难治性胆石病的外科手术经验-附521例报告

目的 探讨难治性胆石病的手术方式与技巧.方法 回顾性分析1990年1月至2007年12月湖南省人民医院肝胆医院收治的521例难治性胆石病患者的临床资料.结果 全组均行手术治疗,除3例术后围手术期并发肝肾功能衰竭死亡,其余518例无严重并发症、痊愈出院.经影像学检查有残石者78例,占15.0%.423例获随访,随访率为81.7%,平均随访时间7年6个月(5个月～17年).效果良好率达90.1%.结论 大部分难治性胆石病可以根治,个体化的手术方案、精细规范的手术操作是保证疗效的关键.

Abstract：

Objective To summarize the experience in operation manner and surgical technique of refractory cholelithiasis.Methods A total of five hundred and twenty one patients with refractory cholelithiasis admitted to Hunan Provincial People's Hospital from Jan.1990 to Dec.2007 were involved in this study for retrospective analysis.Results All patients in this group accepted surgery.Apart from three cases of perioperative death with liver and kidney failure,the remaining five hundred and eighteen cases had no serious complications,were cured and discharged.The imaging examination showed residual stone in seventy cases,accounting for fifteen percent.Four hundred and twenty one patients were followed up.The mean time of follow-up was seven years and six months (range 5 months - 17 years).Good result rate was 90.1%(381/423).Conclusions Most intractable cholelithiasis can be cured radically.Individual surgery programme,fine and standard surgical procedure are the key to treatment effect.     

Successful removal of a potentially lethal left atrial thrombus detected by transesophageal echocardiography following the removal of a left ventricular assist device inflow cannula

The left ventricular assist device (LVAD) is a battery-operated, mechanical pump-type device that helps in maintaining the pumping ability of a failing heart. Thromboembolism poses a significant risk during and after LVAD implantation. It occurs in up to 35% of patients with adverse sequelae. We present the case of a 75-year-old man who underwent coronary artery bypass graft surgery and LVAD implantation for acute myocardial ischemia and severe left ventricular dysfunction. However, subsequent transthoracic echocardiographic examination revealed an LVAD thrombus, and LVAD removal was suggested following the failure of thrombolytic therapy. After the LVAD cannula was removed, transesophageal echocardiography (TEE) revealed a residual thrombus in the left atrium. Thrombectomy was successfully performed by opening the left atrium with cardiopulmonary bypass. We believe that TEE monitoring aided the implantation and removal of the LVAD device. In this case, we found that TEE not only helped in monitoring the ventricular function but also in detecting other problems such as the residual thrombus. We strongly recommend TEE monitoring during the entire LVAD-removal procedure, particularly for patients who need to undergo LVAD removal because of thrombosis formation.     

Tumor suppressor death-associated protein kinase is required for full IL-1β production

Interleukin-1β (IL-1β) is critical for inflammation and control of infection. The production of IL-1β depends on expression of pro-IL-1β and inflammasome component induced by inflammatory stimuli, followed by assembly of inflammasome to generate caspase-1 for cleavage of pro-IL-1β. Here we show that tumor suppressor death-associated protein kinase (DAPK) deficiency impaired IL-1β production in macrophages. Generation of tumor necrosis factor-α in macrophages, in contrast, was not affected by DAPK knockout. Two tiers of defects in IL-1β generation were found in DAPK-deficient macrophages: decreased pro-IL-1β induction by some stimuli and reduced caspase-1 activation by all inflammatory stimuli examined. With a normal NLRP3 induction in DAPK-deficient macrophages, the diminished caspase-1 generation is attributed to impaired inflammasome assembly. There is a direct binding of DAPK to NLRP3, suggesting an involvement of DAPK in inflammasome formation. We further illustrated that the formation of NLRP3 inflammasome in situ induced by inflammatory signals was impaired by DAPK deficiency. Taken together, our results identify DAPK as a molecule required for full production of IL-1β and functional assembly of the NLRP3 inflammasome. In addition, DAPK knockout reduced uric acid crystal-triggered peritonitis, suggesting that DAPK may serve as a target in the treatment of IL-1β-associated autoinflammatory diseases.