2018年·第98卷第36期

Coronary artery bypass grafting (CABG) has become a routine treatment for coronary heart disease, with low complication rate and good safety. However, the problem of venous bridge stenosis after CABG has been paid more and more attention. In the past 20 years, with the deepening of coronary angiography follow-up, the patency rate of arterial bridges was significantly better than that of great saphenous vein (SVG) bridges. The occlusion rate of SVG bridges occurred in 10% ~20% in the first year, and the occlusion rate increased by 5% every year^[1,2,3,4,5]。 In the SYNTAX study, almost all patients undergoing CABG underwent at least one artery graft compared with percutaneous coronary intervention (PCI), and 35.3% of patients underwent multiple artery graft. The use rate of multiple artery graft in the United States is low, only 17%^[6]。 In the past few decades, most surgeons in the United States have used only a single vessel bridge from the left internal thoracic artery (LITA) to the left anterior descending artery (LAD), and the remaining target vessels are still SVG bridges. The average multi-vessel bridge utilization rate in the Adult Cardiac Surgery Database (ACSD) of the North American Society of Thoracic Surgeons (STS) is about 7%^[7]。

PTE and DVT are collectively referred to as VTE. The thrombus causing PTE mainly originates from DVT in the lower extremities, and PTE is a complication of DVT. PTE and DVT have the same predisposition factors and are two clinical manifestations of VTE at different sites and stages.

A 64-year-old female was admitted to the Second Affiliated Hospital of Zhejiang University School of Medicine in September 2014 due to "repeated dull pain in the upper abdomen for more than 20 years". Vital signs are stable and general condition is acceptable. B-ultrasound showed that bilateral cervical lymph nodes were detected. Abdominal enhanced CT (Figure 1) and magnetic resonance examination revealed lymphoma and splenomegaly. There were no obvious abnormal X-ray signs in the lung and diaphragm in the anterolateral position of the chest. Liver function: total bile acid 22.5 μ mol/L, triacylglycerol 1.99 mmol/L, low density lipoprotein 3.60 mmol/L; Blood routine: white blood cell count 6.0×10⁹/L, mature neutrophils 79.1%, hemoglobin 125 g/L, platelet count 135×10⁹/L. The patient underwent "laparoscopic retroperitoneal tumor biopsy" under general anesthesia. During the operation, multiple retroperitoneal enlarged lymph nodes were found, partially fused into masses and adhered to the mesenteric membrane. Intraoperative intestinal membrane root and retroperitoneal lymph node pathology considered as small cell lymphoma (FIG. 2A)。 Conventional pathology showed that small lymphoid cells (retroperitoneal lymph nodes and mesenteric root lymph nodes) were obviously proliferated, and combined with immunohistochemical staining, it was consistent with B-cell small lymphocytic lymphoma (B-SLL) /chronic lymphocytic leukemia (CLL). Immunohistochemical results (Figure 2B): CD3 scattered +, CD20^＋, CD79a^＋CD10^－, Bcl-6^－, MUM-1 focal +, Bcl-2^＋, CD5^＋, CD23^＋, CyclinD1^－CD38^－, Ki-67 5%, P53 scattered^＋, TdT^－CD99 scattered^＋。

