2015年 · 第30卷第09期

Since the first case of parathyroid carcinoma (PC) was recorded in 1904, less than 2,000 cases have been reported in English literature, and about 200 cases have been reported in domestic literature^[1], accounting for 0.005% of all malignancies, with an annual population incidence of approximately 3.5 to 5.7 per 10 000 000^[2,3,4,5]。 It is generally believed that PC accounts for 1% to 2% of cases of primary hyperparathyroidism (pHPT), but 5.1% is reported in Japan^[6]The domestic reports accounted for 3.5%, and the first diagnosis and first treatment of PC in our hospital accounted for about 6.4% of pHPT in the same period, which may be due to ethnic differences^[1]。 Although PC is a very rare malignancy of the endocrine system, Todd et al. in the United States found that the incidence of PC increased by 60% during the 10-year period at the end of the 20th century, which may be related to the routine development of blood calcium measurement and the relaxation of pHPT surgical indications^[7]。 In fact, PCs have indeed increasingly entered the field of vision of endocrinologists and surgeons in recent years.

A 38-year-old female was found to occupy cystic space in the abdominal cavity near the spleen for 5 months without abdominal pain, abdominal distension, nausea and vomiting, and no definite diagnosis and treatment was given. History of previous cesarean section, no other chronic diseases, trauma or surgical history. Abdominal CT in our hospital showed that cystic mass occupied at the splenic hilum of the tail of the pancreas (Figure 1)。 CA 199 68.06 U/ml, CA 125 191.2 U/ml. Exploratory laparotomy and mass resection were performed under general anesthesia, and the left rectus abdominis incision approach was performed. No ascites was observed during the operation, but the left abdominal wall was extensively adhered to the left peritoneum, omentum and left paracolonic sulcus. The upper pole of the mass reached the level of the upper edge of the spleen, the left side was immediately adjacent to the splenic hilum, and the lower pole was adhered to the tail of the pancreas with a clear border. During the operation, the mass was carefully separated to prevent damage to the blood vessels at the splenic hilum. Because the mass originated from the tail of the pancreas, the tail of the pancreas was tightly sutured after resection to prevent pancreatic leakage after operation. The capsule was intact after resection of the mass, and a gray-yellow jelly-like substance was seen after resection (Figure 2)。 Postoperative pathology: The cystic mass was 8.5 cm ×3 cm ×3 cm, containing jelly-like material, with a wall thickness of 0.1~0.3 cm, and a gray-yellow area was seen on the inner wall, 2.5 cm ×1.5 cm ×0.3 cm. Microscopically, the cystic wall was composed of fibers and smooth muscle, lined with bronchial ciliary columnar epithelium and gastric mucosa (Figure 3), consistent with the manifestation of foregut cyst.

A 50-year-old female was admitted to hospital for "left breast mass for three years with areola nipple pruritus and ulceration for two years". The patient accidentally discovered a left breast mass three years ago. Two years ago, the left areola and nipple showed itching and discomfort, accompanied by ulceration and intermittent pale yellow discharge, and the ulceration surface gradually spread to all areolas. Physical examination: The left nipple defect was fused with the areola, and the appearance was slightly reddened, swollen, rough, thickened and tender. At 11 o'clock in the inner upper quadrant of the left breast, a mass with medium size of about 1.5 cm ×1.0 cm, poor mobility, unclear boundary and no tenderness was touched at about 1.5 cm from the edge of the areola. No enlarged lymph nodes were palpable under bilateral axillaries. The tumor markers CEA, AFP, CA125, CA153 and CA199 were all normal. Thoracic and abdominal CT showed no obvious abnormalities. Under local anesthesia, a fusiform incision of the left breast was taken to remove part of the areola and the inner upper quadrant mass, and frozen during the operation: high-grade intraepithelial neoplasia (severe dysplasia) of the squamous epithelium of the left breast mass and Paget's disease of the left areola. Then modified radical mastectomy of left breast under general anesthesia was performed. Postoperative pathology: Left breast squamous cell carcinoma (Figure 1), with nipple areola Paget's disease (Figure 2), there was no cancer involvement in skin margin and basal margin, 21 axillary lymph nodes and no cancer metastasis. Immunohistochemistry: ER (−), PR (−), HER-2 (3+), CK 5/6 (+), P63 (+), calponin (+), Ki-67 (~30%). Postoperative clinical stage: T₃N₀M₀Stage IIB. Cisplatin + docetaxel chemotherapy was given after operation. No signs of tumor recurrence and metastasis were found on CT scans of head, thorax and abdomen and bone scans one month after operation.

