2021年 · 第36卷第11期

A 55-year-old female patient saw a doctor for "repeated epigastric pain for more than 3 years". The patient suffered pain in the upper abdomen half an hour after eating, and a slight systolic blow-like murmur could be reached in the middle and upper abdomen, and lost 15 kg of weight in the past 3 years. Previous history of pancreatitis and no history of traumatic surgery. Gastroscopy revealed chronic non-atrophic gastritis with small polyps in the stomach body. Abdominal CT arteriography showed a sharp "V" shaped depression at the proximal end of the celiac trunk, and the anterior and superior soft tissue band structure diaphragmatic foot compressed the celiac trunk, suggesting median arcuate ligament syndrome (MALS) (FIG. 1A）。 Celiac arteriography showed obvious compression 1 cm distal to the opening of the end-expiratory celiac artery, severe local stenosis, natural running of the distal artery and patent lumen (FIG. 1B）； End-inspiratory phase celiac trunk artery compression, stenosis relief (Figure 1C）。 Laparoscopic median arcuate ligament release and celiac plexus free release were performed (Figure 2) and celiac arteriography. During the operation, the adventitia was obviously adhered to the surrounding soft tissues and fibrous bundles 1 cm below the opening of the celiac artery, and the local lumen was compressed. The electrocoagulation hook was carefully separated and released. After release, celiac artery angiography was performed, and the compression of the end-expiratory celiac artery was significantly reduced compared with before, while the end-inspiratory celiac artery was not significantly compressed and narrowed. The patient recovered well after surgery, and the pain in the upper abdomen improved significantly. The abdominal pain disappeared after eating after operation, and he went to work normally 1 month after operation; Six months after surgery, the patient gained 1 kg.

The 59-year-old male was admitted to hospital for "bloody stool for more than 10 days". Physical examination: The abdomen was flat and soft, without tenderness and rebound pain, and no abdominal mass was palpable. Two raised lesions on the dentate line of the anus can be palpable in the direction of 6 o'clock in the knee-thoracic position of digital anal diagnosis, which can be pushed. Under white light endoscopy, two parallel bulging lesions at the anal opening were seen. Endoscopic ultrasound showed that the cross-sectional size of the two lesions was about 14 mm ×12 mm and 12 mm ×12 mm, respectively (Figure 1), malignant melanoma was diagnosed by pathological biopsy. Pelvic enhanced MRI showed eccentric thickening of the lower rectal wall, slight enhancement of the right wall, and no enlarged lymph nodes around it. Enhanced CT of thorax and abdomen showed no metastasis to liver and lung. Laparoscopic exploration of the abdominal cavity plus combined abdominoperineal resection was performed. After cutting the specimen, two bulging lesions were found at the dentate line and 0.5 cm above the dentate line, with the size of 10 mm ×7 mm ×10 mm and 10 mm ×8 mm ×5 mm, respectively.Figure 2。 Postoperative pathological examination showed that multiple malignant melanoma of the rectum with ulcer formation, all the lesions invaded the submucosa, no intravascular tumor thrombus and nerve invasion were found, and no tumor metastasis was found in 15 periintestinal lymph nodes. Immunohistochemistry showed: HMB-45 (+), Melan-A (+), S-100 (+), PCK (-), Ki-67 (LI: 70%). Genetic testingBRAFWhich is wild type,KITIs a mutant. The patients received 4 cycles of "temozolomide + cisplatin" adjuvant chemotherapy after operation.

The patient was an 83-year-old female. He went to the emergency department of our hospital due to sudden pain in his right lower limb for 2 days. Prior history of atrial fibrillation for 8 years without regular anticoagulation therapy. Physical examination: The skin below the middle of the right calf is blue and purple, which can fade when pressed, the gastrocnemius muscle tenderness is obvious, and the foot and ankle cannot move autonomously. CT angiography showed an occlusion below the distal end of the right external iliac artery (FIG. 1A）。 Electrocardiogram showed atrial fibrillation, and cardiac ultrasound showed no intraatrial mural thrombus. During the preoperative preparation, the patient had sudden severe abdominal pain, accompanied by nausea and vomiting. Preliminary diagnosis of lower extremity arterial embolism, superior mesenteric artery embolism possible. Then, the right femoral artery was incised and thrombectomized under general anesthesia in the interventional operating room. The 4F Fogarty double-lumen thrombectomy catheter was guided by a V18 guide wire to remove a 40 cm long red shaped thrombus from the lower limb (FIG. 1B、1C), the angiography showed patency of the femoral, popliteal, anterior tibial and peroneal arteries. After suturing the femoral artery incision, the right common femoral artery was retrograde punctured under direct vision, and the occlusion section of the main trunk of the superior mesenteric artery was 4 cm long (Figure 1D）。 First, a 4F thrombolytic catheter (the thrombolytic part is 10 cm long) was placed into the occlusion of the superior mesenteric artery, and 600,000 units of urokinase were injected with pulse bolus. Angiography showed severe stenosis of the superior mesenteric artery. 5 mm ×60 mm and 6 mm ×60 mm balloons successively dilated the stenotic segment of the superior mesenteric artery (1E). Angiography showed that the main trunk of the superior mesenteric artery was patent, there was local occlusion at the distal end, and the peripheral collateral branches were well compensated (1F). CT angiography on the 3rd postoperative day showed that the main trunk of the superior mesenteric artery was patent, and there was no mesenteric edema and ascites. The patient exhausted and defecated on the 4th day after surgery, basically returned to normal diet on the 8th day after surgery, was able to move on the ground, and recovered and was discharged.

