2021年 · 第36卷第04期

In recent years, the incidence of adenocarcinoma of esophagogastric junction (AEG) has increased significantly worldwide^[1], possibly associated with Helicobacter pylori infection^[2]And gastroesophageal reflux disease^[3]。 AEG refers to a malignant tumor that occurs at the esophagogastric junction (EGJ), which refers to the anatomical boundary between the esophagus and the stomach rather than the histological concept. The international classification of AEG is Siewert classification^[4]Siewert type I: the tumor center is located 1~5 cm above EGJ and invades EGJ, which is actually lower esophageal adenocarcinoma; Siewert type II: the tumor center is located between 1 cm above and 2 cm below the EGJ and invades the EGJ, which is a true cardia cancer; Siewert type III: The tumor center is located between 2 and 5 cm below EGJ and invades EGJ, which is actually proximal gastric cancer invading EGJ. Nishi typing was used in Japan, defined as the tumor center within 2 cm proximal or distal to the EGJ, regardless of histological type, and divided into 5 types according to the relationship between the tumor center and the esophagogastric junction line: E (mainly on the esophageal side), EG (partial esophageal side), E = G (across the esophagus-stomach), GE (partial gastric side) and G type (mainly on the gastric side)^[5]。 At present, the surgical treatment of AEG tends to preserve gastric function on the premise of ensuring the radical cure of tumor, so as to reduce the long-term complications and improve the quality of life^[6]。 This article reviews the research status of gastric function preservation in AEG surgery.

A 42-year-old woman found a mass of about 2 cm ×2 cm in the right abdominal wall 5 years ago, which did not move with the change of body position and did not disappear after lying flat. In the past 1 month, the patient felt that the mass increased significantly. Physical examination: A tough mass was touched on the right abdominal wall, with clear boundary, smooth surface and no tenderness. MRI showed that a mass shadow of about 5.8 cm ×4.3 cm in size could be seen in the right abdominal wall, with clear boundaries and less smooth edges. Compared with muscles, T₁WI is isosignal, T₂WI lipid suppression sequence showed high signal, DWI diffusion was limited, enhancement showed uneven enhancement, and the boundary with rectus abdominis muscle was still clear (Figure 1)。 The mass was surgically removed. Postoperative pathological examination showed that spindle-shaped tumor cells were arranged in a vortex and cord shape in the dermis, with obvious cell atypia, easy to see nuclear division, infiltrated the surrounding adipose tissue, and no vascular tumor thrombus was seen (Figure 2)。 Pathological diagnosis: dermatofribrosarcoma protuberans (DFSP) of the right abdominal wall.

A 25-year-old female was admitted to the hospital for "13-year-old tumors in the buttocks and perineum". He has a history of surgery for "left calf bone disease" for more than 10 years. Physical examination: Left lower limb claudication, thoracic scoliosis, more than 10 flaky coffee spots on the back of the trunk and buttocks, and brown freckles in the groin. Specialist examination: melanin deposition on the right buttock and labia majora, obvious hypertrophy, softness, sagging skin, no tenderness (Figure 1)。 CT examination of chest showed that the bone quality of T3~6 thoracic vertebrae was changed, bulging to the right side, and deformity was changed. Perineal MRI showed: the skin of the perineum and right buttock was thickened, and multiple clockwork-shaped long T1 and long T2 signal shadows were seen subcutaneously. The shape was irregular and the boundary was unclear, involving the urethra, vagina and anal canal, and the boundary was unclear. The levator ani muscle was acceptable in shape (Figure 2)。 Perineal neurofibroma resection flap repair was performed. During the operation, the perineal fascia layer was cut, and the excess tissue of perineum and buttock was removed. The buttock near the anal canal and the right ischiorectal fossa were not treated, and the postoperative healing was good. Pathological diagnosis: (perineal) neurofibromatosis (Figure 3)。

The patient was a 61-year-old female. See a doctor because of "fever for 4 days and blood in stool for 5 hours". The patient underwent "uterine and bilateral adnexectomy + lymph node dissection" due to "endometrial cancer" 50 days ago. Routine blood test after admission: WBC 12.9×10⁹/L, Hb 88 g/L, serum procalcitonin 15.9 ng/ml. Abdominal CT examination: mixed density shadow in front of the right iliac bone, containing gas, and compression and displacement of the right external iliac artery (Figure 1)； Digital subtraction angiography: pseudoaneurysm of the right external iliac artery with local contrast extravasation (Figure 2)。 Exploratory laparotomy was performed. Intraoperative diagnosis: pelvic abscess, small intestinal perforation, iliac artery pseudoaneurysm, hemorrhagic shock, and "femoral artery-femoral artery bypass grafting + right iliac artery ligation + small intestinal perforation repair" was given. After operation, the bacterial culture of pus was "Candida parapsilosis", and the patient was treated with anti-infection. The patient was successfully discharged from hospital, followed up for 2 months, and recovered well.

A 67-year-old female was admitted to the hospital due to chills, chills and fever for 3 days. Specialist physical examination: flat abdomen, tenderness in the right upper abdomen and subxiphoid process. Abdominal color Doppler ultrasound showed that all organs were inverted, and multiple bright light clusters accompanied by acoustic shadows could be seen in the left intrahepatic bile duct, one of which was about 27 mm ×16 mm in size, and the inner diameter of the left intrahepatic tertiary bile duct was 4.6 mm. Blood routine: white blood cells 13.6×10⁹/L, neutrophils 35.3%; ALT 41.2 U/L, AST 101.6 U/L. X-ray of thorax and abdomen showed dextrocardiac position (Figure 1)。 CT showed that the whole organ was inverted (Figure 2，Figure 3), left intrahepatic bile duct stones and biliary dilatation. Abdominal magnetic resonance cholangiopancreatography showed multiple filling defects in the left intrahepatic bile duct (Figure 4)。 Combined with the patient's symptoms, signs, past history and related examination results, the diagnosis was as follows: intrahepatic bile duct stones and cholangitis; Total organ inversion; Hypertension Grade 3; Type 2 diabetes; Coronary heart disease is suspicious. Preoperative preparation was improved and laparoscopic left lateral lobectomy was performed under general anesthesia. The patient takes the head high and the feet low, and the body tilts to the left side by 15 to 30 degrees. The operator stood on the left side of the patient, made a small incision under the umbilicus and placed a laparoscope to explore the abdominal cavity. The main operation hole is located to the left of the midline of the left clavicle of the patient, and a 5 mm poke hole is placed under the costal margin of the midline of the right clavicle and the right anterior axillary line as an auxiliary operation hole. During the operation, the liver, spleen, stomach, colon, gallbladder and other organs were all reversed, showing a mirror image position. The hepatoduodenal ligament was dissected to free the left hepatic artery. The round hepatic ligament, sickle ligament, left coronary artery and left triangular artery were cut by ultrasonic scalpel, revealing the second hepatic hilum and left hepatic vein. After the left lateral lobe of the liver was fully free, a pre-tangent line was drawn 1 cm to the right of the sickle ligament. The liver parenchyma was dissected according to the conventional surgical method of left lateral lobectomy. The left hepatic vein was dissected by disposable cutting and closing device, and the specimen was removed to end the operation. The patient was discharged on the 8th postoperative day.