2017年 · 第32卷第07期

gastrointestinal stromal tumors (GIST) are rare mesenchymal tissue tumors, accounting for 0.1% ~3% of all gastrointestinal malignant tumors, with an incidence of 1~1.5/100,000. GIST can occur in any part of the digestive tract, most commonly in the stomach and small intestine. The molecular mechanism is caused by activating mutations in the gene encoding the tyrosine kinase receptor protein gene KIT (CD117) or the platetet-derived growth factor receptor alpha (PDGFRA) gene^[1]。 In the last 20 years, the understanding of GIST-related signal transduction pathways and advances in molecular targeted therapies have greatly improved the overall efficacy and prognosis of GIST patients. This paper reviewed the progress of GIST in epidemiology, pathology, imaging, surgery and targeted therapy.

Gastrointestinal stromal tumors mainly occur in the stomach (60% ~70%) and small intestine (20% ~30%), while less occur in the colorectum (<5%), and there are few studies on its treatment modalities and prognosis^[1,2]。 A total of 21 patients with colorectal stromal tumors have been treated in our hospital in the past 25 years. The clinical characteristics and surgical treatment of colorectal stromal tumors are summarized as follows.

laparoscopic abdominoperineal resection (LAPR) can significantly shorten hospital stay without affecting local tumor recurrence and long-term survival^[1]。 However, failure to perform high-quality pelvic floor peritoneal suture during operation will significantly prolong the operation time and even lead to serious complications. Our surgical team has performed LAPR since September 2013 with barbed suture (V-Loc ™ 180) Combined with Hem-o-lok ligation clip to close the pelvic floor peritoneum, the effect is good and is now reported as follows.

Liver transplantation is an effective method for the treatment of end-stage liver disease. Pleural effusion is one of the most common complications after liver transplantation, but refractory massive pleural effusion seriously affects the prognosis and quality of life of patients. In this paper, the clinical data of 28 patients with refractory massive pleural effusion after liver transplantation were retrospectively analyzed, and the treatment methods and effects were further discussed.

Among closed abdominal injuries, gastrointestinal tract injuries are relatively rare. This study retrospectively analyzed the clinical data of CT diagnosis and surgical treatment of 12 patients with gastrointestinal tract injury, which are reported below.

The concept of enhanced recovery after surgery (ERAS) believes that preparation and evaluation before surgery, meticulous operation during surgery and rational use of analgesics after surgery can alleviate patients' pain, promote rapid recovery after surgery, shorten hospital stay, and effectively improve patients' medical experience^[1,2,3]。 In this case, combined with the diagnosis and treatment process of a patient who underwent laparoscopic-assisted extended right hemicolectomy, the application experience of ERAS in our center is summarized and reported as follows.

This study investigated the safety and feasibility of hand-assisted laparoscopic surgery in patients with T4 locally advanced colorectal cancer by comparing the short-term and long-term results of radical multiple organ resection completed by hand-assisted laparoscopy, laparoscopy-assisted and open surgery.

