2020年 · 第35卷第11期

A 65-year-old female was admitted for "pain in the right lower abdomen with nausea and vomiting for 9 days". Physical examination: slightly swollen abdomen, no gastrointestinal pattern and peristaltic wave, soft abdomen, tenderness and rebound pain in the right lower abdomen, no muscle tension, no mass in the whole abdomen, no moving void, intestinal sound 6 times/min, high-profile intestinal sound and air passing through water can be heard. Colonic inflation test (+). Antibodies against Treponema pallidum were positive (1:2 560). Ultrasound revealed: right lower abdominal mass, approx. 4 cm ×4 cm ×2 cm. Abdominal CT examination showed intussusception (Figure 1)。 Diagnosis: intussusception with intestinal obstruction. Intraoperative intussusception reduction was difficult, so right hemicolectomy was performed. Dissection of the intestinal tube revealed a bulging mass at the ileocecal valve of the terminal ileum, approx. 3 cm ×1.5 cm ×1 cm (Figure 2)。 Postoperative pathological report: syphilitic ileitis, syphilitic gum formation (Figure 3)。

Example 1A 65-year-old female was admitted to hospital with "recurrent abdominal pain for more than 1 year and recurrent attack for 3 days". She had a history of gallbladder stones for 1 year. Physical examination: positive tenderness in the right upper abdomen. Auxiliary examination: liver function: total bilirubin 24.9 μ mol/L, direct bilirubin 5.9 μ mol/L, indirect bilirubin 19.0 μ mol/L, tumor marker: CA19-9>1 000.0 U/ml. No obvious abnormalities were found in the remaining examinations. Abdominal ultrasound: the size of the gallbladder was normal, the cyst wall was rough and thickened, and a strong echo mass was detected in the gallbladder, with a size of about 0.9 cm ×0.5 cm. Gallbladder stones and cholecystitis were considered. Gastrointestinal endoscopy showed no obvious abnormalities. Diagnosis: Gallbladder stones with cholecystitis, gallbladder cancer is not excluded. Laparoscopic cholecystectomy was performed on the second day after admission. During the operation, there was no rupture of the gallbladder wall and no overflow of bile. The removed gallbladder was completely placed in the specimen bag and taken out by poking the card hole. Intraoperative pathology: chronic cholecystitis. On the second day after operation, CA19-9 was reexamined: 111.3 U/ml, blood routine and liver function were normal. He was discharged on the third day after surgery, and returned to hospital for reexamination at 1 month after surgery for CA19-9: 25.0 U/ml.

A 29-year-old female was admitted to the hospital because of "a huge mass found in the left upper abdomen during prenatal examination for 1 week". Physical examination: abdominal swelling, no tenderness in the whole abdomen, huge mass palpable in the left upper abdomen, clear boundary, poor mobility. Abdominal CT examination showed that a huge soft tissue mass shadow could be seen in the left abdominal cavity, with clear boundary and close relationship with the stomach wall. Considering the possibility of stromal tumor, the surrounding structure was compressed and displaced (Figure 1)。 Preoperative diagnosis: abdominal mass, possibility of gastric stromal tumor, intrauterine pregnancy at 25 weeks. After improving the preoperative preparation, cesarean section was performed on the same stage to terminate the pregnancy, followed by exploratory laparotomy. During the operation, a huge solid mass of about 22 cm ×18 cm ×13 cm protrusion from the posterior wall of the stomach body was seen. The stomach wall showed infiltrative growth, tough texture and clear border (Figure 2), the pancreatic envelope was intact without adhesion. During the operation, most of the distal stomach and the tumor were completely resected, the resection margin was 3 cm away from the tumor margin, and the peripheral swollen lymph nodes were dissected. Postoperative pathological report: gastric invasive fibromatosis (Figure 3), the tumor invasive growth involved the gastric wall from the serosa to the submucosa, the distal and proximal resection margins were negative, and no tumor tissue was found in the large and small curved lymph nodes. The results of immunohistochemistry showed that β-catenin (+) (Figure 4)。 The patient recovered smoothly after surgery, and no tumor recurrence or metastasis was observed after 16 months follow-up.

