulmonary dysfunction. The lung replacement therapy includes both lung transplantation and artificial lung, the lung transplantation is the feasible method of the lung replacement therapy nowadays, but this operation is limited to the shortage of the donor lungs. The future practical use of the long-term artificial lung will be the radical solution. According to the 12 cases of lung transplantation reported by NTUH (National Taiwan University Hospital) and checking the effectiveness of the lung replacement therapy in NTUH, it is contributive to perform the artificial lung by virtue of the understanding and mature practice of the lung transplantation. The indications for lung replacement therapy in NTUH include chronic obstructive pulmonary disease, primary pulmonary hypertension and Sauropus Androgynus-induced bronchiolitis obliterans. To understand the successful key factors of the lung transplantation in NTUH, e.g. control of the infection, immunosuppression for the rejection, and the skill of the vascular anastomosis, is helpful to the successful performance of the artificial lung. The gas exchange of the artificial lung could occur across a man-made membrane. The spiral coiled membrabe lung is the forerunner of the ECMO (extracorporeal membrane oxygenation). ECMO and intravascular oxygenator allow only for days to weeks, but paracorporeal artificial lung provides the longer duration than ECMO or intravascular oxygenator. The configurations of the paracorporeal artificial lung include pulmonary artery to left atrium, pulmonary artery to pulmonary artery, right atrium to pulmonary artery, and the double lumen venovenous configuration with a pump. The task requirement for long-term artificial lung is based on the limitation of the shorter utility of ECMO and the technique requirement for long-term artificial lung is mainly to overcome the problem of the biocompatibility of the man-made membrane of ECMO. Therefore, it causes the application of stem cells. The character of the stem cells will be totally compatible with the artificial lung while the artificial lung is treated with the pulmonary stem cells covered the biocompatible scaffold. This biomedical technology will combine the surgical skill of the lung transplantation and biotechnique of the proliferation of the stem cells of the recipient with the biocompatible scaffold to regenerate the artificial lung. The perfect solution of the long-term lung replacement therapy will be the stem-cell regeneration of the artifiial lung.