2020年 · 第35卷第07期

A 50-year-old female was admitted with "sudden severe pain in the left lower abdomen for 8 h". In the emergency department, exploratory laparotomy was performed under general anesthesia, and intestinal adhesion release, transverse colon perforated intestinal segment resection, transverse colon single-lumen stoma, abdominal irrigation and drainage, incision closure and negative pressure drainage were performed. On the 4th day after operation, liquid food was eaten and the stoma was unobstructed; On the 6th day, fever occurred, body temperature was 39 ℃, and turbid purulent fluid was found to drain from the incision under negative pressure. When the suture on the surface of the incision was removed, a large number of blood clots and dehiscence of the sheath layer under the incision were seen. The hematoma was removed and the skin was sutured again. The color of the negative pressure drainage tube changed from pale blood to dark green on the 7th postoperative day. Detection of amylase in subcutaneous drainage fluid: 80 520 U/L. With somatostatin, up to 1 500 ml of intestinal fluid can be drawn from the incision. Diagnosis: High-flow extraintestinal fistula. Endoscopic placement of intestinal obstruction catheters and gastric tubes. The intestinal obstruction catheter was repeatedly adjusted 110 cm away from the nasointestinal tube. After the posterior water sac was inflated to 40 ml, no intestinal fluid was drained from the subcutaneous drainage tube, and no intestinal fluid exudation was observed on the incision wound. Self-made vacuum negative pressure suction was used to seal the incision wound. Then an attempt was made to instill a short peptide type enteral nutrition solution (2 000 ml/d, energy 1 800 kcal/d) via an intestinal obstruction catheter. If the gastric tube drains more, the digestive juice sucked out of the gastric tube is recovered and dripped through the intestinal obstruction catheter to reduce electrolyte loss. After 3 weeks of enteral nutrition, the balloon was released and oral administration was attempted, and the wound was filled with fresh granulation seeFigure 1No intestinal fluid spillage was observed. External intestinal fistula occlusion is shown inFigure 2，Figure 3。

A 46-year-old woman was admitted for "intermittent epigastric pain, abdominal distension for 5 months, aggravated for 1 month". Physical examination: There is no deformity in the thorax, and the apical beat can be palpable in the fifth intercostal of the midline of the right clavicle, and the heart boundary can be knocked out and the heart sounds can be heard. The left chest cavity did not touch the apical beat, and the percussion was voiceless, unable to knock out the heart boundary. The abdomen was flat and soft, the upper abdomen was tender, there was no rebound pain and muscle tension, and the liver and spleen were not touched. Gastroscopy showed that the folds of the large curved side of the stomach body were disordered, and local shallow ulcers formed. Pathological examination revealed: poorly differentiated adenocarcinoma with signet ring cell carcinoma. X-ray examination revealed: situs inversus totails (SIT). Abdominal CT showed localized thickening of the lateral wall of small curvature of stomach body; SIT (Figure 1)。 Intraoperative exploration showed that the patient had total visceral inversion in the abdominal cavity, the liver and gallbladder were located on the left side, the spleen was located on the right side, the fundus of stomach and the great curvature of stomach were located on the right side, and the pylorus and duodenal bulb were located on the left side. The tumor was located in the middle and upper part of the stomach body, with a size of about 6cm ×5cm. The serosa was not infiltrated, and there was no metastasis of peripheral lymph nodes, and no organ metastasis or peritoneal dissemination in other parts of the abdominal and pelvic cavity was seen. Radical total gastrectomy was performed, and the inverted common hepatic artery, right gastric artery, coronary vein, left gastric artery and splenic artery were marked with colored vascular elastic bands (Figure 2)。 Postoperative pathological report: (Gastric) poorly differentiated adenocarcinoma with signet ring cell carcinoma, invasion to subserosa, upper and lower incision were negative, and regional lymph nodes showed cancer metastasis (1/79). Pathological stage: pT3N1M0, stage ⅡB. Six cycles of chemotherapy were given postoperatively, and no tumor metastasis or recurrence was observed after 6 months of follow-up.

The patient was a 79-year-old male. He was admitted to hospital for "upper abdominal distension and pain for more than 3 months". History of previous surgery for hepatic artery embolization. Physical examination: A solid mass can be palpable slightly on the right of the umbilicus, about 8 cm ×8 cm in size, hard in texture, with poor mobility, smooth surface and mild tenderness. Laboratory examination: Tumor markers were normal, blood routine, complete set of biochemistry, and coagulation function were normal. Pancreatic enhanced CT: The huge space occupied in the abdominal cavity was unclear from the distal end of the hepatic artery and the pancreatic head area. The enhanced scan showed small patches of enhancement, and the range of enhancement in the delayed phase was enlarged, and multiple tiny vascular shadows were seen inside. Local stenosis of lower main portal vein and inferior vena cava; The body and tail of the pancreas are atrophied, and the main pancreatic duct is dilated (Figure 1)。 Endoscopic ultrasound: A huge cystic-solid mass can be seen on the head of the pancreas with clear boundaries, compressing the superior mesenteric vein, portal vein and common bile duct. The internal echo of the lesion is uneven, scattered in multiple anechoic areas, and patchy hyperechoic shadows can be seen. The color Doppler blood flow signal is not rich, and the echo of the pancreatic body and tail is uniform. Ultrasound-guided fine needle puncture pathology: a large number of necrotic tissues with very few acinar-like cells, no clear oncology basis was found (Figure 2)。 Surgical exploration: A round mass was seen on the head of the pancreas, about 10 cm in diameter, hard in texture, smooth in surface, with good mobility, compressing the surrounding tissues and blood vessels, and pancreaticoduodenectomy was performed (Figure 3)。 Postoperative pathology: cavernous hemangioma of the head of the pancreas with hematoma formation, lesion size 12 cm ×10 cm ×9 cm. Acinar atrophy in some areas of surrounding pancreatic tissue (Figure 4)。