2020年 · 第35卷第10期

A 56-year-old female was admitted to the hospital for "repeated epigastric pain for more than 20 years and recurrent aggravation for 3 days". More than 20 years of history of gallstones and cholecystitis. Physical examination: deep tenderness in the upper abdomen, and the remaining signs were negative. Hepatitis B surface antigen positive (+), hepatitis B surface antibody negative (-), hepatitis B e antigen negative (-), hepatitis B e antibody positive (+), hepatitis B core antibody positive (+); CA125 13.13 U/ml; CA199: 41.10 U/ml. CT: low-density focus in the left external lobe of the liver, considering cholangiocarcinoma (Figure 1)。 Preoperative diagnosis: intrahepatic cholangiocarcinoma. A small amount of ascites in the abdominal cavity, extreme atrophy of the right liver, hypertrophy of the left liver, mainly in the left inner lobe of the liver, and a mass can be palpable on the visceral surface of the left outer lobe of the liver, about 4.0 cm ×3.0 cm in size, hard in texture and unclear in boundary. During the operation, lymph nodes in groups 7, 8 and 12 were enlarged and hard in texture. Postoperative specimens: A gray-white hard mass, about 3.5 cm ×2.5 cm ×2 cm in size, was seen in the left outer lobe of the liver immediately adjacent to the liver resection margin and the capsule. The section of the mass was gray-white, solid and hard, and gray-white substances on the mucosa of the intrahepatic bile duct could be seen growing into the lumen, and the dilated bile duct contained stones (Figure 2)。 Postoperative pathology: sarcomatoid carcinoma of the liver. Lymph nodes showed cancer metastasis (2/16). Immunohistochemical staining: mesenchymal cell marker staining Vimentin (+); epithelial cell marker CK (partial +); Hepatocytes: CK7 (partial +), CK19 (partial +), CK20 (-), Hepa (-) (Figure 3，Figure 4)。

A 54-year-old male was admitted to the hospital with "bronchial asthma and atrial fibrillation" mainly due to "cough, chest tightness, asthma for 10 years and palpitations for 4 years". Seretide 250 μ g once a day was inhaled to control asthma attacks, and the dose was not reduced after 10 years of medication. Electrocardiogram showed atrial fibrillation, sinus rhythm was restored after oral amiodarone, 0.2 g once/d, and the dose could not be reduced after 4 years of medication. No acid reflux, heartburn, abdominal distension and belching. No history of allergies and familial-related diseases, small alcohol consumption. Physical examination after admission: breathing sounds in both lungs were coarse, and dry and wet rales were not heard. No abnormalities in lung function were observed. Esophageal manometry showed that lower esophageal sphincter pressure was lower than normal. Esophageal pH + impedance monitoring at 24 h showed more weak acid reflux than normal, with a DeMeester score of 19.2. Diagnosis of gastroesophageal reflux disease, atrial fibrillation, bronchial asthma. Cardiac constriction under gastroscopy was performed. Treatment with seretide and amiodarone was discontinued on the same day after treatment, and the symptoms were completely relieved after 6 months. Electrocardiogram showed: sinus rhythm. Esophageal manometry showed normal lower esophageal sphincter pressure. No pathological reflux was observed by 24-h esophageal pH + impedance monitoring, and the DeMeester score was 10.8.

The patient was a 36-year-old male. He was admitted to hospital because he "found a painless lumbosacral mass for more than 10 years". Physical examination: There was no kyphosis in the thoracolumbar vertebrae, no ulcer on the back, a 4 cm ×2 cm mass was seen in the lumbosacral part at the level of the sacral 1~2 vertebral bodies, with clear boundaries, mobile activity, no ulcer, no redness and swelling, no pain at touch, and normal feeling of movement of both lower limbs. Color ultrasound examination showed that a hypoechoic mass with a range of about 37 mm ×40 mm ×19 mm could be seen near the lumbar spine, with unclear boundaries, uneven internal echoes, dark areas, and blood flow signals could be seen in CDFI. MRI of lumbar spine showed that irregular abnormal signal shadows were seen subcutaneously in the lumbosacral region at the level of sacral 1 to sacral 2 vertebral bodies, T1WI showed a slightly higher signal, T2WI showed a slightly higher signal, T2-FS sequence showed a high signal, the internal signal was uneven, the boundary was clear, the size was about 41 cm ×2.7 cm ×3.6 cm, the boundary was clear with adjacent muscles, and the spinal canal was obstructed (Figure 1)。 Resection of lumbosacral masses under intraspinal anesthesia. During the operation, the mass was slightly hard, about 5 cm ×6 cm in size, with a clear border, no adhesion to the border, and deep to the deep fascial layer. Postoperative pathological report: superficial CD34-positive fibroblastic tumor of lumbosacral region with negative peripheral margin (Figure 2)。 Immunohistochemical staining: CD34 (+) (Figure 3), Desmin (−), SMA (−), S-100 (−), CD68 (−), CK (partial +), Ki-67 (+, about 2%). After 3 months follow-up, no recurrence and metastasis were observed.

