2023年 · 第38卷第07期

thoracoabdominal aortic aneurysm (TAAA) is a dilated lesion involving the thoracic and abdominal aortas, accounting for approximately 10% of aortic aneurysms^［1］。 When the TAAA diameter was>6.0 cm, the incidence of aortic events increased significantly and the 5-year survival rate began to decrease; Under this diameter, the risk of developing aortic adverse events such as acute aortic dissection, aortic rupture, and death ranged from 9.3% to 19.0%^{［2, 3］}； The total 10-year mortality rate of untreated TAAA was approximately 51.0%^［4］。 The etiology of TAAA may be degeneration of vascular wall midlayer structural proteins plus hemodynamic shock. Degeneration is common in senile atherosclerotic changes, and may also be secondary to chronic dissection and connective tissue diseases, such as Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome and Turner syndrome. Less common causes include infection, vasculitis and trauma^{［5, 6］}。

The patient, a 34-year-old male, was admitted to hospital with "upper abdominal pain for more than 2 months". More than 2 months before admission, there was dull pain in the middle and upper abdomen after a full meal, and the pain was progressively aggravated. There was no discomfort such as nausea, vomiting, hematemesis, abdominal distension and skin itching. CT in other hospital showed cystic lesions in hilar with dilatation of intrahepatic bile duct and gallbladder stones. Liver function: total bilirubin 109.0 µmol/L, alkaline phosphatase 380.0 U/L. The symptoms were not significantly relieved after hepatoprotective treatment. CT and MRI of upper abdomen after 2 months showed that gallbladder carcinoma may involve the adjacent liver parenchyma. Reexamination of liver function: total bilirubin 19.8 µmol/L, alkaline phosphatase 279.0 U/L. The patient was admitted to our hospital for further treatment. Upper abdominal enhanced CT after admission: gallbladder wall thickening, hilar bile duct wall thickening, considered malignant, with involvement of adjacent liver parenchyma, intrahepatic bile duct dilation, hilar lymph node metastasis; Gallbladder stones. PET-CT showed uneven thickening of the gallbladder wall, hypermetabolic changes, considering gallbladder cancer, and metastases in the hilar region (possible bile duct involvement), invasion of the adjacent liver and colon, and lymph node metastasis in the hilar region (Figure 1). Liver function: total bilirubin 8.9 µmol/L, glutamyltransferase 205.0 U/L, the rest normal. Tumor indicators were normal. Physical examination is no different. The initial diagnosis was: space-occupying lesions of the gallbladder, gallbladder stones. Multidisciplinary discussion concluded that the patient's jaundice and liver function improved after liver protection and other treatments, and there were no obvious abnormalities in tumor markers, and the clinical manifestations were inconsistent with malignant tumors. However, the imaging findings of the patient suggested that gallbladder carcinoma was more likely to be complicated by cholangiocarcinoma, and PET-CT suggested that gallbladder carcinoma was complicated with metastases in the hilar area (possible bile duct involvement), invading the adjacent liver and colon, and metastasizing in the hilar lymph nodes. The patient is a young man. It is recommended to undergo ultrasound-guided puncture or laparoscopic biopsy to confirm the pathology. According to the pathological results, the next treatment plan is decided. If it is malignant, it is recommended to undergo surgical resection after neoadjuvant chemotherapy. Ultrasound-guided pathological puncture was performed, but the operation was discontinued due to the unclear limitation of the hepatic hilar region and the high risk of puncture injury to the bile duct. Laparoscopic exploration was performed after perfect preoperative examination. Under laparoscopy, the size of the gallbladder was about 8 cm ×6 cm ×4 cm, the triangle of the gallbladder was not clear, the adhesion to adjacent tissues was dense, and the adhesion between hepatoduodenal ligament and omentum was dense. Exploratory laparotomy was performed, and the median incision of the upper abdomen was taken. After dissection, the triangular adhesion of the gallbladder was dense. The hepatoduodenal ligament was dissected, and an abscess with a diameter of 3 cm in the 4b segment of the liver was seen. The abscess was opened and a large amount of pus was aspirated. The abscess cavity was flushed, and the abscess cavity was explored to be not communicated with the biliary tract. It was decided to only incision and drainage the liver abscess. Free the base of the gallbladder to the cystic duct, suture the opening of the cystic duct, and remove the gallbladder. Hemostasis by electrocoagulation of the gallbladder bed. The specimen was removed and several stones in the gallbladder were seen. Intraoperative freezing pathology: xanthogranulomatous cholecystitis. Postoperative pathology: xanthogranulomatous cholecystitis. Recovery was acceptable after surgery and finally discharged from hospital.