A 69-year-old female was admitted to the hospital in July 2016 due to "abdominal pain and abdominal distension for 1 week". One week before admission, the patient suddenly suffered from persistent distension and pain in the lower abdomen, accompanied by nausea and vomiting of stomach contents. There was no defecation in the past 5 days, and the anal exhaust was significantly reduced compared with before. The patient had a history of "radical left nephrectomy" 3 years ago, and the postoperative pathological report was renal clear cell carcinoma. Physical examination: An oblique old surgical scar of about 15 cm in length was seen in the left waist. Abdominal swelling, no gastrointestinal pattern and peristaltic waves, obvious tenderness and rebound pain around the umbilicus and right lower abdomen, no palpable mass, whole abdominal percussion drum sound, negative mobile voiced sound, intestinal sound 10~12 times/min, and the sound of gas passing through water can be heard. Routine blood test: Hb 89 g/L. Serum tumor markers: CA-125 102 U/ml (normal range: 0-35 U/ml), CEA, CA19-9 normal. Abdominal X-ray film showed that the middle and upper abdominal intestinal tube was dilated and accumulated gas, and the shape of the intestinal tube was spring-shaped, with unequal air and liquid surfaces, suggesting incomplete intestinal obstruction. Total abdominal CT plain and enhanced scans showed multiple slightly larger lymph nodes in hilar and retroperitoneum, ileocecal intussusception and secondary intestinal obstruction, local intestinal wall edema, abnormal enhancement of some intestinal walls, and space-occupying lesions were not excluded (Figure 1)。 Exploratory laparotomy showed: about 200 ml of pale yellow ascites in the abdominal cavity, and no metastases were found in the pelvic cavity, peritoneum and liver. The ileum was intussuscepted 100 cm away from the ileocecal region, resulting in intestinal obstruction. The intestinal tube above the obstruction site was dilated and the intestinal wall was edematous. A hard mass about 3 cm ×5 cm in size could be palpable in the intussuscepted intestinal tube. Small intestinal decompression and partial intestinal resection were performed. Postoperative pathological report: metastatic clear cell carcinoma of the small intestine with a high possibility of renal origin (Figure 2，Figure 3)。 Immunohistochemical staining examination: CD10 (2+) (Figure 4), CK (+), Ki-67 (40% +), RCC (individual +), Vim (+), EMA (+), CD56 (+). The patient was followed up for 3 months, the incision healed well, no symptoms such as abdominal pain and abdominal distension appeared again, no chemotherapy was performed after operation, and no tumor recurred.

The patient was a 47-year-old female. Admission due to "left breast mass found for 3 days", outpatient breast color ultrasound: heterogeneous echo mass on the lateral side of the left breast, BI-RADS grade 3, adenolipoma? Physical examination: A mass of about 5 cm ×6 cm in size can be found in the upper quadrant of the left breast, which is soft in texture, without tenderness, and can be moved. There are no swollen lymph nodes under both axillaries. Under local anesthesia, a radial incision was made on the surface of the mass, and the skin and subcutaneous fat were incised. A mass about 5 cm in size was found, with a capsule and mucous content, and it was removed along the periphery of the mass. Postoperative pathology: superficial angiomyxoma of left breast, immunohistochemical stellate spindle cell Vimentin and CD34 positive (Figure 1,Figure 2,Figure 3,Figure 4), a small number of cells were positive for SMA and MSA, and negative for Desmin. The patient was followed up for 1.5 years, and there was no recurrence or distant metastasis.

A 27-year-old female was admitted to the hospital for 10 days due to hairs in the stool, and 8 days after endoscopy revealed "colon mass". Physical examination: digital anal examination can touch the lower edge of the tumor, and the finger cuff is not stained with blood. Colonoscopy revealed that a spherical mass of about 3 cm in diameter was visible at a distance of 16 cm from the anus, covered with hair, and the biopsy pathology reported teratoma (Figure 1)。 Exploratory laparotomy was performed. During the operation, a dense adhesion between the end of the sigmoid colon and the left ovary was seen, and a spherical mass, about 5 cm in diameter, was palpable in the corresponding intestinal lumen, with a large range of mobility, and it seemed that there was a cord connected to the left ovary. It was gradually free along the surface of the cord until it entered the intestinal lumen, which confirmed that the cord was the pedicle of the tumor. The mass was completely removed and the colon wall was repaired. At the same time, it was found that there was also a cystic-solid mass in the ipsilateral ovary, about 2 cm in diameter, and it was completely removed. Postoperative pathological report: mature teratoma of colon, mature cystic teratoma of left ovary (Figure 2)。