An 18-year-old female was found to have a slow increase in the mass at the front of the neck for 3 years. Color ultrasound in the local hospital showed: a subcutaneous cystic-solid echo mass at the level of the median hyoid bone at the front of the neck, with a size of about 25 mm ×12 mm, a clear boundary, and a punctate strong echo. Color Doppler flow imaging showed an abnormal echo mass, and a small amount of blood flow signal could be seen in the solid part. Solid heterogeneous hypoechoic masses were observed in both thyroid lobes. No abnormalities in thyroid function were found, thyroglossal duct cyst was diagnosed, and "thyroglossal duct cyst resection" was performed in the local hospital. The cyst and part of the hyoid bone were completely removed during the operation. Postoperative pathology: The morphology was consistent with the papillary carcinoma of thyroid origin. The cancer cells invaded the striated muscle, and a small number of abnormal cells were seen in the hyoid bone tissue. Postoperative oral Tc^99mScan: No abnormal concentration and sparse areas were found in the neck (Figure 1)。 One month later, he was transferred to our hospital. Reexamination of neck color ultrasound showed: bilateral solid hypoechoic thyroid nodules (TI-RADS grade: 4a) and bilateral abnormally enlarged lymph nodes in the neck. Pathological section consultation showed "papillary carcinoma of thyroglossal duct" (Figure 2)。 Then "bilateral thyroid lobectomy + bilateral regional neck lymph node dissection" was performed under general anesthesia. During the operation, nano-carbon tracer was injected into the gland, and the bilateral thyroid glands were completely removed, and the black-stained lymph nodes in areas 3, 4 and 6 of the neck were dissected. The postoperative pathological report: bilateral papillary thyroid carcinoma, and no metastatic cancer was found in the cervical lymph nodes. I was performed in the Department of Nuclear Medicine of our hospital 1 month after operation¹³¹100 mCi Treatment. Thyroxine tablets were administered orally after discharge, and TSH was controlled below 0.1 μ IU/ml by monthly review. I was administered orally again after 5 months¹³¹Whole body imaging showed no concentration of abnormal radioactivity distribution.

The patient was a 33-year-old male. He was admitted to hospital for 17 years due to intermittent painless hematochezia, aggravated with anemia and fatigue for 2 years. Physical examination: anemia appearance, an old surgical scar about 20 cm long was seen on both buttocks, and blue-purple tumor-like varicose veins were seen on the skin of the penis and scrotum, protruding from the skin surface. A cluster of nevus, about 3 cm ×4 cm in size, was seen on the left side of the anus (FIG. 1A)。 The patient has blood in the stool about 2 to 3 times a day, each time the amount is about 30 to 80 ml. Blood routine : Hb 50 g/L, WBC 3.92×10⁹/L, PLT 310×10⁹/L. Fiber-optic colonoscopy showed blue-purple hemangioma-like changes in the mucosa from 30 cm to the anal margin (FIG. 1B), and no abnormalities were observed in the rest of the intestinal segments. No abnormalities were found in gastroscopy and abdominal color ultrasound examination. He claimed that he had undergone capsule endoscopy and found no positive lesions in the small intestine, so he refused to be examined again. A bilateral buttock mass was discovered 33 years ago (14th day of birth), and surgical treatment was performed. Postoperative diagnosis was "lymphoma?". 13 years ago, abnormal branch embolization of inferior mesenteric artery and left internal iliac artery was performed. The symptoms of blood in stool did not improve and tended to be aggravated.

