Non-touch isolation hepatectomy and extra-corporeal anticancer therapy for liver tumors-Feedback of surgical technique in living-related partial liver transplantation to liver surgery-

探讨了发展“非接触分离法”用于肝恶性肿瘤切除的技术问题。为了防止肝切除过程中肿瘤ce11的播散，根据活体部分肝移植的捐献技术，首次获得无恶性肿瘤的肝叶，而不操纵肝脏的荷瘤部位。然后用IVC整片切除肝脏肿瘤部分。对于保存完好的肝叶再植入术，重建下腔静脉和肝静脉是新技术的难点。在置换IVC的Gore-Tex血管与肝静脉吻合中，肝静脉直接吻合Gore-Tex血管的侧壁是最适合肝引流和稳定移植肝脏的。在肝动脉重建中，采用微芯片进行肝动脉与脾动脉末梢端对端微吻合，可获得快速的手术过程和良好的通畅性。术后凝血功能障碍的高发生率是该技术的另一个问题。由于弹性蛋白酶在手术后很容易被激活，因此在整个手术期间给予蛋白酶抑制剂以避免引发DIC的发生。预防性使用蛋白酶抑制剂使术后止血相当容易。结果，动物可以存活10天以上，压倒了术后急性期。由于手术过程复杂和人工血管的使用，感染的控制是目前尚待解决的问题。在对手术中受损肝脏的保护研究中，利用“应激反应”激活细胞的“自我保护机制”是最有希望的。本研究证明，在应激干预之前，肝组织中诱导热休克蛋白（HSP）对热缺血再灌注损伤具有良好的保护作用。在正常肝脏中，肝脏热缺血30分钟后50%的死亡率提高到95%以上的存活率。再灌注后的能量代谢恢复也得到较好的维持。即使在热休克以外的其他方法（如缺血或药理学预处理）诱导热休克蛋白后，也能实现这种效果。这种保护作用也在受损肝脏模型中得到证实。在由四氯化碳产生的纤维化肝脏中，术后存活率从50%提高到90%。胆碱缺乏饮食引起的脂肪肝动物的存活率也从33%提高到87%。少

Technical aspects for the development of 'Non-touch isolation method' of hepatectomy for hepatic malignancies were investigated. The liver lobe without malignant tumor was first procured according to the technique for the donation of living-related partial liver transplantation without manipulating the tumor bearing parts of the liver in order to prevent the tumor ce11 dissemination during hepatectomy. The tumor bearing part of the liver was then extirpated in one piece with IVC.For the re-implantation of the preserved healthy liver lobe, reconstructions of the IVC and hepatic vein were of difficulty in this new technique. In the anastomosis between the Gore-Tex vessel for the replaced IVC and hepatic vein, direct anastomosis of the hepatic vein to the lateral wall of Gore-Tex vessel was most suitable both for hepatic drainage and for stabilization of the implanted liver. In the reconstruction of the hepatic artery, end-to-end micro-anastomosis between the hepatic artery and peripheral … More end of the splenic artery using micro-chip for vascular anastomosis was effective to obtain rapid procedure and the good patency. The high rate occurrence of postoperative coagulopathy was the other problem in this technique. Since elastase was easily activated after operation, protease inhibitor was administered throughout the operative period so that the initiation of DIC was not triggered. This prophylactic administration of protease inhibitor made postoperative hemostasis quite easy. As a result, animals could survive more than 10 days overwhelming the postoperative acute phase. The remaining problem is the contro1 of infection due to complicated operative procedure and the usage of artificial vessels.In the part of study for the protection of damaged liver during opertion, activation of 'self-protection mechanism' of the cells utilizing the 'stress response' was most promising. In this study, it was proven that the induction of heat shock protein (HSP) in the liver tissue prior to stressful intervention could confer excellent protection against warm-ischemia reperfusion injury. In the normal livers, 50% mortality in rats due to 30-minute warm ischemia of the liver was improved to more than 95% survival. Recovery of energy metabolism after reperfusion was better maintained as well. This effects was realized even after the induction of HSPs by other methods than heat shock, such as ischemic or pharmacological preconditioning. This protective effects were also demonstrated also in the damaged liver models. In the fibrotic livers produced by carbon tetrachloride, the postischemic survival was improved from 50% to 90%. The survival of the animals with fatty livers, which was produced by the choline deficient diet, was also improved from 33% to 87%. Less