2022年 · 第37卷第01期

A 33-year-old male was admitted to the hospital because "physical examination found that the liver occupied space for 2 weeks". Physical examination showed that a huge mass was palpable in the right upper abdomen, which was tough in texture, without tenderness, with clear boundaries and acceptable mobility. The hepatitis indexes were normal, and the serum tumor marker CA724 was 13.06 U/ml. MR enhanced scan: the space-occupying focus of liver segment VI, about 10.5 cm ×9.1 cm ×8.1 cm in size, showed fast-in and fast-out after enhancement, considering liver cancer (Figure 1), multiple abnormal small nodules in the liver, considering metastasis. CT-guided puncture biopsy was performed, and the pathology was consistent with chronic hepatitis. Laparoscopic liver tumor resection was performed. Intraoperative findings were as follows: exophytic tumor in segment VI of the liver, with a diameter of about 11 cm. Laparoscopic ultrasound exploration also showed hypoechoic occupied space on the left side of the gallbladder bed and segment II, with a diameter of 2 cm and 1 cm respectively. These three lesions were accurately removed under ultrasound guidance (Figures 2, 3). Rapid freezing and postoperative pathology showed that all three nodules were liver adenomas (Figure 4). There was no recurrence after 6 months of follow-up.

A 50-year-old male was admitted to the hospital due to "abdominal distension and fatigue for 5 months". Physical examination: The right upper abdomen was swollen, and a hard mass of 15 cm ×13 cm could be palpable. Laboratory tests: ALT 209.0 U/L, AST 1 421.0 U/L, lactate dehydrogenase 1 110.0 U/L; AFP 90.50 ng/mL. Abdominal enhanced CT: An irregular mass shadow with a size of about 13.2 cm ×11.4 cm ×9.2 cm was seen in the right anterior lobe of the liver, and the left branches of the middle hepatic vein and portal vein were truncated (Figures 1 and 2). Because the patient's tumor is huge and combined with the invasion of important blood vessels, conversion therapy was performed after discussion by a multidisciplinary collaborative team. Lenvatinib (8 mg orally once daily) combined with sintilimab (200 mg intravenously dripped once every 3 weeks) was treated with transcatheter arterial chemoembolization (TACE). After 1 month, CT reexamination showed that the tumor was smaller than before, so the original regimen was continued and TACE was treated again. CT reexamination of liver tumor after 3 months showed that the tumor volume decreased from 886 ml to 247 ml (Figure 3); AFP 73.80 ng/ml. Open partial hepatectomy under general anesthesia. Pathological diagnosis: hepatocellular carcinoma. Long-term lenvatinib after discharge at the same dose as before. CT reexamination 5 months after operation showed compensatory hyperplasia of residual liver, but no tumor recurrence and metastasis (Figure 4); AFP: 1.79 ng/mL.

A 50-year-old female was admitted to hospital for more than one year due to the discovery of an earthworm-like reducible mass in her left lower limb. The superficial vein of the patient's left lower limb was tortuous and dilated, accompanied by soreness and heaviness of the left lower limb, pelvic organ distension and episodic dull pain and discomfort in the lower abdomen. Lower extremity vein color ultrasound Doppler: left femoral vein valve regurgitation time>1.5 s. CT venography (CTV) showed severe stenosis of both inferior vena cava and left inferior vena cava across the abdominal aorta. Anterior and posterior projections of the left lower extremity veins and inferior vena cava antegrade angiography showed that the deep veins of the left lower extremity were patent, and the left femoral vein and great saphenous vein valves showed regurgitation during Valsalva operation, and the contrast medium returned from the suspected left inferior vena cava through the left iliac vein. The left iliac vein was anterograde punctured and catheterized, and part of the contrast medium circulated through multiple thick collaterals of the pelvic cavity to the right inferior vena cava for return (Figure 1). Severe stenosis of the left inferior vena cava across the abdominal aortic segment was consistent with the CTV findings (Figure 2). Intravenous manometry showed a lower venous pressure of 18 cm water column in the left inferior vena cava (below the abdominal aortic segment) and a total inferior vena cava venous pressure of approximately 5.5 cm water column. The diagnosis was double inferior vena cava and severe stenosis of the left inferior vena cava in the upper segment of the left renal vein. The stenosis segment of left inferior vena cava was dilated with a 12 mm ×40 mm balloon. After dilatation, a 14 mm ×120 mm stent was placed, and then the stent was post-dilated with a 14 mm ×40 mm balloon. The angiography showed that the stenosis was relieved, the contrast medium returned rapidly, and the original thick pelvic collateral circulation basically disappeared (Figure 3). Revenous manometry showed that the lower venous pressure of left inferior vena cava (below the abdominal aorta segment) was about 7 cm water column, and the total inferior vena cava venous pressure was about 6 cm water column.

