2020年 · 第35卷第03期

A 55-year-old female was admitted to the hospital because of "abdominal mass found for more than 4 months". Physical examination: The abdomen was soft, and a tough mass was palpable in the left hypochondrion of the upper abdomen, about 5 cm ×6 cm ×5 cm in size, with acceptable mobility and no tenderness. Abdominal enhanced CT showed: a mass of abnormal density shadow was seen in the upper abdomen, with clear edges, about 6.2 cm ×5.8 cm in size, uneven density in the lesion, obvious enhanced area and cystic non-enhanced area were seen, and the lesion was closely related to the intestinal tube of the small intestine (about the beginning of the jejunum), and small arterial branches were seen inside; No obvious enlarged lymph nodes were seen retroperitoneally (Figure 1)。 After ultrasound-guided puncture biopsy, the pathological examination showed that the cells showed acinar and trabecular growth, which were relatively consistent. The nucleus was round and oval, and pseudo-inclusion bodies were seen in the nucleus, but no clear mitotic image was seen. Combined with immunohistochemical staining results (CgA +, Syn +, CK +, Ki-67 positive rate<1%), diagnosed as duodenal neuroendocrine neoplasms (D-NENS), stage G1. Laparoscopic-assisted partial duodenectomy was performed to remove the mass completely (Figure 2), postoperative pathology showed: D-NENS, invasion of serosa, no involvement of surgical margin. Immunohistochemical staining results: CgA +, Syn +, CK +, Ki-67 about 2%. Pathological staging : WHO pT2NX.

A 53-year-old male was seen 6 months ago due to low back pain after standing and walking. Three-dimensional reconstruction of renal vascular enhancement CT showed that the main trunk of the right renal artery was thickened, with upper and lower branches visible, the upper branch was thickened, and a downward protruding shadow was visible at the beginning, with a size of about 4.4 cm ×5.3 cm ×4.5 cm, and the lower branch was slender; Left kidney, spleen deficiency (Figure 1)。 Left nephrectomy and splenectomy were performed in 1992. A history of hypertension for more than 20 years, oral felodipine sustained-release tablets 5 mg twice a day, blood pressure can be controlled. Physical examination showed no positive signs. B-ultrasound: The right renal hilum showed a sac without echo, about 4.2 cm ×3.4 cm in size. Mixed blood flow signals were seen in the sac, arterial pulsation was seen, the sac wall was thin, and the boundary with the surrounding tissues was still clear. Clinical diagnosis: right renal aneurysm, left kidney + splenectomy, hypertension. Under general anesthesia, open surgery was performed, and the left side was lying in a high waist position. During the operation, a true aneurysm at the right renal hilum was seen, with a long diameter of about 5 cm, and a clear boundary with the surrounding tissues. The tumor wall was mildly atherosclerotic. Two arteries emanated from the aneurysm to supply the right kidney (Figure 2)。 Part of the aneurysm was closed by clamping above the aneurysm with lateral wall clamps, which showed that the aneurysm atrophy, the intratumoral pulsation disappeared, the inflow artery and the two outflow arteries pulsed well, and the renal blood supply was good (Figure 3)。 Part of the tumor wall was removed along the side wall forceps surface, and the forceps were continuously sutured with non-absorbable thread, and intermittent 8-figure sutures were used to reinforce. After complete hemostasis, two 1 cm ×7 cm artificial blood vessel patches (Braun, Germany) were used to wrap the wall of the artery and suture with non-absorbable thread (Figure 4)。 The pulsation of the distal artery at the palpation anastomosis was good, the blood supply to the kidney was good, and clear urine was visible in the urine bag. Rivaroxaban 10 mg/d was administered as anticoagulant therapy after operation. On the 6th postoperative day, color ultrasound examination showed that the inner diameter of the main trunk of the right renal artery was 0.7 cm, the maximum flow velocity was 0.81 m/s, and the resistance index RI was 0.64. Three months after the operation, color ultrasound revealed no stenosis of the main trunk of the right renal artery, and the blood flow velocity was normal.