A 50-year-old male was admitted to the hospital due to the discovery of a "huge abdominal mass for 1 month". Physical examination: abdominal swelling, huge masses can be palpable in the middle and upper abdomen and left pelvic cavity, with a surface size of about 30 cm ×20 cm, tough in texture, poor mobility and smooth edges. Abdominal CT examination showed huge cystic-solid mass occupation in the abdomen and pelvis (Figure 1), lobulated, closely related to the gastric antrum, and local intestinal compression. The upper edge of the lesion reached the top of the diaphragm, and the lower edge reached the level of the pelvic sacro-vertebral body. The size of the larger layer was about 217 mm ×126 mm. After enhancement, the lesion was slightly unevenly enhanced. Gastroscopy revealed: stomach bulging lesions. Surgical exploration showed a small amount of ascites in the abdominal cavity and a huge mass in the abdominal cavity, about 35 cm ×20 cm ×15 cm in size, originating from the stomach and occupying the small omental sac (Figure 2), the proximal end is soft and cystic, and the distal end is hard. Up to the top of the liver-stomach space diaphragm, push the liver and stomach body; Push the splenic flexure of the colon and the spleen to the left behind the splenic flexure of the colon; It grows expansively downward through the posterior transverse mesocolic space to the lower abdomen and reaches the pelvic cavity on the left side. The surface is densely covered with mesenteric blood vessels, pushing the transverse colon forward, and the transverse mesenteric colon surrounds the middle and lower tumor bodies and adheres to the surrounding tissues; Posterior adhesion to the pancreatic capsule is dense. "Abdominal tumor resection" was performed. Separate the gastrocolic ligament, enter the small omental sac, separate the adhesion between the mass and the transverse colon and its mesangium, protect the important blood vessels of the mesangium, and remove the mesangium invaded by the mass. Because the mass was tightly adhered to the pancreas, part of the pancreatic envelope and part of the pancreatic tissue were removed together, and the wound surface was carefully stopped bleeding. There was more bleeding and exudation during the operation, blood pressure decreased slowly, and blood cells and plasma were transfused urgently during the operation. The mass was separated and adhered to the splenic flexure of the colon. Because the tumor invaded the splenic hilum and adhered tightly to the splenic vein, the ligaments of the spleen were separated, the splenic hilum was treated, and the spleen was removed. During the operation, it was found that the mass originated from the posterior wall at the junction of gastric fundus and gastric body. Part of the gastric wall was removed, and together with the tumor body, the tumor was completely removed. Postoperatively, the tumor weighed about 4 900 g, and the mass was cystic-solid with intact capsule (Figure 3)。 Postoperative pathological examination showed that the size of the tumor was 36 cm ×23 cm ×12 cm. The tumor cells are spindle-shaped, arranged in bundles and vortices, and mitotic<5/50 HPF, necrosis was observed in the focal area. Immunohistochemical staining results: CD117 (+), DOG-1 (+), CD34 (+), H-caldesmon (+), CKpan (-), Desmin (-), S100 (-), SMA (-), Ki67 (~2% +). Diagnosis: Gastric stromal tumor, spindle cell type. According to the pathological risk assessment, it is high risk. There was no involvement of the tumor margin.