A 34-year-old male was admitted for "perianal pain with fever for 4 d". The maximum body temperature of the patient reached 38.5 ℃. Physical examination: abdominal distension, mild tenderness in the whole abdomen, percussion pain in the lower back, fluctuating sensation on the right side of the anal margin, tenderness (+), and dark red blood extraction. Whole abdominal CT scan showed multiple exudation foci and fluid effusion in perianal and right superficial fascia-pelvic cavity-bilateral posterior pararenal space-perirenal (significant on the right side). Blood routine: WBC 13.55×10⁹/L, blood glucose 17.55 mmol/L, serum albumin 30.5 g/L. The diagnosis was peri-rectal and retroperitoneal infection, and "peri-rectal and anal abscess incision and drainage" was performed in the emergency department. Obvious abdominal swelling and high abdominal pressure were found on the second day after surgery, and the abdominal pressure was 25 cmH measured by bladder₂O, arterial blood gas analysis showed: PCO₂50.1 mmHg, PO₂42.6 mmHg, HCO3-33.4 mmol/L, SB 31.2 mmol/L, ABE 8.0 mmol/L, SaO₂77.4%。 Re-examination CT showed a barrel-shaped abdomen with positive round abdomen sign (Figure 1). Consider intraabdominal hypertension syndrome (IAH), and administer non-invasive ventilator-assisted respiration to correct hypoxemia and hypercapnia; For abdominal hypertension, citrate anticoagulant blood purification treatment, fasting, continuous gastrointestinal decompression and anal canal exhaustion; Anti-infective treatment with broad-spectrum antibiotic meropenem and perianal drainage fluid and blood culture to clarify the etiology; Correct water-electrolyte disorders and acid-base balance disorders; Continuous insulin pump lowers blood sugar; Intermittent infusion of human albumin to correct hypoalbuminemia; A small dose of nalbuphine was pumped for analgesia; Enteral nutrition was used after improvement of abdominal pressure. After 4 days of treatment with the above rescue measures, the patient's abdominal pressure dropped to normal.

A 33-year-old male accidentally found a painless mass under the abdominal wall for 1 month. There was no redness, swelling, ulceration and pus on the skin of the affected area. Abdominal CT examination showed irregular masses in the anterior and middle abdominal walls, with multiple budding growth nodules at the periphery (Figure 1), uneven density, no internal calcification, uneven enhancement of the lesions on enhancement scan, and progressive enhancement in the internal relatively low density area. PET/CT examination showed uneven radioactivity uptake in the lesion, increased uptake in the peripheral local area (Figure 2), the maximum standard uptake value was 2.8, and there were no metastases or primary lesions in the rest of the body. The patient was suspected of being a malignant tumor before operation and was indicated for surgery. He underwent "abdominal wall lesion resection, incisional hernia repair, and abdominal wall plasty". During the operation, a mass with a long diameter of about 8 cm could be palpable at the white line of the upper abdominal wall (Figure 3), which was hard and reached the peritoneum. Postoperative pathological examination showed that the morphology of tumor cells under light microscope was relatively consistent, round, oval or short fusiform, the cytoplasm was eosinophilic red, partially vacuolar, and the mitotic image was rare, showing cord-shaped, reticular, cluster-shaped and sheet-shaped arrangement structures, with a large number of mucoid matrix between the cells, and local interstitium was accompanied by hemorrhage (Figure 4). The postoperative pathological diagnosis was extraskeletal myxoid chondrosarcoma (EMC).

A 39-year-old woman was admitted with "right abdominal pain for 8 d". Physical examination: soft abdomen, slight fullness, mild tenderness in the right middle and lower abdomen, no mass palpable. Total abdominal enhanced CT examination showed: ileocecal-ascending colon intussusception, considering ascending colon tumor (Figure 1). Colonoscopy showed that a large mass occupied the intestinal lumen in the ascending colon, the surface was congested and eroded, slightly nodular, and the source may be ileocecal. Colonoscopic pathological examination showed: villous adenoma of ascending colon with moderate epithelial dysplasia. Laparoscopic right hemicolectomy was given. Postoperative anatomical specimens showed that the appendix was completely inverted in the cecal cavity, and a cauliflower-like mass of about 3.0 cm ×4.0 cm in the head and body of the appendix was inserted into the ascending colon together with the ileocecal part (Figure 2). Pathological report: villous adenoma of the appendix, broad base, partially serrated, with moderate dysplasia of the epithelium. There were no abnormalities in total abdominal enhanced CT and colonoscopy at 3 months and 1 year postoperatively.

A 62-year-old male was admitted with "pain and discomfort in the left lower abdomen for 1 d" with persistent abdominal pain and paroxysmal aggravation with abdominal distension. Physical examination: Abdominal swelling, obvious left lower abdominal swelling, left lower abdominal tenderness and rebound pain, a mass about 30 cm ×20 cm in size can be palpable, hard in texture, poor mobility and tenderness. Blood routine : HGB 76 g/L. Abdominal enhanced CT examination showed that massive mixed density shadows could be seen in the abdominopelvic cavity (Figure 1), and the CT value was about 20~74HU. The enhancement was not enhanced, and the lesions were lobulated, considering the possibility of lymphangioma and bleeding. An exploratory laparotomy was performed in the emergency department. During the operation, a large amount of dark red blood, about 800 ml, was seen in the pelvic cavity of the left lower abdomen. A cyst about 20 cm ×12 cm in size was detected at the mesileal 80 cm away from the ileocecal region with a rupture. A cyst about 12 cm ×10 cm in size was palpable at the mesileal 120 cm away from the ileocecal region without rupture. Intraoperative diagnosis: mesenteric lymphangioma with hemorrhage. The cyst was separated along the edge of the cyst, the mesileum around the cyst was ligated and dissected, and the two lymphocysts were completely removed. Postoperative exploration showed that the adjacent small intestine was black, so it was removed. Postoperative pathological examination showed: (abdominal mass) two gray-white and gray-red cystic masses, the sizes were: 16.0 cm ×9.5 cm ×6.0 cm and 12.5 cm ×10.0 cm ×4.0 cm, respectively. The incision surface was honeycomb-shaped, the large one contained a large amount of blood clots, and the small one contained brown-yellow liquid. Pathological diagnosis: lymphangioma with hemorrhage (Figure 2).