The patient, 50-year-old female, was admitted for 1 d with abdominal pain. Abdominal pain is mainly in the upper abdomen, which is persistent dull pain, no back tightness, no fever, no nausea, vomiting, no hematemesis and melena. Admission physical examination: mild anemia appearance, unpalpable swelling of superficial lymph nodes. All abdominal softness, tenderness in the upper abdomen, no muscle tension and rebound pain, and negative mobile voicing. Laboratory tests: Blood routine: Hb 8.9 g/L. Abdominal enhanced CT revealed a solid mass in the left upper abdominal sac, the solid part was obviously enhanced, originating from the large curvature of the stomach, and fluid density shadows were seen around and in the left paracolonic sulcus, which was considered as the possibility of gastric stromal tumor with rupture (Figure 1)。 Gastroscopy showed a bulge about 2 cm in diameter in the posterior wall of the fundus junction, and the surface mucosa was eroded and bleeding. Endoscopic ultrasound showed a heterogeneous mass at the lesion of the posterior wall of the stomach, which was irregular in shape, with some anechoic changes, protruding outside the cavity, with poor boundaries, originating from the muscle propria, and was considered as gastric stromal tumor. Operation was performed on 20 May 2014. Intraoperative exploration showed that there was a 15 cm ×10 cm cystic mass in the posterior wall of the stomach and the front of the pancreas, with high tension, most of which was pale blood fluid, and there was jelly-like substance near the tail of the pancreas and the posterior wall of the stomach, with unclear boundaries and easy bleeding when touched. 200 ml of light blood fluid was seen in the abdominal cavity, and flaky erythema-like tissue was seen on the serous surface of the gastric antrum and gastric body. Total gastrectomy was performed, and the stomach wall was incised. A 3 cm ×2 cm erosion and hyperplasia in the posterior wall of the fundus of the stomach was seen, which was hard in texture, followed by a jelly-like mass (Figure 2)。 The operation went smoothly. Postoperative pathological report: Gastric plexiform angiomyxoma of the posterior wall of the gastric body, with unequal lobulated tumor components, invasive growth and transition to smooth muscle fibers. Among the tumor components, scattered spindle cell proliferation is the main one, accompanied by interstitial mucinous degeneration and inflammatory cell infiltration (Figure 3)。 The lesion involved the lamina propria of the mucosa to the outside of the serosa, and the local small blood vessels showed tumor-like proliferation. Mucosal erosion, hyperplasia of mucosal glands in some areas, goblet cell hyperplasia with disordered arrangement. Immunohistochemical staining: CD117 (-), CD34 (-), Dog-1 (-), CgA (-), Syn (-), Ki-67 (+<1%), P53 (+), SMA (focus +), Vim (+), S-100 (-), Galretinin (-), Vim (+), CD21 (-), CD35 (-), calretinin (-). Diagnosis: gastric plexiform angiomyxoma (plexiform angiomyxoid myofibroblastic tumor, PAMT). The patient recovered and was discharged smoothly after operation, and no recurrence or metastasis was found on CT review six months later.

Massive hemorrhage is considered to be one of the main factors of serious complications and prognosis of liver surgery. When the blood flow into the liver is blocked, the hemorrhage during hepatectomy mainly comes from the reflux of the hepatic vein and the short hepatic vein. Hepatic vein hemorrhage is closely related to central venous pressure (CVP)^[1]Reducing CVP can reduce bleeding during hepatectomy. In recent years, our department has adopted postural adjustment and subhepatic IVC occlusion, a low central venous pressure (LCVP) technique that can be controlled by surgeons, combined with intrahepatic blood flow occlusion, which can effectively reduce the bleeding during hepatectomy. The report is as follows.

thromboangiitis obliterans (TAO) is a vascular inflammatory disease that occurs in young and middle-aged men who smoke cigarettes. Small and medium arteries and veins are often involved, causing stenosis of the arteries of the lower and upper limbs^[1]。 Because lesions often involve small and medium vessels, vascular bypass surgery cannot be performed in most cases due to lack of good outflow tract^[2]。 From May 2009 to June 2014, the First Affiliated Hospital of Nanjing Medical University treated 15 patients (16 limbs) with thromboangiitis obliterans for endovascular treatment, which is reported as follows.

The principle of surgical treatment of choledocholithiasis is to relieve the obstruction, remove the lesion and unobstructed drainage. After laparoscopic common bile duct exploration (LCBDE), the primary suture method of common bile duct has the advantages of less pain, faster recovery and less complications than the traditional T-tube drainage. In recent years, 59 cases of laparoscopic common bile duct suture and intraoperative common bile duct angiography were completed in our hospital. No bile leakage, residual bile duct stones and bile duct stenosis were found after operation, and the treatment effect was satisfactory. The report is as follows.

