2021年 · 第36卷第05期

The patient was a 53-year-old male who was admitted to the hospital for "19 years of finding elevated blood sugar". Physical examination: blood pressure 171/89 mmHg, significant accumulation of abdominal fat, height 170 cm, weight 102 kg, abdominal circumference 118 cm, BMI 35.29 kg/m²。 He has a history of "type 2 diabetes" for 19 years, and his fasting blood glucose is as high as 17 mmol/L. Now, he is treated with insulin aspart 50 R (20 U in the morning and 16 U in the evening), and his blood glucose is controlled at 7~12 mmol/L. Laboratory tests: glycated hemoglobin 6.6%, postprandial 2 h blood glucose 12.96 mmol/L, fasting C-peptide 3.29 ng/ml, triacylglycerol 1.89 mmol/L. Ultrasound: fatty liver, carotid arteriosclerosis with plaque formation, arteriosclerosis of both lower limbs. Gastrointestinal endoscopy: chronic non-atrophic gastritis, duodenitis, rectal polyps. Fundus examination: diabetic retinopathy (non-proliferative phase). After perfect preoperative preparation, duodenal transposition with Da Vinci robot-assisted biliopancreatic bypass was performed. Surgical procedure: The stamping card of Da Vinci robotic surgery system adopts the "5-hole method" layout (Figure 1）。 Pneumoperitoneum was established by puncturing the inferior umbilical edge and placing an 8 mm poke card as an observation hole. 8 and 12 mm poke cards were placed in the left upper abdomen and left lower abdomen, 8 and 12 mm poke cards were placed in the right upper abdomen and middle upper abdomen, respectively. The poke card holes in the right upper abdomen (A), middle upper abdomen (B), and left upper abdomen (E) were placed into the robot No. 1, 2, and 4 robot arms, and the No. 3 arm entered the umbilical hole (C). The 12 mm poke card (D) was placed in the left lower abdomen as an assistant operation hole. Starting from the great curvature of the stomach 4 cm away from the pyloric ring, sleeve gastrectomy was performed under the guidance of a 34 F support tube. The lower incision margin was tracted with appropriate tension to be about 0.5 cm away from the edge of the guide tube. Then, the duodenum was cut off 1.5 cm below the pyloric, and the small intestine was cut off 300cm away from the ileocecal part. The distal end was anastomosed with the proximal end of the duodenum, and the diameter of the anastomosis was about 2 cm. The proximal end of the small intestine was anastomosed with the small intestine 100 cm away from the ileocecal part, and the diameter of the anastomosis was about 2 cm (Figure 2）。 Each mesangial hole was closed, and no leakage was observed after methylene blue was injected. The gastric margin was reinforced and sutured with the omentum, and a latex drainage tube was placed on the duodenal stump. The operation was completed. The operation lasted 295 min, and the patient was treated with acid suppression and parenteral nutrition support after recovery. The patient was discharged on the 6th postoperative day, no complications occurred during the hospitalization, and the weight at discharge was reduced by 4 kg compared with that before the operation.

The patient was a 50-year-old male. Admission due to "examination found liver occupying space for 3 d". Has a history of hypertension in the past, and usually takes amlodipine besylate regularly. Hepatitis B history for more than 20 years, no family history of tumor. Physical examination: pulse 122 beats/min, body temperature 37.4 ℃. The face is slightly purple-red, and the periorbital edema is slight. Laboratory tests: ALT 99.2 IU/L, AST 207.7 IU/L, lactate dehydrogenase 551.0 IU/L; Creatine kinase 1 923.0 IU/L, creatine kinase isoenzyme 95.0 IU/L, myoglobin 376 ng/ml, creatinine 60 μ mol/L, urea nitrogen 8.52 mmol/L; Hepatitis B three-line HbsAg (+), HbsAb (-), HbeAg (-), HbeAb (-), HbcAg (+); hepatitis B DNA 7.52 x10³IU/ml; AFP 1 975.58 ng/ml, CEA 2.50 ng/ml, CA19-9 66.2 U/ml; The indexes of liver fibrosis were all increased; Immunoglobulin G4 0.74 g/L. Specific antibody test: anti-Jo-1 antibody (-); anti-RNP antibodies (-); anti-SCL antibody (-); Anti-NXP2 antibody (+ +). Upper abdominal enhanced magnetic resonance MRI revealed an abnormal signal of 5.3 cm ×6.6 cm in the left inner lobe of the liver. After admission, the patient's periorbital edema worsened, and purple-red edematous erythema gradually appeared on the face, both eyelids, chest and upper back (Figure 1), erythema and Gottron papules can be seen on the back of both hands. Preoperatively, he was given liver protection and enzyme reduction treatment, without immunosuppressant and glucocorticoid treatment, and liver cancer complicated with dermatomyositis was considered in the consultation of rheumatology and immunology department. Laparoscopic resection of left inner lobe tumor was performed under general anesthesia. The operation was successful, and AFP decreased to 435.78 ng/ml on the 6th postoperative day. On the 12th postoperative day, the patient's rash clearly resolved. Postoperative pathology: Primary hepatocellular carcinoma with negative margins. After operation, anti-inflammatory, fluid rehydration, liver protection and entecavir antiviral treatment were given. No hormones and immunosuppressants were used. The patient recovered well, the symptoms of low back and leg pain were relieved, and the muscle enzyme index was normal. He was discharged from hospital on the 12th day after operation. On the 19th day after operation, the patient's rash completely subsided (Figure 2）。 The tumor was treated with hepatic artery interventional chemoembolization twice after operation. The tumor was followed up for 1 year without recurrence. AFP and muscle enzyme indexes were normal after reexamination.