2022年 · 第37卷第04期

A 61-year-old woman was examined 2 weeks ago for "low back pain". CT plain scan showed a round soft tissue density shadow next to the right iliac fossa and psoas major muscle, with scattered patch-like high density shadows, about 4.7 cm ×4.3 cm in size (Figure 1). MRI plain scan + enhancement: lesion T₁WI is equal, T₂WI was moderate and slightly high signal, and the enhancement scan was obviously uniform enhancement. The adjacent intestinal canal and iliopsoas muscle migrated and changed, and suspicious cord shadows were connected to the intervertebral foramen, which was considered as retroperitoneal neoplastic lesion. Laparoscopic retroperitoneal mass resection was performed. During the operation, the tumor was located at the outer edge of the right psoas major muscle, with a size of about 4 cm ×5 cm. During the blunt separation, two nerves were invaded and wrapped by the tumor (located in the middle and lower part of the tumor body), and the tumor was severed and completely removed. Gross postoperative pathology: nodular tissue, 6.5 cm ×5.5 cm ×4.5 cm in size, gray-white and gray-red in section, with granular sensation in parenchyma, like bone-like tissue. Under light microscope, spindle cells were the main tumors, and the histopathological tendency was retroperitoneal spindle cell soft tissue tumors. Immunohistochemical staining revealed that spindle cells Vim + + +, CKpan + (Figure 2), EMA + + +, bcl-2+, SMA +, Ki-67+, β-Catenin +, S-100-, P53-, CD99-, DES-were diagnosed as primary retroperitoneal ectopic meningioma. The patient underwent MRI examination of head and spine at later follow-up, but no positive signs of space occupation were found. No tumor recurrence and metastasis were seen after 18 months of follow-up.

The patient was a 39-year-old female. Admitted for "cough, pharyngeal discomfort, accompanied by nausea and vomiting for 6 d". Gastroscopy showed that there was a submucosal bulge in the cardia, about 3.0 cm in size, with smooth surface mucosa and thin coating locally. Endoscopic ultrasonography showed that the submucosal bulge of the cardia (stromal tumor or external pressure possible), and the bulge-type lesion of the cardia showed moderate and high echoic changes, adjacent to the 4th layer of muscularis propria, with uneven echoes and unclear size. Abdominal CT examination showed that a round-like abnormal density shadow was seen at the gastric cardia, with clear boundaries and a size of about 4.1 cm ×3.7 cm ×4.2 cm, considering the possibility of gastric cyst (Figure 1). X-ray examination of the upper gastrointestinal tract showed a semi-elliptical filling defect in the cardia and right anterior lateral wall, about 3.0 cm ×1.5 cm in size, and the contrast medium could still pass (Figure 2). Intraoperative exploration: It was seen that the tumor was located in the cardia, and most of the tumor entered the mediastinum with the esophagus. The hepatogastric ligament was incised along the small curve of the stomach, and the blood vessels were ligated to fully expose the proximal side of the small curve of the stomach. The peritoneum at the diaphragm angle of the esophageal hiatus was incised. The cardia and the tumor were completely pulled into the abdominal cavity with an ultrasonic scalpel. The tumor was carefully peeled off, and the tumor was completely peeled off from the stomach wall. The damaged part of the stomach wall was continuously sutured with a barb thread, and the seromuscular layer was embedded. Postoperative pathological examination showed: (gastric mass) cystic mass, homogeneous powder stained without structure, scattered focal cholesterol crystals and granuloma, local cyst wall lined with columnar epithelium, histological morphology was benign lesion, excluding gastric duplication deformity (Figure 3). Upper gastrointestinal X-ray examination showed no leakage after surgery.

A 33-year-old female was admitted for "intermittent abdominal pain for more than 1 month and aggravated for 2 days". Abdominal plain scan + enhanced CT examination showed that the left abdominal cavity was irregular and slightly lower density shadow with clear boundary and uneven enhancement. Gastrointestinal stromal tumor (colon) may be considered (Figure 1). The last menstruation was more voluminous and darker than the previous one. History of marriage and childbirth: Previous "in vitro fertilization-embryo transfer" due to "bilateral fallopian tube blockage". Physical examination: flat and soft abdomen, tenderness in the left upper abdomen, and negative mobile voicing. Laparoscopy was performed, and a descending mesocolic mass was seen during the operation, which was dark red, with a ruptured surface, a clear boundary with the surrounding organs, tough in texture, and cystic-solid (Figure 2). There is dark red blood accumulation in the pelvic cavity about 100 ml. Laparoscopic resection of mesenteric mass + partial resection of descending colon was performed. Postoperative pathological examination showed: dark red clot-like tissue, 5.5 cm ×4.0 cm ×4.0 cm in size, partially intact capsule, dark red cross section, visible villus tissue and trophoblast cells. Pathological diagnosis: (descending mesocolic) ectopic pregnancy (Figure 3). Human chorionic gonadotropin β subunit (β-HCG) was detected 10 days after operation: 2.36 mIU/ml; Color Doppler ultrasound of uterus and adnexus: No abnormalities were found.

A 64-year-old male was admitted for "hematemesis and melena for 4 d". The patient had no abdominal pain or fever. Previous history of coronary heart disease, irregular aspirin use. Physical examination: blood pressure 105/53 mmHg, conscious, anemic appearance, soft abdomen, no tenderness and rebound pain. Blood routine: red blood cells 2.45×10⁹/L, Hb 67 g/L. Gastroscopy and colonoscopy showed no abnormalities in the stomach, the descending part of the duodenal bulb and the large intestine. Abdominal enhanced CT found multiple calcified plaques in the wall of abdominal aorta and bilateral iliac artery walls. The bifurcation of abdominal aorta near the common iliac artery showed tumor-like dilatation, about 25 mm ×24 mm. The tumor body convexed to the level of duodenum, and the fat gap between duodenum and duodenum disappeared. No contrast medium overflowed into the adjacent intestinal lumen (Figure 1). On the 10th day after admission, the patient had blood in the stool again three times, with a total volume of about 1 300 ml, and had loss of consciousness, progressive decrease in blood pressure, arterial blood gas Hb 37 g/L, lactic acid 6 mmol/L, and was transferred to general surgery ICU for blood transfusion and anti-shock therapy. After the patient's circulation was stable, there was no overflow of contrast medium after angiography in the emergency department. During exploratory laparotomy, gastroduodenoscopy revealed a large amount of fresh blood and blood clots in the gastric cavity, duodenal bulb and descending part, without bleeding points, and active bleeding at the level of the duodenum. Then, the duodenum was incised for exploration, and a small ulcer was seen at the level of the duodenum, with jet bleeding from the center of the ulcer, which communicated with the abdominal aortic aneurysm. When the bleeding was compressed, the pulsating abdominal aorta outside the intestinal wall and the calcified plaque of the hard abdominal aorta could be palpable. Combined with preoperative enhanced CT, the intraoperative diagnosis was: aortoduodenal fistula (ADF). Abdominal aortoduodenal fistula suture closure + gastric antrum dissection closure + gastrojejunal Bi II Roux-en-Y anastomosis were performed. The hemorrhage stopped after surgery, and the three-dimensional reconstruction of CT aortic angiography on the 5th day after surgery revealed an abdominal aortic aneurysm without contrast spillage (Figure 2). On the 20th day after surgery, the patient had blood in the stool again. After emergency abdominal aortic stent implantation, the patient had no gastrointestinal bleeding and was cured and discharged.