A 61-year-old female was referred to our hospital by another hospital due to "periumbilical pain for 4 years and aggravated for half a year". On admission there was a typical triad of chronic superior mesenteric artery occlusion: postprandial pain, fear of eating, weight loss. Weight loss of up to 20 kg in 4 years. computed tomography angiography (CTA) examination in an outside hospital showed that "the openings of the celiac trunk, superior mesenteric artery and inferior mesenteric artery were occluded, accompanied by the formation of a large number of collateral arteries" (Figure 1A). Diagnosis: superior mesenteric artery occlusion; celiac trunk occlusion; Occlusion of the inferior mesenteric artery. After completing all preoperative preparations, celiac arteriography was performed to confirm complete occlusion of the opening of three mesenteric arteries, and endovascular treatment was abandoned because there was no access. Change to open surgery, choose retrograde bypass, surgical method: middle superior mesenteric artery-right common iliac artery artificial blood vessel bypass grafting (Figure 1B), the patient's abdominal pain symptoms quickly relieved, weight gained, CTA artificial blood vessel patency was reviewed (Figure 1C). Half a year later, the patient had sudden abdominal pain, and CTA suggested thrombosis in the artificial blood vessel (Figure 2A). Angiojet thrombosis of the right iliac-superior mesenteric artery artificial blood vessel was performed. During the operation, the guide wire retrograde through the artificial blood vessel through the opening of the superior mesenteric artery to the abdominal aorta (Figures 2B and 2C), and then further balloon dilation + superior mesenteric artery stent placement (1 Lifestent 8 mm ×60 mm bare stent) (Figure 2D) was performed. The artificial blood vessel was left open, and the postoperative outpatient review (Figure 2E) showed that the artificial blood vessel and stent were unobstructed, and there was no abdominal pain symptom. Up to now, the patient has been more than 2 years after the operation, and the artificial blood vessel has been gradually occluded due to bidirectional blood flow, but the superior mesenteric artery stent remained unobstructed, which did not affect the intestinal blood supply, and recovered well.

The 85-year-old female was admitted to the hospital due to "intermittent abdominal pain and abdominal distension for 1 month, and recurrent aggravation for 3 days". Past history: 1 month ago, she was treated in the hospital due to "incomplete intestinal obstruction and intussusception", and her condition improved and she was discharged. Physical examination: Abdominal swelling, no gastrointestinal pattern and peristaltic wave, a mass of 8 cm ×7 cm can be palpable in the right lower abdomen, with tough texture, unclear boundary, poor mobility, accompanied by tenderness, no rebound pain and muscle tension, and intestinal sounds 1~2 times/min. Laboratory tests: percentage of neutrophils in blood routine: 87.8%, serum CRP: 59.9 g/L, procalcitonin: 0.085 ng/ml. Abdominal enhanced CT examination: small bowel obstruction, intussusception (ileocecal type) (Figure 1A), full thickness of the bowel wall in the sheath part, thickness of the bowel wall in the lower abdomen, and multiple bowel wall thickness. Considering space-occupying lesions and chronic inflammatory lesions to be differentiated (Figure 1B), lipoma in the cecal area may be (Figure 1C). Preoperative diagnosis: space-occupying lesions of small intestine; Intussusception is an incomplete intestinal obstruction. An exploratory laparotomy was performed in the emergency department. During the operation, the whole small intestine was dilated, and the terminal ileum of about 8 cm was inserted into the cecum, and the ileum segment was reduced. The intestinal wall of the inserted ileum and cecum was congested and edema, the intestinal wall was thickened, the diameter of the cecum was thickened, and a solid mass was found in the terminal ileum, which could move up and down. Terminal ileum and cecum resection, appendectomy and ileostomy were performed. The specimen was dissected, and a 4 cm ×3 cm size tumor tissue was found in the ileum 7 cm away from the ileocecal region. It was located under the mucosa, with tough texture, and the surface mucosa was partially necrotic and blackened (Figure 2A). The tumor tissue was incised, and it was a yellow fat-like matter with fine texture (Figure 2B). Pathological examination showed tumor-like hyperplasia of terminal ileal submucosal adipose tissue (Figure 3).