The patient, female, 48 years old, was admitted to hospital due to "repeated melena with dizziness and fatigue for 2 months". She was anemic, and the blood routine showed: red blood cell count 1.53×10¹²/L, hemoglobin 39 g/L; Abdominal MR showed irregular thickening and abnormal enhancement of the walls of the descending colon and sigmoid colon, diffuse abnormal signals in the abdominal cavity, pelvic cavity and retroperitoneal cavity, and angiomas were mostly considered (Figure 1)； Mesenteric arteriovenography showed dilated lymphatic vessels in the intestinal wall and delayed return in the venous phase (Figure 2)； Electronic colonoscopy showed that congestion and edema of intestinal mucosa could be seen at 28~50 cm from the anus, and obvious ecchymosis could be seen. Preliminary diagnosis: ischemic bowel disease? Colonic angioma? Concurrent hemorrhage. Surgical treatment was performed after correction of anemia. Surgical exploration showed that the inferior mesenteric vein was the main trunk, and the branch veins on the mesenteric were tortuous and dilated obviously, with multiple cystic protuberances. The intestinal wall above the splenic flexure of transverse colon, descending colon, sigmoid colon and rectal peritoneal reflux all had cystic protuberances, tortuous and dilated vessels, and the intestinal wall was dark purple, edematic, thickened and stiff (Figure 3)。 Exploration decided to perform extended left hemicolectomy. The intestinal tube was separated from the normal intestinal wall approximately 2.0 cm each near and distal to the vessel tortuosity of the intestinal wall under the transverse colon near the splenic flexure and peritoneal reflux. The examination specimens confirmed that the diseased intestinal tube and mesangium were completely removed, and end-to-end transverse colonorectal anastomosis and prophylactic ileostomy were performed. A large amount of blood and white turbid fluid flowed out when the specimen was cut after operation (lymphatic fluid may be) (Figure 4), postoperative pathology: cavernous angiolymphangioma of the left colon. Immunohistochemistry : CD31 (+), CD34 (+), Ki-67 (index 2%), CKp (+), D2-40 (+), FVIII-RAG (+) (Figure 5，Figure 6，Figure 7，Figure 8，Figure 9)。

A 41-year-old female was admitted to the hospital on January 5, 2018 due to "discovery of abdominal tumor for 1 week". One week ago, the patient planned to undergo appendectomy in the local hospital due to right lower abdominal pain. During the operation, the lesion was found to be an abdominal tumor, which could not be removed. The biopsy pathology showed "malignant tumor" and was transferred to our hospital. Admission physical examination: vague palpable movable mass in the lower abdomen. Relevant examination and pathological consultation diagnosis in our hospital: The tumor cells in the tissue submitted for examination are composed of a large number of naive mesenchymal cells, and the tumor cells are mostly short spindle-shaped, some of which are nodular (Figure 1)； Cells are abundant, arranged in clusters or cords, and mitotic images are common, showing pathological mitosis (Figure 2)； Interstitial mucoid, with focal and lamellar necrosis. Immunohistochemistry: Vimentin (+), CD117 (-), CD34 (-), CD99 (-), CK (-), Desmin (-), epithelial membrane antigen (EMA) (-), Ki-67 (60% +), MyoD1 (-), neuron-specific enolase (NSE) (-), S100 (-), smooth muscle actin (SMA) (-), Syn (-); A spindle cell malignancy of the abdominal cavity is considered, with a tendency towards extraosseous mucinous chondrosarcoma. CT: Consider cystic-solid mass of lower abdomen (Figure 3), possibly from the intestine, peritoneum, or ovary. Female tumor marker: CA125 was 104.5 U/ml.

Cornelia de Lange syndrome (CdLS) is a rare genetic disease involving multiple organs. The main clinical manifestations include characteristic facial appearance, growth and development retardation, limb defects, congenital heart disease and gastrointestinal dysfunction^[1]。 In 1933, Dutch pediatrician Cornelia de Lange first reported the syndrome and named it after her. At present, the global incidence of CdLS is about (1.6~2.2) /100,000, but due to the diversity of disease manifestations, some cases with atypical or mild clinical manifestations may be missed^[2]。

Acinetobacter baumannii is a class of Gram-negative coccidia, which exist widely in natural environment, especially in hospital environment, and is one of the most widespread nosocomial acquired infection pathogens worldwide. In recent years, the study of virulence of Acinetobacter baumannii has become a research hotspot, and many potential virulence factors have been identified, including outer membrane proteins, lipopolysaccharides, capsular polysaccharides, phospholipases, penicillin-binding proteins, outer membrane vesicles, iron acquisition, etc. This article will briefly review the virulence factors of Acinetobacter baumannii.