2019年 · 第34卷第12期

A 25-year-old male was admitted to the hospital due to "lower abdominal pain without obvious trigger 7 hours ago", accompanied by nausea and vomiting, and the vomit was gastrointestinal content. He went to the local hospital for treatment with anti-inflammatory and fluid rehydration, but the symptoms could not be relieved, so he came to our hospital for further treatment. The patient had the same symptoms 3 years ago and 5 days ago, and it was relieved spontaneously. The patient had no history of abdominal trauma. Physical examination: tenderness in the right upper abdomen, accompanied by muscle tension and hyperactivity of intestinal sounds. Blood routine: white blood cell count 17.2×10⁹/L, the neutrophil ratio was 92.2%. Abdominal CT: the small intestine of the right abdomen is gathered, the mesenteric blood vessels are collected, the intestinal volvulus is possible, and the small intestine may drill into the retroperitoneum (Figure 1)。 During emergency laparotomy, it was found that the duodenojejunal flexure of the patient was located to the right of the midline of the lower abdomen, and there was a defect in the peritoneum at the back of the duodenojejunal flexure, with a fissure about 3 cm ×3 cm in size, through which a large number of small intestines herniated into the retroperitoneal space (Figure 2)。 The small intestine was slowly pulled out from the hiatus for reduction. During the operation, the color of the small intestine was dark red. After standing for a few minutes, the color of the small intestine gradually changed to rosy, without necrosis and good vitality. The hiatus was closed by intermittent suture, and several needles were fixed to the small intestinal serosa layer at the beginning of the jejunum to close the hiatus (Figure 3)。 The patient recovered well after surgery, and there were no complications and similar symptoms at follow-up.

A 70-year-old male was admitted with chest and back pain for 3 h. Thoracoabdominal aortic CTA: Aortic dissection, the rupture is about 3 cm away from the left subclavian artery, the dissected hematoma reverse tears involving the left subclavian artery, the left vertebral artery starts from the aortic arch, the celiac trunk and inferior mesenteric artery start from the false cavity, and the remaining branches start from the true cavity (Figure 1)。 Diagnosis: (1) Thoracic aortic dissection (Standford type B); (2) Left vertebral artery variation. The patient was operated after 2 weeks of conservative treatment. The left vertebral artery and left brachial artery were exposed by incision, and 6F short sheath and pigtail catheter were inserted into the ascending aorta respectively after successful puncture (Figure 2)。 A labeled catheter was inserted along the right femoral artery and aortic arch angiography was performed. The proximal end of the thoracic aortic stent was released close to the opening of the left common carotid artery, and the left vertebral artery was exchanged with a Viabahn 5 mm ×50 mm (Gore) stent as a chimney stent. The proximal end of the left subclavian artery was fenestered in situ (21G puncture needle: Olympus). After successful puncture and membrane rupture, the fenestration was pre-dilated with an ordinary balloon (4 mm ×40 mm, 6 mm ×40 mm), and a Viabahn 8 mm ×50mm covered stent was placed. The final angiography showed that the left vertebral artery, left subclavian artery and brachiocephalic trunk had smooth blood flow, no endoleak, and the stent was not folded (Figure 3)。 After 2 months of CTA, the patient showed that the vertebral artery and subclavian artery stent had smooth blood flow, and the prognosis of the incision was good without special discomfort.

A 63-year-old male was admitted for "intermittent claudication of both lower limbs for 8 years with resting pain of the left lower limb for 3 days". Rutherford Grading: Grade 4. Previous history of hypertension, coronary heart disease and long-term smoking. In 2010, bilateral femoral-popliteal artery bypass grafting and right artificial blood vessel-popliteal artery stent implantation were performed in a foreign hospital. Physical examination: The pulsation of the left femoral artery was weak, and the pulsation of the remaining artery was not reached. Laboratory tests: Blood homocysteine 23.9 μ mol/L, triacylglycerol 3.41 mmol/L. Ankle-brachial index (ABI): 0 bilaterally. CTA: Severe stenosis of left external iliac artery, occlusion of right external iliac artery and common femoral artery, and complete occlusion of bilateral superficial femoral artery and artificial blood vessels; Right artificial vessel-popliteal artery stent occlusion (Figure 1)。 The left brachial artery was punctured under local anesthesia, 5F sheath was placed, and Pigtail catheterography was performed. The 6F long sheath, 0.035 inch Quickcross catheter and 0.035 inch stiffened guidewire were exchanged through the occlusion section. The right external iliac artery and common femoral artery were dilated with balloon and stent implanted. The right common femoral artery was punctured, the 7F mountain sheath was exchanged, and the left external iliac artery was balloon dilated and stented. After successfully traversing the lesion, the V-18 guidewire was exchanged, and a 2.0 mm Turbo-Elite catheter (Spectranetics) was pushed to the occlusion segment of the superficial femoral artery and connected to the CVX-300 excimer laser system (wavelength: 308 nm), set to 45 mJ/mm²/45HZ Perform laser ablation (Figure 2)。 The left lower extremity artery was balloon dilated, and flow-restricting dissection of P3 segment of popliteal artery occurred during opening. 5 mm ×150 mm and 5 mm ×60 mm Everflex stents were implanted in the distal end of superficial femoral artery and popliteal artery. Postoperatively, double antiplatelet drugs were given. Postoperative review left ABI: 0.91.

A 74-year-old female was admitted for "finding a mass in the right neck with progressive enlargement for 3 months". Physical examination: A mass about 6.0 cm ×5.5 cm in size can be palpable in the right lobe of the thyroid gland, with hard texture and unclear boundaries, moving up and down with swallowing. Carcinoembryonic antigen, calcitonin and thyroid function are in the normal range. Cervical ultrasound: 5.5 cm ×4.2 cm hypoechoic mass in the right thyroid lobe, and cervical CT: 6.6 cm ×4.6 cm hypodensity mass in the right thyroid lobe (Figure 1), fine needle puncture pathology: nonepithelial malignancy of the thyroid gland. During the operation, a mass of about 6.0 cm ×5.5 cm in the right lobe of the thyroid gland was found, which was hard and infiltrative to the outside of the capsule. Total thyroidectomy + lymph node dissection in the central area of the neck was performed, and the invaded tissue was removed at the same time. Postoperative pathological diagnosis: Thyroid leiomyosarcoma, the tumor cells are composed of spindle cells, with atypia, see mitotic images (Figure 2)。 Immunohistochemistry: Tumor cells positively expressed desmin (desmin) (Figure 3), smooth muscle actin (SMA), and vimentin (vimentin), while the epithelial membrane antigen S-100 protein, keratin, and myoglobin were negative for expression. The patient died 4 months postoperatively.