2019年 · 第34卷第10期

China is a country with high incidence of gastric cancer, accounting for 42.6% and 45.0% of the global number of cases and deaths, respectively. According to the data of 2015, the incidence of gastric cancer in China is 29.31/100,000, ranking second in malignant tumors; The mortality rate was 21.16/100,000, ranking third among malignant tumors. Gastric cancer in China is characterized by less early stage, mainly advanced stage, and high morbidity and high mortality. Peritoneal metastasis is the primary cause affecting the long-term survival of patients with gastric cancer, and it is the biggest challenge faced by the clinical diagnosis and treatment of advanced gastric cancer.

A 67-year-old female was admitted for "anal pruritus for 3 years, aggravated for 1 week". Anal specialist examination (lithotomy position): The anal position is normal, and a rash-like bulge can be seen at the 1, 3, 5, 7 and 11 hours of the anal margin, which is gray-white in color and about 1 cm ×2 cm in size. Digital diagnosis: the anal canal is unobstructed, the anal contractility is normal, the anus is not narrowed, the rash is soft to touch, the anal canal is not touched with tumor, and the finger cuff is withdrawn without blood staining (Figure 1)。 Admission diagnosis: anal eczema. Perianal eczema closure was performed, and the rash tissue was taken during the operation and sent to pathological examination. Pathological report: (perianal) extramammary Paget's disease. Extensive local resection, perianal Paget resection and free transfer of perianal flap defect were performed at elective time. Intraoperative rapid freezing pathological results showed that Paget cells were found in tooth line tissue, but no Paget cells were found in the end of rectum tissue. Therefore, the incision was made to the end of rectum, and the resection range was 1 cm from the outer edge of the lesion, without damaging its sphincter. After resection, the perianal flap defect was removed, and the surrounding skin was taken as a flap for free transfer. Postoperative pathological report: (perianal) extramammary Paget's disease with chronic inflammation and acute suppurative inflammation with congestion. No tumor tissue was found in perianal subcutaneous tissue, distal rectal mucosa and internal anal sphincter (Figure 2)。 The free skin flap appeared necrotic at 7 days after surgery and was removed. The wound recovered well after resection. Up to now, no recurrence has been observed in the perianal area.

The patient was a 45-year-old male. The eggplant was stuffed into the anus by himself. After 3 days, abdominal distension and abdominal pain appeared, which showed persistent dull pain, accompanied by nausea, vomiting, stopping exhaustion from the anus and defecation, and the symptoms were aggravated for 1 day. Physical examination: abdominal muscle tension, periumbilical tenderness, percussion pain in the right kidney area. Emergency CT examination: 28 cm abnormal density shadow of tubular structure was seen in the right abdominal cavity, with stiff shape and extremely low density in the tubular structure. CT value: -400 HU, uneven density, with slightly higher density flocculate shadow, and the lower segment of the tubular shadow showed layered structural shadow of intestinal wall mucosa (FIG. 1A)。 The upper end is located in the liver-kidney space, and the lower end is located in the sigmoid colon. Scattered dotted free gas shadows were seen in the abdominal cavity (FIG. 1B), the fat in the peritoneal cavity of the right middle abdomen was slightly turbid. Structural disorders of rectum and sigmoid colon, and peritoneal effusion. Emergency surgery was performed. During the operation, 28 cm long eggplant was found in the abdominal cavity, 1/3 of which was located in the sigmoid colon and 2/3 in the abdominal cavity, and 15 cm long sigmoid colon necrosis was seen, with feces scattered throughout the abdominal cavity. Necrotic intestinal resection was performed.

A 78-year-old female was admitted for "7 years of skin mass in the left lower abdomen". Physical examination: A raised plaque with a size of 3.5 cm ×5.0 cm was seen at the upper two transverse fingers at the junction of the left axillary front line and the anterior superior iliac spine, which was cauliflower-shaped, reddish-brown and black, with a slightly rough and uneven surface, no erosion and exudation, no tenderness, and could move with the skin (Figure 1)。 Superficial lymph node enlargement was not palpable throughout the body. All body surface masses were resected under local anesthesia, and there was no residue to the naked eye. Postoperative pathological examination showed that the epidermal and superficial dermal pore carcinoma cells formed mass and lumen structure, and the nucleus had atypical mitotic image and obvious atypia, suggesting that the pore carcinoma (Figure 2)。 Residual tumor can be seen at the resection margin. The patient refused to undergo secondary surgical extended resection due to his advanced age and underlying diseases. Local electron ray radiotherapy was performed at the dose of CTV70Gy/35f, and there was no recurrence at present.