A 29-year-old male was admitted with "right upper abdominal pain for 1 d". The patient developed right upper abdominal pain without obvious trigger, the pain was persistent colic, accompanied by nausea and vomiting, the vomit was stomach content, accompanied by abdominal distension, and went to the emergency department of our hospital. Blood routine: white blood cells 12.92×10⁹/L, neutrophils 10.76×10⁹/L, hemoglobin 151.0 g/L, platelets 301×10⁹/L. Blood biochemistry : ALT 651 U/L, AST 630 U/L. Upper abdominal CT: The gallbladder is large and the density in the cavity is increased, and the possibility of intracavity bleeding in the gallbladder is not ruled out (Figure 1）。 Abdominal color ultrasound showed that the size of the gallbladder was about 7.4 cm ×3.7 cm, the wall thickness was 0.4 cm, the wall of the gallbladder was rough, the sound transmission in the cavity was poor, a large number of punctate strong echo filling was seen, and the diameter of the common bile duct was 0.6 cm. Income undergraduate with "acute cholecystitis". The patient was previously in good health. Partial prothrombin time (APTT) was 18.6 s, and the residual coagulation indexes were within the normal range. Carcinoembryonic antigen, alpha-fetoprotein and carbohydrate antigen 199 were all in the normal range. After active anti-infection, fluid rehydration and other supportive treatment, the patient's pain was not relieved and progressively aggravated, so it was decided to undergo cholecystectomy + common bile duct exploration. During the operation, the size of the gallbladder was about 10 cm ×5 cm ×4 cm, and the tension was high. After decompression of the gallbladder, the gallbladder was anterograde removed, and the gallbladder specimen was dissected. A large amount of old blood clots were deposited in the gallbladder. After removing the blood clots, there were 2 black hard stones with a diameter of about 1.0 cm in the gallbladder. There was a cauliflower-like mass about 3 cm ×3 cm in size on the inner wall of the gallbladder near the gallbladder floor. When the mass was dissected, it was seen that the mass was white "fish-like" tissue, which was tough to touch (Figure 2）。 Intraoperative diagnosis of malignant tumor of gallbladder, "radical gallbladder cancer resection" was performed, the liver tissue around the gallbladder bed about 1 cm was removed, and the 12a and 12b lymph nodes were dissected. A large amount of old blood clots were also deposited in the common bile duct when the common bile duct was incised. The blood clots were removed, the common bile duct was flushed, and the choledochoscopy explored the bile duct without stones and active bleeding, and a T tube was placed. A drainage tube was placed in the Venturi hole. The procedure went smoothly with about 20 ml of bleeding and no transfusion. The patient was given supportive treatment such as anti-infection, acid suppression and fluid rehydration after operation. The patient was exhausted on the second day after operation, the abdominal drainage tube was removed on the sixth day after operation, and the patient recovered well and was discharged on the seventh day after operation. Postoperative pathology: differentiated adenocarcinoma of the gallbladder (Figure 3), invaded the peripheral connective tissue of the muscle layer, but did not invade the gallbladder neck. No cancer was found at the proximal margin of the cystic duct. No cancer metastasis was found in the lymph nodes 12a and 12b submitted for examination, and no cancer was found in some liver tissues submitted for examination. Immunohistochemistry: CK (+), S-100 (neural +), Ki-67 (+60%).

The 8-year-old male was admitted to hospital in May 2019 due to "comprehensive treatment of lumbar desmoid fibroma for more than 7 years and progressive enlargement of right thoracic tumor for 2 years". Past history: The child was found to have a back mass at the age of 6 months. In 2011, he underwent "back mass resection". Postoperative pathological report: "desmoid fibroma". In 2013 and 2015, they underwent "back tumor resection" again due to recurrence, and received 23 radiotherapy sessions for a total of 50 Gy. In 2018, "back and thoracic tumor resection" was performed in an external hospital due to "progressive enlargement of the back mass and tumor growing into the right chest". Postoperatively, the tumor increased progressively, and the tumor completely occupied the right chest and squeezed the mediastinum to the left. Physical examination: There were multiple masses of different sizes in the neck, shoulders, back and waist, the larger ones were located in the lower back, about 25 cm ×15 cm in size, and the surface skin defects with ulceration (Figure 1）。 MRI examination showed: diffuse huge blood-rich mass on the back, protruding into the right chest cavity, invading the left chest wall, and invading the right mediastinal pleura and pericardium (Figure 2）。 After multidisciplinary discussion, the treatment plan of "palliative resection of giant tumor of the back + chemotherapy" was decided. Femoral artery catheter chemotherapy was administered 2 weeks after surgery (regimen: doxorubicin liposome 20 mg/m²/d, dacarbazine 300 mg/m²/d, continuous medication for 3 days, 21 days for 1 cycle), a total of 5 cycles. Thoracic tumors began to decrease after 3 courses of chemotherapy. Intrathoracic tumors decreased by 60% after 1 year (Figure 3), and the residual tumors of neck, shoulder and back were reduced by 60% after surgery (Figure 4）。 Up to now, the tumor has been further reduced.