2022年 · 第37卷第06期

Esophageal and gastric variceal bleeding is a serious and dangerous complication of portal hypertension, and the mortality rate is very high. The main purpose of surgical treatment is to control and prevent its serious consequences. Because the etiology of portal hypertension in China is quite different from that in European and American countries, the surgical treatment strategies in European and American countries are not suitable for the current situation in China. At the same time, the current economic and medical conditions in China do not allow the surgical treatment strategies in European and American countries to be copied. Therefore, the traditional surgical methods, namely selective shunt and pericardial vascular devascularization, still play a leading role for a long time. With the continuous development of minimally invasive techniques and the continuous improvement of techniques, laparoscopic surgery has become a trend, and patients recover quickly after surgery, with less damage to liver function. However, there are still some problems worth exploring from the current situation of surgical treatment, which will have a crucial impact on the clinical development of portal hypertension in China in the future.

A 65-year-old male was admitted to the hospital because "CT examination on physical examination found that the left lower abdomen occupied space for 7 months". Physical examination: Enhanced CT examination showed a rounded slightly high-density shadow outside the small intestine lumen, about 2 cm ×2 cm in size, with a CT value of about 78 Hu on plain scan, about 81 Hu on arterial phase and about 90 Hu on portal phase (Figure 1). There was no intestinal dilatation, no abnormal gas and fluid accumulation, no fluid effusion and lymph node enlargement in the abdominal and pelvic cavities. Small intestinal stromal tumor was considered for preoperative diagnosis, and laparoscopic exploration was performed. Intraoperative tumor was found to be located in the mesjejunum. Considering the high risk of mesangial injury by laparoscopic operation, we converted to open laparotomy, and the tumor was found to be 160 cm away from Treiz's ligament, and the tumor was completely resected. The size of the specimen was about 1.8 cm ×1.8 cm, tough in texture, yellowish-white in section, and no necrosis was seen (Figure 2). Postoperative pathological examination showed that spindle cell tumor with sparse cells and extensive collagen deformation in the interstitium, which conforms to mesenchymal tumor. Immunohistochemical staining revealed: CD34 (+), CD117 (-), DOG1 (-), S-100 (-), desmin (-), PDGFR (-), SDHB (-), Ki-67 (30% +), considering solitary fibrous tumor (SFT). After 1 month follow-up, no signs of recurrence and metastasis were seen.

A 41-year-old male was admitted to the emergency department for "pain in the middle and upper abdomen for more than 1 d". Previous history of gastric ulcer, not regularly treated. Physical examination: pulse 120 beats/min, breathing 36 beats/min, blood pressure 100/70 mmHg, acute painful face, abdominal bulge, plate-like abdomen, total abdominal tenderness with rebound pain, obvious upper abdomen, and weak intestinal sounds. Laboratory test: white blood cell count 23.77×10⁹/L, neutrophil count 22.09×10⁹/L, serum CRP 284.12 mg/L. Abdominal CT scan showed: free gas shadows under the diaphragm and abdominal cavity, suggesting perforation of digestive tract; Portal pneumatosis; Intestinal obstruction (Figure 1). The diagnosis was digestive tract perforation, acute diffuse peritonitis, portal pneumatosis. Exploratory laparotomy was performed in the emergency department. During the operation, a large amount of food residue and digestive juice were found in the abdominal cavity, and the gastrointestinal tract was distended obviously, and the abdominal cavity infection was serious. See also a huge perforation in the anterior wall of the gastric antrum, about 4 cm ×4 cm in size, with gastric contents flowing out. During the operation, part of the peritoneal fluid was taken for bacterial culture + drug susceptibility test, and the perforation repair of the gastric antrum + biopsy of the gastric antrum + peritoneal irrigation and drainage were performed. The patient's blood pressure was low after operation, so he was given the vasoactive drug norepinephrine to maintain his blood pressure. At the same time, he was given imipenem cilastatin + tigecycline combined with anti-infective treatment after operation (combined with intraoperative pus culture, it was suggested that Klebsiella pneumoniae). The postoperative pathological examination revealed that the fibrous connective tissue presented acute inflammatory changes, which coincided with the changes of the tissue around gastric perforation. Complete absorption of gas from portal vein in the liver was revealed on abdominal CT 2 weeks after operation.