The patient was a 61-year-old male. He was admitted to hospital on August 4, 2015 with "repeated abdominal distension, anorexia for more than half a year, and left upper abdominal pain for more than 10 days". More than 10 days ago, I developed dull pain in my left upper abdomen with melena. I complained that a mass could be palpable in my left upper abdomen. Recently, my weight lost 10 kg. Physical examination: A huge mass can be palpable in the left upper abdomen, about 18 cm ×15 cm ×10 cm in size, with medium texture, clear border, smooth surface, no adhesion to the abdominal wall, poor mobility and no tenderness. Laboratory test: Hemoglobin 96 g/L, serum tumor marker C12 protein was not abnormal. Upper gastrointestinal iodinography: space-occupying lesions of gastric fundus, mass in the left middle and upper abdomen, and obvious compression and displacement of the large curvature of the gastric body. Gastroscopy: External pressure bulge of the posterior wall of the stomach, erosion of the surface of the bulge, red blood clot in the middle, and no active bleeding. CT examination revealed: large soft tissue mass in left upper abdomen, seeFigure 1。 During the operation, a huge tumor in the left upper abdomen was seen, about 25 cm ×18 cm ×12 cm in size, growing from the fundus of the stomach to the outside of the cavity. The tumor invaded the tail of the pancreas body and the transverse mesocolon and surrounded the splenic arteries and veins (Figure 2), reaching the perirenal fat and below the abdominal segment of the esophagus, and multiple miliary pale pink metastatic nodules can be seen on the surface of the omentum. Total stomach combined with body and tail of the pancreas + splenectomy + partial transverse mesocolectomy + omentectomy + esophagojejunal Roux-en-Y anastomosis was performed. The postoperative resected specimens showed that the tumor originated from the posterior wall of the base of the stomach and grew out of the cavity. A penetrating ulcer about 3 cm in diameter formed in the gastric cavity and eroded the blood vessels of the gastric wall. Pathological examination showed: malignant gastric stromal tumor, with multifocal malignant stromal tumor metastatic nodules in omental adipose tissue. Immunohistochemical staining showed: VIM (partial +), CD117 (+), DOG1 (+) (Figure 3), CD34 (+), SMA (−), Caldesmon (−), S100 (−). The patient recovered acceptably after surgery but was not treated with imatinib. Retroperitoneal mass on the left side was found on CT scan half a year after surgery. Considering tumor recurrence, imatinib 400 mg/d was administered orally, and the drug was discontinued spontaneously after 2 months, and it is still alive.

Case 1 male, 35 years old, was admitted for "paroxysmal abdominal pain with fever for 1 week". Physical examination: A mass can be palpable on the lower right side of the umbilical cord, about 10 cm ×10 cm in size, and the tenderness of the whole abdomen is not obvious. Routine blood test: WBC 15.9×10⁹/L, N 0.706, C-reactive protein:>170 mg/L. CT examination showed: cystic-solid mass occupation in the left abdomen, small intestinal obstruction, and a small amount of pelvic effusion (Figure 1)。 An exploratory laparotomy was performed, and a cystic-solid mass about 10 cm ×10 cm in size was found at the root of the mesenteric jejunum, which invaded the mesenteric vein and the horizontal segment of the duodenum. Mass resection + partial small intestine resection was performed. Pathological examination: 1 segment of small intestine, 30 cm long, 2.5-3 cm in diameter, a mass in the mesangium, 8 cm ×6.5 cm ×5.5 cm in size, gray-white and dark-red in section, and a fissure-like cystic cavity, 2 cm long and 1 cm deep, was seen. Another segment of small intestine was 27 cm long and 2.5 cm in diameter, with smooth mucosa and dark red hemorrhagic foci in the mesangium. Six lymph nodes around the small intestine were found, with a diameter of 0.3 to 0.5 cm. Case 2 female, 29 years old, was admitted with "sudden lower abdominal pain for 2 d". B-ultrasound: A mixed echo mass with a size of about 54 mm ×45 mm was seen in the right pelvic cavity, and the boundary was still clear. An exploratory laparotomy was performed. During the operation, a mass of about 5 cm ×4 cm in size was found in the mesentery at the distance of 10 cm from the ileocecal region of the ileum. The texture was hard, which was considered as a small intestinal stromal tumor. Ileocecal tumor resection + intestinal anastomosis were performed. Pathological examination: 1 segment of ileum, 15 cm long and 2 to 2.5 cm in diameter. A mass was found in the mesangium, 5.5 cm ×4.5 cm ×2.5 cm in size, and the gray-white matter on the section was tough, mostly solid, with a strip-like fissure-like structure (Figure 2)。 Ten lymph nodes with a diameter of 0.2 to 1.5 cm were found. Two cases showed under light microscope: there was a fissured cavity on the inner section of small intestinal mesenteric mass, part of the cavity was lined with small intestinal epithelium, part of the mucosa was detached, the lumen was filled with inflammatory necrosis, the surrounding spindle cell proliferation, accompanied by inflammatory cell infiltration, lymphoid tissue proliferation, and the muscle layer of intestinal wall was weak (Figure 3)。 Immunohistochemical examination showed that spindle cells were CD117 negative, DOG1 negative, and CD34 positive (Figure 4), SMA partially positive, considered as small intestinal duplication malformation with infection and fibrous tissue hyperplasia, peri-intestinal lymph node reactive hyperplasia.

