2022年 · 第37卷第02期

GERD is a disease caused by a series of symptoms and/or complications caused by reflux of gastric contents to the esophagus, throat, mouth, nasal cavity, middle ear, trachea and lungs. The gastrointestinal symptoms of GERD include acid reflux, heartburn, refusion, belching, chest and back pain, upper abdominal fullness, dysphagia, etc. Symptoms outside the gastrointestinal tract include oropharyngeal foreign body sensation, sore throat, hoarseness, nasal congestion, runny nose, oral ulcer, cough, expectoration, wheezing, holding breath and even choking. Injurious lesions caused by GERD include esophageal erosion, Barrett's esophagus, laryngeal edema, vocal cord granuloma, subglottic stenosis and pulmonary fibrosis. In addition, GERD can also cause hypertension, arrhythmia, sleep disorders, anxiety, depression, etc. through nerve, immune and other mechanisms.

Primary ductal adenocarcinoma accounted for 90% of pancreatic malignant tumors, and metastatic tumors accounted for 2% ~5%^［1］。 Common primary tumors with pancreatic metastasis include renal cancer, colorectal cancer, lung cancer, breast cancer and sarcoma^［2］Among them, pancreatic metastasis of renal clear cell carcinoma accounted for 1.3%^［3］。 The Department of Hepatobiliary Surgery of the Second Hospital of Hebei Medical University performed laparoscopic pancreaticoduodenectomy (LPD) on 9 patients with pancreatic metastasis of renal clear cell carcinoma from 2013 to 2020. The data of 9 patients were retrospectively collated, and the diagnosis, surgical treatment and follow-up results of pancreatic metastasis of renal clear cell carcinoma were analyzed.

A 42-year-old female was seen with "dull pain in the right upper abdomen for 2 months" as the main complaint. Physical examination: No abnormalities were found. CT examination of the upper abdomen showed: irregular mixed density foci were seen retroperitoneally on the right side, about 8.5 cm ×5.2 cm ×7.7 cm in size, cystic, with clear border, fat and calcification density were seen inside, and the inferior vena cava, liver, right kidney and right adrenal gland were compressed and displaced. No obvious enhancement was seen after enhancement scan (Figure 1). Retroperitoneal mass resection was performed. During the operation, the tumor was located in the retroperitoneal position, cystic, soft in texture, about 8 cm ×7 cm ×4 cm in size, with intact surface envelope and gray-yellow color. Its anteromedial side was adhered to the duodenum and inferior vena cava, and the posterior inferior pole was adhered to the spine and part of the renal fat sac. After sharp separation and adhesion, the cyst wall was completely removed and the specimen was submitted for examination (Figure 2). Postoperative pathological findings: (retroperitoneal) bronchogenic cyst (Figure 3).

A 48-year-old male was admitted to the hospital with "pain in the left upper abdomen for 3 weeks with yellow urine staining for 1 week". Physical examination: abdominal distension, left upper abdominal tenderness, rebound pain, percussion pain in liver and spleen area, and positive mobile voiced sound; Family history: Uncle died of "liver disease". Abdominal CT (Figure 1): Diffuse snowflake-like changes in the liver suggest diffuse lesions in the liver and spleen, considering hereditary hemorrhagic telangiectasia (HHT) and arteriovenous fistula; Larger mass of the spleen with hemorrhage, consider hemangioma. Hb 66 g/L, splenectomy and liver biopsy were performed under emergency general anesthesia. During the operation, about 3 000 ml of dark red blood accumulated in the pelvic and abdominal cavity. The liver showed cirrhotic changes, multiple small hemangioma-like changes were seen on the surface, a tumor with a size of 15 cm ×12 cm ×10 cm was seen at the lower pole of the spleen, and the diaphragm surface ruptured and bled. Postoperative pathology: (1) hemangioendothelioma of the spleen (FIG. 2A); (2) Liver histoscopy showed cavernous hemangioma-like changes in focal small blood vessels in the liver parenchyma (Figure 2B). Immunohistochemistry: Spleen tumor: CD34, CD31 and ERG were all positive; Liver biopsy: CD34 (FIG. 2C), CD31 positive, Hepatocyte negative. The hepatic function injury was progressively aggravated after postoperative review. Postoperative abdominal CT (Figure 3) showed an increase in diffuse liver lesions. On the 4th postoperative day, the patient developed renal insufficiency, respiratory failure, pulmonary hypertension, cardiopulmonary insufficiency and sepsis. The patient refused to undergo liver transplantation, and his family asked to be transferred back to a local hospital for treatment. The patient died after a week of follow-up after discharge.