A 25-year-old female was admitted to the hospital due to "nausea and abdominal distension for more than 1 month, and the abdominal cavity was found to occupy space for 5 days". Physical examination: The abdomen is slightly swollen. AFP: 15.44 U/ml, CA-125: 118 U/ml. Enhanced CT: The boundary between the tumor and the bladder, uterus and rectum is not clear. Reconstruction shows that there are tortuous and disordered thick blood vessels inside and around the tumor, which seem to be connected to the hepatic artery and splenic artery (Figure 1)。 Puncture biopsy: angiomyolipoma (AML) of the abdominal cavity. Under general anesthesia, the tumor was located behind the peritoneum during exploration through the median abdominal incision, and multiple thick vine-like blood vessels surrounded it on the surface (Figure 2，Figure 3), the exploration showed that the tumor was completely free in the abdominal cavity, and the boundary with the surrounding organs was clear. Blood vessels were ligated near the end of the mass to remove the mass completely, with a size of about 32 cm ×25 cm. The abdominal cavity was explored, and multiple masses were palpable in the posterior wall of the uterus, with the largest diameter exceeding 10 cm. The frozen section of posterior uterine wall mass was the same as the puncture result of abdominal cavity mass, and the uterine wall mass was removed together. Postoperative pathology: The abdominal cavity mass was epithelioid angiomyolipoma (EAML), the uterine wall mass was partially uterine fibroids, and the edge was epithelioid angiomyolipoma. Immunohistochemical staining: HMB45 (+) (Figure 4), SMA (+), bcl-2 (+), CD34 (vascular +), EMA (+), Ki67 (5%).

The child was a 7-year-old male. Admitted for "2 weeks with abnormal urination found". Two weeks before admission, it was found that the child's urine contained feces such as gas and food residues, and even freshly eaten sesame seeds. The child had a history of Hirschsprung's surgery (transanal Soave) 4 years ago. Long-segment megacolon was identified during the operation, and subtotal colectomy was performed, with 25 cm of ascending colon preserved, and the colon was inverted and dragged out for anastomosis. Postoperative proximal colonic pathological examination showed that ganglion cells were visible in the intermuscular area, and the development was acceptable. Small ulcer foci and granulocyte infiltration were visible in the mucosal layer. Admission physical examination: Old surgical scar was seen on the left abdomen, no stenosis in anastomosis in anal diagnosis, and no positive signs in the rest. VCUG examination showed no intestinal visualization, and the bladder wall was smooth (Figure 1)。 X-ray examination of diluted iohexol 100 ml enema showed no vesicointestinal fistula. After accelerating the injection speed of contrast medium, the posterior wall of bladder communicated with the abnormal intestinal fistula, and the intravesical contrast medium was rapidly filled (Figure 2)。 Surgical treatment is performed after the diagnosis is defined. During the operation, the small intestine, colon and bladder adhesion in the pelvic cavity were severe. Carefully separate the adhesions, and see that the whole colon is about 30 cm, and the colon and the posterior wall of the bladder are adhered closely at 20 cm from the ileocecal region. Separating the adhesions shows that the colon and the posterior wall of the bladder are communicated with the fistula. A 6F gastric tube was placed through the bladder fistula, and blue liquid could be aspirated, and the fistula was clear (Figure 3)。 Suture and repair of bladder fistula and intestinal perforation respectively, and perform terminal ileostomy. The postoperative recovery was smooth, and the catheter was indwelling for 3 weeks. Three months after operation, VCUG and water-soluble contrast enema X-ray examination were performed. No colonovesical fistula was found, and the ileostomy was closed. The patient recovered well after operation and was followed up for 3 months. There were no symptoms of pneumuria, fecal urine and urinary tract infection.