Plasmcell mastitis (PCM) occurs in non-lactating young women. Traditional surgical treatment is easy to destroy the shape and has a high recurrence rate^[1,2,3]Since January 2014, 53 cases of plasma cell mastitis have been treated by vacuum-assisted rotary mastectomy system (Mammotome) combined with minimally invasive drainage in our hospital. Now the therapeutic effect is analyzed.

congenital internal hernias (CIH) is one of the rare causes of intestinal obstruction^[1]The incidence rate is low, accounting for only 0.2% to 0.9% of the causes of small bowel obstruction^[2]However, when patients have symptoms of intra-abdominal hernia accompanied by acute intestinal obstruction, their mortality rate is as high as more than 50%^[3]。 From April 2009 to April 2014, a total of 8 adult patients with intestinal obstruction caused by CIH were treated in our hospital. The analysis and report are as follows.

The necrosis and ulceration of huge tumors on the body surface is accompanied by severe infection, and the infection is prolonged, so the treatment is very difficult; Extended tumor resection is the only way to treat such patients. Because of the large surgical wound, autologous skin grafting is needed. For contaminated surgery, skin grafting fails due to secondary infection after surgery. In view of this, 7 cases of huge tumor with necrosis accompanied by infection were treated in our department. Extended tumor resection was performed, and vacuum sealing drainage (VSD) was used to avoid postoperative wound infection. Second-stage skin grafting achieved good results. The summary report is as follows.

thyroid cancer is the most common malignant tumor in human endocrine system, and its incidence has increased rapidly in recent years. papillary thyroid carcinoma (PTC) is the most common pathological tissue type of thyroid cancer, and about 38.2% of the new cases of papillary thyroid carcinoma in China^[1]Thyroid micropapillary carcinoma (papillary thyroid microcarcinoma, PTMC). As defined by the WHO, PTMC refers to PTC with a tumor diameter ≤1 cm^[2]。 PTMC is small in size and has no special clinical symptoms. It is difficult to find it simply by clinicians' palpation examination before operation. Some PTMC is found during the patient's physical examination, and some PTMC is found when the patient sees a doctor for benign thyroid lesions. It is reported in the literature that the detection rate of PTMC in thyroid specimens resected by surgery due to benign lesions is 24.0%^[3]PTMC was detected as high as 35.6% in necropsies of deaths due to non-endocrine diseases^[4]。 At present, with the development of high-frequency ultrasonic examination equipment, ultrasonic examination has greatly improved the detection rate of PTMC.

pancreatic segmental portal hypertension (PSPH) is a rare extrahepatic portal hypertension caused by pancreatic diseases, and its incidence is increasing year by year in recent years. As a possible cure portal hypertension, it is especially important to diagnose and treat it in a timely and accurate manner. In the past, due to the low incidence of this disease, the understanding of it is insufficient, which makes the treatment of PSPH single. In this paper, the individualized treatment of PSPH is proposed for the first time, and its etiology, clinical manifestation, auxiliary examination and various treatment methods are reviewed.

Because of the changes in diet structure, population growth and aging, vascular disease has become the most common disease that threatens the health of Chinese people. Surgical reconstruction of blood flow is an important method for the treatment of vascular diseases; Selecting appropriate vascular graft materials is crucial to the efficacy of surgery. Vascular graft materials mainly include autologous blood vessels, allogeneic blood vessels, artificial blood vessels and tissue engineered blood vessels. Autologous blood vessels such as great saphenous vein have no immune rejection and high near-and long-term patency. They are widely used in lower limb arterial bypass grafting^[1,2]Coronary artery bypass grafting^[3]； However, the source of autologous blood vessels is limited, and it cannot be used for the reconstruction of large blood vessels, such as thoracic and abdominal aorta. At present, there is no ideal autologous blood vessel to replace. Artificial blood vessels have been widely used in clinical practice, but the near-and long-term patency rate of small and medium artery artificial blood vessel bypass, such as inferior genicular artery bypass^[4]； At the same time, once the artificial blood vessel is infected, it is necessary to remove the graft and reconstruct the blood vessel^[5]。 Although tissue engineered blood vessels have great development potential, there is no mature commercial blood vessels for clinical use at present. The allogeneic vessel has good anti-infection effect, and the diameter and length of the vessel can be matched with the target vessel. It has high application value in blood flow reconstruction surgery for large vessel infectious lesions and small and medium vessel diseases without autologous vessel^[5,6]。