A 62-year-old male was diagnosed with poorly differentiated adenocarcinoma with neuroendocrinization by gastroscopic biopsy before surgery. CT examination of chest and whole abdomen showed: total visceral inversion (heart, liver, spleen, pancreas, gallbladder and other organs seen), the tumor was located in the small curve of cardia, and the image stage was T4aN0M0 (Figure 1)。 Vascular reconstruction showed that the left gastric artery emerged from the abdominal cavity and then entered the gastric wall to the left; The splenic artery emanates from the celiac trunk and runs to the right; The common hepatic artery branches from the celiac trunk, rotates on the right side of the abdominal aorta, turns to the left side and walks, and divides into two intrinsic hepatic arteries behind the portal vein and merges into the left half of the liver; The inferior mesenteric vein merges with the inferior margin of the pancreas into the superior mesenteric vein, and then merges with the splenic vein to form the portal vein.

The patient was a 30-year-old male. Admitted for "liver space pending examination". Upper abdominal enhanced CT: A soft tissue mass was seen near the gallbladder in the right lobe of the liver, with blurred boundary and an extent of about 5.3 cm ×4.0 cm. Its internal density was uneven, and the center showed a fissure-like low-density shadow. The periphery of the lesion was obviously enhanced in the arterial phase of enhanced scan, the lesion continued to enhance in the portal vein phase, and the center showed a fissure-like low-density shadow. The density of the lesion was similar to that of the adjacent liver parenchyma in the equilibrium phase, and the range of the central low-density shadow was significantly reduced (Figure 1，Figure 2)。 HBsAg 0.05 IU/ml. Anti-HCV negative. AFP 10.83 ng/ml. Under general anesthesia, the reverse "L" incision was made into the abdomen, and the liver was free. The lesion was completely resected 1 cm along the periphery of the tumor without hilar occlusion. The resected mass was about 5 cm ×5 cm ×4 cm. The cross-section was uniform, and the cross-section was gray-yellow and slightly tough. Pathology: The tumor has a fibrous envelope, the hepatocytes are arranged in an irregular nodular shape, the liver plate is thickened, the hepatocyte nucleus is atypical, the cell volume is increased, the small bile duct in the interlobes is proliferated, and the infiltration of inflammatory cells such as lymphocytes and plasma cells is seen. Immunohistochemistry: AFP (-), Hep-parl (+), CK8/18 (3+), CK7 (-), CK19 (-), CK20 (-), CEA (-), CD34 regional capillary (+), P53 (-), Ki67~5%. Pathological diagnosis: hepatocellular adenoma, local cell dysplasia, carcinogenesis (well differentiated hepatocellular carcinoma), no vascular invasion (Figure 3)。 pTNM staging: T1bNxMx. No recurrence and metastasis were observed after 10 months of follow-up.

A 48-year-old female was admitted to the Department of Rheumatology and Immunology of our hospital with a diagnosis of systemic lupus erythematosus (SLE) due to "rash for 5 years and chest tightness for 3 days", and had a history of hypertension for 1 year. An enhanced CT scan of the chest showed abnormal descending aorta density, considering plaque with penetrating ulcer formation (Figure 1)。 Aortic CTA revealed descending aortic dissection (Figure 2), the patient was transferred to undergraduate treatment. Physical examination: The skin temperature at the end of both hands was reduced and slightly bruised. Endovascular repair of thoracic aortic dissection is proposed. The right femoral artery was punctured, and a catheter was placed in the ascending aorta. Transcatheter angiography showed that the contrast medium overflowed into the tumor cavity at the lower edge of the aortic arch, and the branch artery was visualized in the tumor cavity. Then, a microcatheter was taken to enter the bronchial aneurysm cavity under the guidance of a guide wire, and 2 COOK coils of 14~8 mm, 14~10 mm, 7~4 mm and 4 of 5~5 mm were implanted into the tumor cavity respectively (Figure 3), the tumor body was not developed again, and the aorta and branches were well developed. The patient came to the hospital for re-examination 1 month after operation, and showed no symptoms such as chest pain, cough, hemoptysis, etc. After re-examination of CTA, the lumen of the aneurysm was completely filled by the coil, and no blood filling was found in the aneurysm. The surgical effect was good.