Case 1 female, 47 years old, was admitted with "metastatic right lower abdominal pain for 3 d". Physical examination: soft abdomen, tenderness in the right lower abdomen, rebound pain, mild muscle tension, unpalpable mass, drum sound in whole abdomen percussion, negative mobile voiced sound, bowel sound 5 times/min, and positive colon inflation test. Routine blood test: WBC 12.1×10⁹/L, N 0.755. B-ultrasound examination showed abnormal intestinal echo in the right lower abdomen. Appendicectomy was performed in the emergency department. During the operation, the pelvic position of the appendix was seen, the blind end was enlarged, the serosa surface was purple-brown, wrapped with purulent coating, and it was tortuously adhered to the pelvic infundibular ligament. The appendix was separated and removed. Case 2 female, 54 years old, had recurrent right lower abdominal pain for 3 months. It improved after treatment with "acute appendicitis". Surgical history of "endometriosis and bilateral chocolate cyst" 8 years ago. Physical examination: soft abdomen, no tenderness and rebound pain in the whole abdomen, drum sound in the percussion of the whole abdomen, negative mobile voiced sound, bowel sound 5 times/min, and positive colon inflation test. CT examination showed that the mesangium around the superior mesenteric artery was blurred, the appendix was not swollen, a small amount of gas accumulated in the cavity, the uterus was not well displayed, and there was no abnormal density shadow in the adnexal area. Atrophy of the appendix, severe adhesion of the right pelvic cavity, stiffness of the appendix and adhesion to the cecum were seen during the operation. The appendix and cecum were separated during the operation. Pathological examination: There is no special appendix in general, and the lumen is occluded. One piece was taken from the appendix and one piece from the blind end of the appendix. Clusters of clear cells were found in the muscular layer, and one focal glandular duct was seen on the serous surface. Appendix carcinoid was suspected. Pathological examination: In case 1, the appendix was 7.5 cm long and 0.8 cm in diameter, the cavity was occluded, the posterior half was swollen to 1.5 cm in diameter, there was congestive pus inside, and the serosa was covered with purulent coating. Example 2 The appendix was 3.5 cm long and 0.5 cm in diameter. The lumen was occluded, and the surface of the serosa was rough and congested. Under light microscope, glandular ducts of different sizes were scattered in the muscular layer of the appendix and the fat around the serosa, without connection with the mucosa of the appendix, and the lumen was lined with cubic and ciliated columnar epithelium. Case 1: The blind end was accompanied by acute gangrenous appendicitis, with hemorrhage in the lumen of the muscular layer and intraserous glands, surrounded by endometrioid stroma (Figure 1)。 Example 2 The mucosa of the appendix was basically intact, the fibrous adipose tissue in the wall of the duct was proliferated, the serosa was congested, and there were proliferative clusters of clear cells distributed in the muscle layer around the glandular duct, which resembled appendix carcinoid (Figure 2)。 Immunohistochemical staining showed that CK7 (+), EMA (+), ER (+), PR (+), CA-125 (+), CK20 (-) were distributed in the muscular layer and serous surface of the appendix in 2 cases; Example 1 CD10 (+) of local periductal stromal cells (Figure 3)； CK7 (−), Syn (+) and CgA (+) were proliferated around the muscular glandular duct. Pathological diagnosis: Case 1, appendix endometriosis with acute gangrenous appendicitis; Example 2: Appendix endometriosis with chronic periappendicitis and proliferation of ganglion cells in the wall of the appendix.