A 47-year-old male complained of decreased appetite and decreased frequency of defecation without obvious trigger 1 month ago. Physical examination: The abdomen was slightly swollen, no abdominal mass was touched, no tenderness or rebound pain. Under colonoscopy, a huge irregular mass in the liver area of the colon 75cm away from the anal margin was seen, with surface erosion, resulting in luminal stenosis (Figure 1). The pathological examination showed a transverse colon bulge type medium differentiated squamous cell carcinoma (Figure 2). Serum tumor markers: CEA and CA199 were increased. Squamous cell carcinoma of the colon was diagnosed. Exploratory laparotomy + palliative right hemicolectomy (distal closure + proximal stoma) was performed, and the symptoms of intestinal obstruction were relieved after operation.

A 33-year-old male was admitted due to "distension and pain in the upper abdomen for 3 years, repeated vomiting for 3 months and aggravation for 2 days". Three years ago, the patient developed persistent upper abdominal distension and pain without obvious trigger, with the left upper abdomen as the priority. After changing the position, there was no relief, no radiation to other parts, and he was treated with oral medication outside the hospital. Repeated vomiting occurred 3 months ago, and the vomit was stomach contents and bile, which was significantly aggravated 2 days ago. No previous history of abdominal surgery or trauma. Physical examination: tenderness in the left upper abdomen. Abdominal CT: An enveloped pouch-like structure was seen behind the left upper abdomen and stomach, containing disordered small intestinal haptics. The mesenteric blood vessels ran abnormally, and the vascular trunk shifted left, suggesting left paraduodenal hernia (Figure 1). Diagnosis: Left paraduodenal hernia. Laparoscopic reduction of left paraduodenal hernia and suture closure of hernia ring under general anesthesia. Intraoperative observations: A huge hernia sac can be seen in the left transverse mesocolon of the duodenal Trigger's ligament. The diameter of the hernia ring is about 5 cm, the diameter of the hernia sac is about 20 cm ×15 cm, and the jejunum herniates into the hernia sac about 50 cm below the Trigger's ligament (Figures 2, 3). The patient was cured and discharged on the 6th postoperative day. The patients were followed up for 11 months without hernia recurrence and complications.

A 56-year-old male was admitted for "3 days after exploratory laparotomy and repair of intestinal perforation". Abdominal CT showed that the colon was thickened to varying degrees, the density was unevenly reduced, the periintestinal fat space was blurred, and multiple exudations were seen. The whole jejunum and the proximal and middle ileum were diffusely thickened, slightly enhanced after enhancement, intestinal dilatation, gas and fluid accumulation, and dense and multiple swollen lymph nodes of different sizes were seen in the mesenteric space (Figure 1). Partial small intestinal resection and fistula + abdominal abscess clearance and drainage + partial resection of mesenteric mass were performed. During the operation, hemoperitoneum, high intestinal dilatation, congestion, edema and brittleness of the intestinal wall, large amount of intestinal contents, multiple necrosis of some intestinal walls, high mesenteric hypertrophy, diffuse multiple swollen masses, with a maximum diameter of about 6 cm, were seen, and some masses were ruptured with bleeding. Postoperative pathological examination showed that a large number of red-stained homogeneous substances were deposited in the mucosal layer and submucosal layer of the small intestine, accompanied by bleeding and a large number of neutrophil infiltration. The mesangial mass was multiple lymph nodes, and a large number of red-stained homogeneous substances were deposited. Immunohistochemical staining: CD31 (+), ERG (+), Ki-67 (30% +), κ (+), λ (+), Congo red (+), AB-PAS (+), D-PAS (+), Masson (+), combined with clinical exclusion of secondary changes caused by myeloma and other diseases, the diagnosis of primary small intestinal amyloidosis.

retroperitoneal tumor (RPT) is a type of tumor originating from soft tissues such as fat, muscle, nerves, lymph nodes and blood or lymphatic vessels in the retroperitoneal space. Except for tumors occurring in retroperitoneal organs, this article does not include neuroblastoma occurring in children, and lymphadenopathic diseases related to lymph node metastasis of malignant lymphoma, primary germ cell tumor and other primary tumors occurring in adults. retroperitoneal tumors include benign, intermediate and malignant tumors, while about 70% ~80% of tumors originating in retroperitoneal soft tissues are malignant tumors, mostly retroperitoneal sarcoma (RPS), with new RPS cases every year. About 0.5~1/100,000.