A 55-year-old male was admitted to the hospital for 10 days due to the discovery of a left neck mass. Physical examination showed that a mass about 4 cm ×4 cm in size could be palpable below the mandibular angle of the left neck. There was no redness or swelling around it, tough in texture, no tenderness, and the range of mobility was acceptable. One week after admission, the patient underwent left carotid body tumor resection + left external carotid artery ligation + left internal carotid artery stent reconstruction + vagus dissection under general anesthesia (Figure 1). During the operation, the tumor body adhered to the carotid artery and bifurcated obviously, and the left external carotid artery was blocked and ligated. After the blood supply in the tumor cavity was reduced, the tumor body was completely separated and the left common carotid artery was successfully punctured under direct vision, and then a 7F short sheath was placed. Under the guidance of a loach guide wire, a Viabahn 5 mm ×50 mm (Gore Company) covered stent was placed to reconstruct the blood supply to the left internal carotid artery. Intraoperative exploration showed that the tumor cavity partially invaded the vagus nerve, and the nerve and tumor cavity were released by careful separation. The operation lasted 2.5 h with intraoperative bleeding of 100 ml. Antiplatelet and anticoagulant therapy were continued after operation. Postoperative pathology: carotid body tumor (Shamblin type III) (Figure 2). Discharge physical examination: good answer, normal muscle strength of limbs, slightly right-side tongue, slightly hoarse pronunciation, able to swallow solid food, but sometimes choking cough. One month after surgery, carotid stent patency was reviewed in outpatient clinic (Figure 3). No abnormalities were found in chest CT, and the symptoms of choking and cough were similar to those at discharge. The patient was admitted to hospital with sudden fever and cough 2.5 months after operation for 1 day. Chest CT showed that the left lung occupied space (Figure 4), and was diagnosed as left lung abscess. After 18 days of active anti-infective conservative treatment, reexamination of chest CT (Figure 5) showed that the abscess had been completely absorbed.

A 64-year-old female was admitted to the hospital due to the discovery of a "left axillary mass for 1 month". Physical examination: A mass of about 3.0 cm ×2.0 cm was palpable in the left axillary, which was hard in texture, and no mass was palpable in bilateral breasts. Mammography showed that a mass of 2.7 cm ×1.9 cm in size was seen in the left axil, with unclear boundaries and irregular shape. Left axillary lymph nodes were swollen (Figure 1). General examination showed no signs of distant metastasis. Puncture pathology of left axillary mass suggested invasive ductal carcinoma, considered to be derived from accessory breast (Figure 2). Immunohistochemical staining: Her2 (3+), Ki67 (about 40% +). Take Allred scores: ER =0 points, PR =0 points. Cancer cells were seen by fine needle puncture of swollen lymph nodes in the left axilla. Clinical diagnosis: left accessory breast cancer. After 8 cycles of chemotherapy, left accessory breast cancer was resected and left axillary lymph node dissection was performed. Postoperative pathology showed fibrous tissue hyperplasia with collagenization and chronic inflammatory cell infiltration in the tumor bed area, and no clear cancer tissue remained. Miller-Payne grade 5. No cancer metastasis was observed in 16 lymph nodes of left axillary. After operation, the patient completed radiotherapy and targeted therapy for 1 year, and no metastasis and recurrence were seen until the follow-up.

gastroesophageal reflux (GERD) refers to the pathological symptoms and complications caused by the reflux of gastrointestinal contents from the stomach to the esophagus and even the mouth, throat and airways through the anti-reflux barrier^［1］。 GERD is a common condition, with up to 27% of North American adults living with GERD^［2］。 While the prevalence of GERD in children is difficult to estimate, it can be as high as 6%^［3］。 The cost of GERD treatment is also high. proton-pump inhibitors (PPIs), as the main treatment for GERD, cost more than $10 billion annually in the United States^［4］。 GERD can significantly reduce the quality of life and work efficiency of patients^{［5, 6］}。 PPI is commonly recommended as first-line treatment for GERD^［7］Although it can effectively solve erosive esophagitis caused by gastric juice reflux to the esophagus, many patients still have reflux symptoms^［8］。 In addition, there are growing concerns about the long-term consequences of indefinite PPI use, including indigestion, vitamin and electrolyte deficiencies, bone fractures, small intestinal bacterial overgrowth, pneumonia and C. difficile infections, among others^［9］。