2020年 · 第35卷第09期

An 81-year-old male was admitted for "abdominal pain with melena for 6 d". Blood routine: red blood cells 2.27×10¹²/L, hemoglobin 68 g/L. Emergency examination of abdominal aorta CTA: abdominal aortic aneurysm, retroperitoneal hematoma (Figure 1)。 Admission diagnosis: ruptured and bleeding abdominal aortic aneurysm. After admission, 3.5U red blood cells were transfused, and the hemoglobin was reexamined at 71 g/L. Considering the rupture of abdominal aortic aneurysm and continued bleeding, after perfect preoperative preparation, laparotomy was performed for artificial blood vessel replacement in the emergency department. During the operation, severe retroperitoneal adhesion, obvious local edema, exposed and free proximal segment of abdominal aortic aneurysm, about 6 cm in diameter, eccentric, abdominal aortic sclerosis, and free bilateral common iliac arteries, about 8 mm in diameter. After systemic heparinization, the proximal abdominal aorta and distal bilateral iliac arteries were blocked with occlusion forceps, and the abdominal aortic aneurysm was incised antegrade, and thrombosis and inflammatory necrotic tissue in the abdominal aorta were seen. Abdominal aortic aneurysm near the ligament of Trigger duodenal fistula, fistula about 5 mm, no obvious intestinal fluid outflow. The inflammatory necrotic tissue and exudation were removed, and the artificial blood vessel 16 mm ×8 mm was taken. After pruning, the proximal and left and right iliac arteries were anastomosed, and the wall of abdominal aortic aneurysm was sutured. After duodenal fistula fistula suture, duodenal decompression fistula + proximal jejunal nutrition tube fistula was performed. Surgical bleeding 3 800 ml, transfusion plasma 800 ml, red blood cells 13.5U. Postoperatively transferred to ICU. Antibiotics were used to fight inflammation until the body temperature was normal for 1 week and discontinued. The patient took care of himself for 3 months after surgery.

A 38-year-old male was admitted to hospital because of "gallbladder stones found in physical examination for more than 3 years and intermittent right upper abdominal pain for more than 9 months". The previous history of hypertension for more than 10 years, the highest blood pressure can reach 220/140 mmHg (1 mmHg =0.133 kPa), oral "Luohuoxi" treatment, blood pressure control is not good. Surgical treatment for "snoring" 10 years ago. Physical examination after admission: blood pressure 140/100 mmHg. Height 188 cm, weight 145 kg, BMI 41 kg/m²。 Specialist physical examination: abdominal distension, negative Murphy sign. Abdominal B-ultrasound: the liver is full in shape, the intrahepatic echo is dense and enhanced, and the posterior part is attenuated; The gallbladder is not large, with multiple strong echoes in the cavity, the larger one is about 1.1 cm, accompanied by acoustic shadow and displacement, and the common bile duct is not wide. After admission, the preoperative examination was completed, and laparoscopic cholecystectomy (LC) was performed after excluding surgical contraindications. During the operation, the liver was in line with the manifestation of severe fatty liver, the gallbladder was full in shape, about 8 cm ×4 cm ×3 cm in size, slightly adhered to the omentum, and the adipose tissue in the triangle of the gallbladder was thick (Figure 1), blunt and sharp free gallbladder triangle, the cystic duct was dissected, hemolock clipped and then severed, no clear gallbladder artery was seen, the gallbladder was completely stripped from the gallbladder bed, and the specimen was removed. No active bleeding and bile leakage were found on the wound. A drainage tube was placed under the liver, and the operation was completed. After operation, flurbiprofen axetil was routinely administered for analgesia and fluid rehydration. On the first day after surgery, I ate semi-liquid food and got out of bed to move. After movement, blood drainage fluid was visible in the drainage tube, with a volume of about 250 ml. There was no complaint of abdominal pain, thirst, dizziness, fatigue and other discomfort. The blood routine hemoglobin was 121 g/L (151 g/L before surgery). The total volume of abdominal drainage on the second postoperative day was about 180 ml, bright red in color, and there were no other complaints of discomfort; On the third day after operation, 100 ml of abdominal drainage was performed, and the color was slightly lighter than before. The blood routine hemoglobin was 125 g/L, and there was no obvious change compared with before. Considering that there was no active bleeding, the abdominal drainage tube was removed. The abdominal enhanced CT examination showed a flaky high-density shadow at the lower margin of the right liver, about 12.9 cm ×8.4 cm ×4.0 cm in size. After enhancement, there was no enhancement. Considering subcapsular hemorrhage of the liver, a high-density shadow of 4.4 cm ×2.8 cm was seen in the gallbladder fossa (Figure 2)。 The patient was instructed to stay in bed, avoid strenuous activities, and dynamically monitor the changes of hemoglobin and subcapsular hemorrhage. The patient recovered smoothly, and the subcapsular hematoma of the liver was slightly smaller when reexamined by abdominal B-ultrasound 2 weeks after operation, so he was discharged and followed up in the outpatient clinic. The scope of abdominal B-ultrasound hematoma was significantly smaller when reexamined 8 weeks after operation (Figure 3), size approx. 8.8 cm ×7.0 cm ×6.4 cm.

