2023年 · 第38卷第03期

A 59-year-old male was admitted to the hospital because "physical examination found that the right liver occupied space for 1 week". One week before the patient was admitted to the hospital, the B-ultrasound of the unit physical examination found that the right liver occupied space, 4.2 cm ×4.0 cm in size, without abdominal pain, abdominal distension, jaundice, decreased appetite and other manifestations. Physical examination: The sclera is not yellow, there is no tenderness in the whole abdomen, and there is no abdominal mass. There was no history of chronic liver disease such as "hepatitis B, hepatitis C, schistosomiasis liver" in the past, a history of hypertension for 5 years, and a history of open splenectomy for traumatic splenic rupture 15 years ago. There were no obvious abnormalities in blood routine, liver function and coagulation function tests, and the tumor markers AFP, CEA and CA19-9 were all in the normal range. Admission CT (Figure 1): The right posterior lobe of the liver occupies space, the border is clear, the plain scan is isodensity, the arterial phase is obviously uniformly enhanced, and the portal vein phase and the equilibrium phase are isodensity. MRI: T2W1 high intensity, TIWI low intensity, uniform enhancement in arterial phase after enhancement, weakened enhancement in portal vein phase and hepatobiliary excretion phase, showing low intensity. Discussion in the department considered that the possibility of benign liver tumor was high, and malignant tumor could not be ruled out. After communication with the patient and family members, surgical treatment was decided. Fluorescence laparoscopic resection of the right liver mass together with the surrounding 2 cm normal liver tissue was performed (peripheral intravenous injection of 25 mg of indocyanine green 48 h before operation). During the operation, the edge of the mass in the posterior lobe of the right liver was clear, surrounded by the surrounding liver tissue and invaginated. There was no indocyanine green residue in the lesion, and some indocyanine green residue in the surrounding 2.0 cm normal liver tissue (Figure 2). The liver parenchyma was dissected by ultrasonic scalpel, and the large duct tissue was clipped by ligation clip before dissection. Intraoperative ultrasound-guided surgical margin was resected, and low central vein technique was used to reduce bleeding. The operation was smooth, postoperative pathology: (liver mass) ectopic spleen.

A 63-year-old male was admitted to hospital for repeated right upper abdominal pain accompanied by chills and fever for more than 20 years, which was aggravated for one month. He underwent open appendectomy in an external hospital more than 30 years ago. Physical examination: Mild tenderness and rebound pain in the right upper abdomen, and obvious percussion pain in the liver area. Laboratory Test: WBC: 5.86×10⁹/L, total bilirubin 15.3 μ mol/L, AST: 33.47 U/L, ALT: 15.2 U/L, ALB: 45.3 g/L. CT showed imbalance of liver proportion, atrophy of left and right lobes, hypertrophy of caudal lobes, dilatation of intrahepatic bile duct, multiple stones in bile duct, and biliary cirrhosis; MRCP showed multiple nodular filling defects in the intrahepatic bile duct, significant intrahepatic and extrahepatic bile duct dilation, and pancreatic duct dilation (Figure 1). Preoperative assessment: The patient was Child-Pugh grade A with good liver reserve function (preoperative 15 min retention rate of indocyanine green was 5.3%), and the whole liver volume calculated by three-dimensional CT reconstruction was 1 331 cm³The caudate lobe volume of the liver was 837cm³。 The standard liver volume (SLV) was calculated using the Urata formula: SLV (ml) =706.2× body surface area (m²) +2.4, the calculated standard liver volume was 1 117 cm³, the remaining liver volume accounted for 74.9% of the standard liver volume. Based on the preoperative assessment, the patient was safe to perform surgery. Laparoscopic subtotal hepatectomy with preservation of the hypertrophic liver caudate lobe alone + exploration of the biliary tract + T-tube drainage was performed (Figure 2). The operation time was 700 min, the intraoperative bleeding was 600 ml, and the intraoperative red blood cell transfusion was 300 ml. The postoperative pathological findings showed no carcinogenesis. The patient recovered well during the perioperative period and was discharged on the 20th postoperative day. The follow-up time was 5 months. No bile duct stenosis and recurrence of calculi were observed.