A 22-year-old female was admitted to the hospital because of "difficulty in defecation with intermittent abdominal distension for more than 10 years, aggravated for 2 weeks". Physical examination: abdominal swelling, no gastrointestinal pattern and peristaltic wave. The abdomen was soft, without tenderness or rebound pain, and no abnormal mass was palpable in the abdomen. The whole abdominal percussion showed drum sound and the intestinal sound was weak. Colonoscopy showed that the descending colon to the transverse colon were significantly dilated, and the intestinal lumen was filled with shaped stool, so the scope could not be continued. Abdominal CT showed that the ascending and transverse colon were obviously dilated, more intestinal contents were seen in the intestinal lumen, no abnormal thickening of the intestinal wall was seen, and the adjacent organs were compressed and displaced (Figure 1)。 The preoperative diagnosis was intestinal obstruction and megacolon. Exploratory laparotomy was performed. During the operation, there was a blind diverticulum of 30 cm ×15 cm ×15 cm in the cecum to the mesangial margin (Figure 2), the wall is thickened, the diverticular cavity is filled with gas and liquid contents, and the diverticulum compresses the left descending colon and sigmoid colon; The intestinal tubes of the ascending colon, transverse colon and descending colon are dilated, the intestinal wall is edema and thickened, and the color is pale; The intestinal lumen at the junction of descending colon and sigmoid colon was narrowed, and there was no dilatation of sigmoid colon and rectum. The stenotic intestinal segment was frozen and pathologically examined. No ganglion cell loss was found in the intestinal wall. Subtotal resection of large intestine (including cecal diverticulum) and ileorectal anastomosis were performed. Postoperative pathological report: Hirschsprung's colon, cecal diverticular mucosa is intact, with full intestinal wall thickness. The patient recovered smoothly, and the defecation was basically regular about 1 year after operation, 1 to 2 times a day, and the stool characteristics were good.

A 63-year-old male was admitted due to "repeated upper abdominal discomfort for 5 years and aggravation for 1 month". Physical examination showed no abnormalities. Serum CA19-9: 94.91 kU/L. Gastroscopy showed a huge ulcerative lesion in the duodenal bulb, and pathology suggested adenocarcinoma of the duodenal bulb (Figure 1)。 Duodenal tumor resection + Bi II anastomosis were performed. Postoperative pathology showed: (duodenal) poorly to moderately differentiated adenocarcinoma, ulcerative type, invading the full thickness to the outside of the serosa (Figure 2)； Pathological stage: T3N0M0, stage II. After 8 months, he was readmitted to the hospital because of "skin yellowing for 1 week". Physical examination: Yellow staining of skin and sclera throughout the body. Total serum bilirubin was 76.8 μ mol/L, conjugated bilirubin was 55.4 μ mol/L, and serum tumor markers were normal. MRCP examination showed that the lower end of the common bile duct occupied space (Figure 3)。 Colonoscopy showed that the colon occupied mass (Figure 4), pathological examination revealed adenocarcinoma. Pancreaticoduodenectomy + radical resection of sigmoid colon tumor were performed. Postoperative pathological report: Moderately differentiated adenocarcinoma at the papilla of the lower common bile duct, carcinoma tissue infiltrated the muscular layer of intestinal wall (Figure 5)。 Pathological stage: T3N0M0, stage ⅡA; Moderately differentiated adenocarcinoma of the sigmoid colon, discoid type, infiltrating the entire intestinal wall to the extraserous fibroadipose tissue (Figure 6), carcinoma metastasis was observed in peri-intestinal lymph nodes (1/8). Pathological stage: T3N1M0, stage ⅡA. This case was a malignant tumor of multiple sources and sites, and radical tumor surgery was performed in time. At the same time, in order to improve the prognosis, considering the impact of multiple tumor treatment, toxic and side effects of chemotherapy, etc., formulate a standardized and individualized chemotherapy plan. No tumor metastasis or recurrence was observed after 6 months of follow-up.

A 55-year-old female was seen for "intermittent abdominal pain for 9 years, aggravated for 1 d". Previous history of palmoplantar impetigo for 10 years and diabetes for 5 years. In 2004, he underwent "cholecystectomy" for "acute cholecystitis", and in 2016, he underwent "anterior cervical approach discectomy, decompression and bone grafting fusion" for "cervical spondylosis". Admission physical examination: bilateral sternoclavicular joint hypertrophy and protrusion (Figure 1), multiple impetigo on the skin of both hands and lower limbs (Figure 2), with skin desquamation. The abdomen was flat, with a surgical incision scar of about 10 cm in length in the right upper abdomen, tenderness in the right upper abdomen, no rebound pain and muscle tension, unpalpable under the costal margin of the liver and spleen, drum sound in the whole abdomen percussion, negative mobile voiced sound, and normal intestinal sound. Routine blood test: WBC 8.56×10⁹/L, N 0.78. Serum CA19-9: 39.16 U/L, serum CA242: 49.25 U/L. Abdominal CT showed: after cholecystectomy. Symptomatic treatments such as anti-inflammatory, fluid rehydration and antispasmodic were given, and abdominal pain could be relieved briefly after phloroglucinol was given intravenously, but the attacks were still intermittent. Because the patient had previously undergone cholecystectomy, he now suffers from pain in the right upper abdomen, which is considered to be related to biliary tract and gastroduodenal diseases. MRCP examination showed: cyst in the square lobe of the liver, but no gallbladder was found. Gastroscopy revealed: chronic atrophic gastritis. Because the patient's abdominal pain is unknown and occasionally has sternal pain, we ask the Department of Rheumatology and Immunology of our hospital for consultation. Combined with sternoclavicular joint hypertrophy and palmoplantar pustulosis, SAPHO syndrome is more likely to be considered. Laboratory tests: serum CRP 4.11 mg/L, ESR: 50 mm, HLA-B27 negative, chest radiograph: sternoclavicular hypertrophy (Figure 3)。 Spinal X-ray: degenerative changes of cervical, thoracic and lumbar vertebrae. The patient was diagnosed as SAPHO syndrome, and was treated with loxoprofen, alendrophosphate, calcic D and calcitriol. After one month, the symptoms of abdominal pain and sternal pain were significantly relieved.