A 73-year-old male was admitted to hospital for "progressive skin yellowing with yellow urine for more than 1 month". Physical examination showed severe skin sclera yellowing and mild tenderness in the middle and upper abdomen. Total bilirubin was 177.0 μ mol/L, direct bilirubin was 136.4 μ mol/L, alkaline phosphatase was 260 U/L, γ-glutamyl transpeptidase was 473 U/L, and total bile acids were 172.9 μ mol/L. Tumor antigens: CA50 37.02 U/ml, CA199 67.26 U/ml, alpha-fetoprotein 1.77 ng/ml, carcinoembryonic antigen 2.70 ng/ml. Enhanced MRI (Figure 1): A round-like long T1-long T2 signal was seen in the hilar area, continuous with the bile duct, about 43 mm ×43 mm in size, stratified inside, and nodular short T1-short T2 signal shadow was seen, a strip-shaped slightly longer T1-long T2 signal shadow was seen in the area adjacent to the bile duct in the left lobe of the liver, a cystic focus was seen in the hilar area, and a filling defect nodule was seen in the cavity. A strip-shaped slightly longer T1-long T2 signal shadow was seen in the area adjacent to the bile duct in the left lobe of the liver, with a range of about 109 mm ×22 mm. The DWI showed obvious high signal, the intrahepatic bile duct was dilated, the boundary was still clear, and the enhancement showed mild delayed enhancement. Diagnosis: Intrahepatic biliary dilatation; The hilar region and the left lobe of the liver occupy space, which considers the possibility of cholangiocarcinoma, and the possibility of cystic dilatation of the biliary duct in the hilar region with small intracavitary stones. After admission, PTCD was performed in emergency department to relieve obstruction and reduce jaundice. In the second stage, hilar bile duct + left hemihepatic + caudate lobe resection, right hepatic duct anastomosis with distal common bile duct + T tube drainage + cholecystectomy were performed. Lesions and stones were found in the bile duct cyst resected during operation. Because the bile duct was dilated at the confluence of the left and right hepatic ducts, the position of the opening of the right hepatic duct was unclear. Cholangiography was performed during operation to clarify the right hepatic duct. During the operation, the right hepatic duct and the distal common bile duct were frozen for pathology, and the pathological return was negative. The right hepatic duct and the distal common bile duct were anastomosed, and a T-shaped tube was placed at the anastomosis. Postoperative pathology (Figure 2): The abnormal glandular epithelium was found in the mass in an irregular glandular tubular arrangement, with large, deeply stained nuclei and infiltrative growth. (Left hemihepatic) bile duct adenocarcinoma grade I-II, most of which are confined to the lumen of the bile duct, with small focal areas invading the wall of the bile duct, and no clear intravascular tumor thrombus and nerve invasion are found. The left hemihepatic margin, the right hepatic duct margin and the common hepatic duct margin were not involved in cancer tissue, and schistosomiasis egg deposition (dead calcification) was seen in the focal area. No cancer metastasis was observed in hepatoduodenal ligament lymph nodes (0/6). (Left caudate lobe) Microscopically, liver tissue, inflammatory cell infiltration in the portal area, a small amount of schistosomiasis egg deposition (dead calcification), and dysplasia of bile duct epithelium in the focal area were seen. (Bile duct cyst) Cancerous tissue is seen under the microscope, invading the wall of the bile duct. (Gallbladder) Chronic cholecystitis, no cancerous tissue involvement. The margin of the gallbladder neck shows chronic inflammation. Postoperative T-tube angiography showed patency of biliary tract (Figure 3)。