Case 1, a 42-year-old female, was admitted to the hospital because "gastric polyps were found for more than 2 months". Gastroscopy showed: multiple polyps in the stomach; Non-atrophic gastritis. Case 2 male, 63 years old, presented for "retrosternal pain discomfort". Focal fading was found in both gastroscopy cases (Figure 1). Case 1 biopsy pathology showed: superficial mucosal tissue, normal shape of gastric fovea, twisted and elongated intrinsic glands, and mild nuclear atypia (Figure 2). Combined with immunohistochemical examination results: ATPase (+), pepsinogen-I (+) (Figure 3), MUC-6 (+), MUC5AC (-) (Figure 4), Ki67 (+, accounting for about 1%), tending to fundus adenocarcinoma. Endoscopic gastric submucosal dissection (ESD) was performed. Pathological examination showed that residual fundus adenocarcinoma, about 0.2 cm in diameter, invaded the mucosal muscle layer. The boundary between tumor tissue and normal tissue was clear, and no vascular invasion was observed. The surrounding tissue showed mild chronic non-atrophic gastritis changes, no HP infection, and the resection margin (-) (Figure 5). Case 2 biopsy pathology showed: (fundus) acid-secreting gland tumor, the gland is twisted, angled, partially anastomotic, partially destroyed mucosal muscle, tending to fundus gland adenocarcinoma. ESD resection was performed, and pathological examination showed: fundus adenocarcinoma, area 1 cm ×0.5 cm, invasion of mucosal muscle layer, resection margin (-) (Figure 6). Case 1 was followed up for 18 months and case 2 was followed up for 6 months. Endoscopic review showed no signs of recurrence.

A 54-year-old female was admitted for "10 months after the discovery of a goiter". Physical examination: 4 cm ×3 cm nodules can be palpable in the right lobe of the thyroid gland, with acceptable movement, tough texture, and can move up and down with swallowing. B-ultrasound examination revealed a solid nodule in the middle of the right lobe of the thyroid gland, with low grade suspected malignancy. Laboratory tests: Serum anti-thyroglobulin antibody (Tg): 26.20 IU/ml (normal range 0.27-4.20 IU/ml), positive for syphilis serum specific antibody. Serum tumor markers and coagulation mechanism examination indexes were all in the normal range. According to the B-ultrasound examination, the size of the nodule in the middle of the right lobe was about 5.1 cm ×2.9 cm ×3.4 cm, with unclear boundary, and the possibility of malignancy was high. Considering that the patient had compression symptoms, total thyroidectomy + radical neck lymphadenectomy was performed. Intraoperative exploration showed that the thyroid gland had close adhesion to the surrounding area, and a nodule could be palpable in the isthmus of the right lobe of the thyroid gland, which was hard and solid, with unclear boundary. Considering the possibility of malignancy, the right lobe and isthmus were resected, and frozen pathological examination revealed malignant tumor. Frozen pathological examination of lymph node dissection revealed suspicious medullary carcinoma, and then the left lobe of the thyroid gland was resected. The postoperative immunohistochemical results showed that CD1a (+), CD207 (Langerin) (+), S-100 (+), CD43 (+) and Ki-67 (30% +) were positive, as shown in Figures 1 and 2. Diagnosis of thyroid Langham cell hyperplasia was confirmed. Because the tumor was found to infiltrate the lymph nodes during the operation, the residual cancer was completely removed by radioactive iodine therapy after operation, and serum thyroid stimulating hormone and Tg were closely followed up and monitored. The serum Tg was 13.60 μ g/L after reexamination. Serum Tg decreased to 1.09 μ g/L after 2 months of radioactive iodine treatment. The patient underwent thyroid function tests and CT scans of the neck, chest, abdomen and pelvis 2, 6 months and 1 year after discharge, and no suspicious lesions were found.

A 38-year-old female was admitted to the hospital due to "physical examination found uterine and adnexal mass for 10 d". The patient was previously healthy, had mild dysmenorrhea, no irregular vaginal bleeding, and underwent cesarean section 12 years ago. Physical examination: A mass that is not easy to push can be palpable in the left adnexal area. Abdominal ultrasound: cystic mass in the left adnexal area, approximately 5.0 cm ×4.4 cm, with clear border, left parauterine vessel dilatation; CTA: Abnormally thickened vascular shadow in the left adnexal area, considered as uterine arteriovenous malformation (UAVM), see Figure 1. uterine artery embolization (UAE) was performed after multidisciplinary discussion. Intraoperative angiography confirmed a giant UAVM, and superselective embolization of the target artery was performed using a mixture of Glubran glue and lipiodol and a spring coil (Figures 2, 3). Pelvic CTA at 2 months (Figure 4) and 2 years postoperatively: distal occlusion of left internal iliac artery and disappearance of UAVM.