The patient, a 56-year-old male, was admitted to the hospital because of "the discovery of a reversible mass in the right inguinal area for more than 3 years". He had a history of hemophilia A (factor VIII deficiency) for more than 30 years. The physical examination at the hospital showed anemia, no bleeding in the skin and mucous membranes of the whole body, a mass about 3 cm ×2 cm in size can be palpable in the inguinal area of the right lower abdomen in the standing position, which is soft, and the mass can be pushed back into the abdominal cavity after lying down. The cough mass did not appear after compressing the inner ring. The diagnosis was "right indirect inguinal hernia, hemophilia (A)". Blood routine: hemoglobin 78 g/L, hematocrit 0.299, mean red blood cell volume 60.9 fl, platelet 409.0×10⁹/L, suggesting moderate microcytic hypochromic anemia; Coagulation function test: Activated partial thromboplastin time (APTT) was 86.8 s, which was 20.0~40.0 s higher than the normal reference interval, prothrombin time (PT) 10.4 s, international standardized ratio (PT-INR) 0.91, fibrinogen (FIB) 2.94 g/L, thrombin time (TT) 17.2 s were all in the normal range; Factor VIII inhibitor detection 0 U; Factor VIII activity assay 2.6; Serum ferritin was 37.02 ng/ml and folic acid 8.5 ng/ml. On the 6th day of admission, the APTT was 53.80 s, and the activity of factor VIII was 26.6. On the 7th day of admission, APTT was 42.4 s, and the activity of factor VIII was 37.3; On the 8th day of admission, APTT was 33.3 s, and factor VIII activity was detected at 100.5. On the 12th day after admission, transabdominal laparoscopic tension-free repair of indirect inguinal hernia was performed under general anesthesia. It was confirmed that it was right indirect inguinal hernia (type II classified by Chinese Medical Association). The right muscle pubic foramen was covered with 3D MAX patch of Bard Company. Continuous intravenous infusion of factor VIII was used after operation. Primary postoperative rehabilitation was free of hematoma and/or seroma in the inguinal area. After 11 months follow-up, no delayed hematoma, seroma, delayed infection and recurrence of inguinal hernia were observed.

Abdominal wall hernia repair is a common surgical procedure in clinic. It is very important to know the area and volume of hernia sac for the selection of surgery and patch and the prevention of postoperative complications^[1]。 General incisional hernias are classified according to the diameter of the annulus, and complex hernias are classified according to the clinically reduced abdominal volume^[2], according to the classification criteria of the European Hernia Society^[3]Abdominal wall incisional hernias are classified according to the hernia location, size and size of hernia mouth. According to the maximum diameter of the hernia ring of 4 cm and 12 cm, they are divided into three categories: small, medium and large. The maximum diameter of abdominal wall defect is>12 cm or the ratio of hernia sac volume to abdominal cavity volume is more than 15% (independent of the maximum diameter of abdominal wall defect), which is defined as giant hernia. The repair of giant hernia is difficult to operate, because the intra-abdominal pressure increases to varying degrees when the contents of the hernia are returned, and it cannot adapt to the "new space" of the narrow abdominal cavity. In some patients, the original abdominal cavity volume may have been significantly reduced, or even smaller than the hernia sac volume^[4]。 If the hernia sac is returned without evaluation and treatment before operation, it may cause a sharp increase in intra-abdominal pressure (IAP) in a short time, and the suture incision is in a high tension state and prone to recurrence. If the intra-abdominal pressure is higher, it may even cause the formation of life-threatening intraabdominal hypertension (IAH) or abdominal compartment syndrome (ACS).