A 90-year-old woman who had no abdominal pain and no fever, was suddenly found to have an intestinal tube prolapsed from the anus during forced defecation 6 h ago. Long history of anal prolapse and constipation. Physical examination: flat and soft abdomen, tenderness in the lower abdomen, no rebound pain, no muscle tension. Most of the small intestine and the mesenteric membrane of the small intestine are exposed outside the anus, and the intestinal tube is obviously edematous and dark in color (Figure 1)。 Exploratory laparotomy was performed immediately. First, the extraanal intestinal canal and its mesangium were washed with a large amount of sterile physiological saline. The abdominal cavity was explored by an incision around the umbilicus in the middle of the lower abdomen: no obvious effusion and purulent secretion were found in the abdominal cavity, a large number of shaped hard fecal balls could be palpable in the transverse colon and sigmoid colon, and there was a longitudinal 5 cm breach in the anterior wall of the upper rectum, from which the small intestine and mesenteric mesenteric herniated into the rectum. The small intestine outside the anus is returned to the abdominal cavity with hand assistance. The small intestine was explored, and the length of the necrotic small intestine from 130 cm from the Treiz ligament to 50 cm from the ileocecal region was approximately 300 cm. The necrotic part of the small intestine was removed, and the length of the remaining small intestine after anastomosis was approximately 180 cm. The perforation and rupture of the rectum had neat edges and no obvious lesions, so it was repaired with intermittent suture and prophylactic sigmoid colostomy. Fully rinse the abdominal cavity with a large amount of normal saline, and place a pelvic drainage tube. The patient was cured and discharged 27 days after surgery.

A 60-year-old female was admitted for "anterior chest wall mass". Physical examination: Localized bulge was seen in the suprasternal fossa, with clear boundary, no tenderness, and no swelling of cervical lymph nodes. Chest CT examination showed (Figure 1): Multiple oval masses were seen on the medial margin of the left sternocleidomastoid muscle, the larger one was about 2.4 cm ×1.8 cm in size, the internal density was still uniform, the CT value was about 46HU, and the enhancement scan showed mild uniform enhancement, considering a benign tumor at the root of the left neck. Surgical exploration showed that the tumor was located in front of the sternal stem, which was soft and easy to push. Complete mass resection was performed. Postoperative pathological examination showed: 1 piece of gray-red plastic tissue, about 4.0 cm ×2.0 cm ×1.5 cm in size, most of the section was cystic, and gray-white nodules were visible on the edge of the cyst wall, which were hard in texture and clear in border. Under the light microscope, the cyst wall was lined with squamous epithelium and stratified epithelium, and proliferating oval and fusiform cells were seen in the wall. There were round cell nests, arranged in a cord-like manner, and adipose tissue was seen (Figure 2)。 Immunohistochemical staining results: CK5/6 (+), P63 (+), P40 (+) (Figure 3), SMA (+), Desmin (-), Caldesmon (+), Ki-67 (1% +), S-100 (-), CD34 (+). Histological morphology and immunohistochemical staining results support the diagnosis of ectopic hamartomatous thymoma (EHT).