2023年 · 第38卷第08期

The incidence and mortality of colorectal cancer (CRC) in China have maintained an upward trend. The 2020 China Cancer Statistics Report shows that the incidence and mortality of colorectal cancer in my country rank second and fifth among all malignant tumors, respectively, with 555,000 new cases and 286,000 deaths in 2020^［1］。 Among them, urban areas are much higher than rural areas, and the incidence of colon cancer has increased significantly. Most patients are already in the middle and late stage when diagnosed.

The patient, a 56-year-old male, was seen for "intermittent melena for more than 2 months and syncope for more than 10 days". Physical examination: anemia, tenderness on the left side of the abdomen, no rebound pain, bowel sounds 4 times/min. Laboratory tests: Hemoglobin 58 g/L, fecal occult blood positive, serum tumor markers normal. Abdominal enhanced CT examination was performed: the wall of the small intestine in the left lower abdomen was annularly thickened (Figure 1), and multiple enlarged lymph nodes were seen in the abdominal cavity, the larger of which was 1.1 cm ×0.8 cm. During the operation, the small intestinal mass was located in the left upper abdomen, 130 cm away from the Trigger's ligament, 11 cm ×10 cm in size, and densely adhered to the peripheral peritoneum and retroperitoneum. The proximal small intestine was slightly dilated, and multiple enlarged lymph nodes were seen in the mesentery, 0.8~1.2 cm in size. Postoperative anatomical specimens: A bulging mass was seen in the small intestine, 11 cm ×10 cm ×5 cm in size. The mass was dark red and necrotic, and the peripheral area was gray-white (Figure 2), involving the whole thickness of the intestinal wall. The tumor penetrated the deep muscle layer to reach the extraserous adipose tissue, invaded the nerve, and saw intravascular tumor thrombus; carcinoma was found in retroperitoneum, but no metastatic carcinoma was found in lymph nodes (0/18). The pathological examination was consistent with sarcomatoid carcinoma (SCA) of small intestine (Figure 3). Immunohistochemical results showed: CK broad spectrum (2+), Vimentin (3+), CK18 (3+), CD117 (-), CD34 (-), Dog-1 (-), S-100 (-), SMA (-), Ki-67 (+, 65% ~70%).

A 33-year-old male was admitted with "blood in the stool for 2 d with dizziness for 1 d". Routine blood test: Hb 130 g/L. After 6 hours of conservative treatment, dark red bloody stool was defecated once again, with a amount of about 500 ml. Within 12 hours after symptomatic treatment with hemostatic drugs, informed dark red bloody stool was defecated intermittently three times, with a total amount of about 1,000 ml, accompanied by palpitations and dizziness. Emergency blood routine: Hb 60 g/L. Abdominal CT examination: (1) The appendix was slightly thicker, about 0.9 cm, and no obvious exudation was seen around it; (2) Multiple gas accumulation in the abdominal cavity and intestine. Blood routine: WBC count 5.85×10⁹/L, Hb 63 g/L, PLT199×10⁹/L; Stool routine: red stool, red blood cells full of visual field, occult blood (+ + + +). Emergency gastroscopy: no bleeding lesions were found; Colonoscopy: A large amount of bloody fluid was seen in the intestinal lumen, and there were more residues in the ascending colon and ileocecal region. After repeated irrigation, the cecal mucosa was smooth, and no ulcers and new organisms were seen. Careful observation showed that fresh blood flowed out of the appendix fossa (Figure 1), and the hemostatic material was sprayed endoscopically. After a few minutes, the bleeding still showed no sign of stopping. Colonoscopy Diagnosis: Bleeding Appendix? Laparoscopic appendectomy was performed in the emergency department. Laparoscopic exploration showed that the abdominal cavity was clean, and the appendix was not bleeding or exudating, so it was removed. Intraoperative colonoscopy showed that the appendix cavity was embedded intact and no active bleeding was observed. After the appendix was removed, the appendix was dissected longitudinally, and inflammation and congestion of the proximal root mucosal wound were seen (Figure 2). Postoperative pathological examination showed that a large number of lymphocytes and plasma cells could be seen in the mucosa, scattered neutrophils could be seen on the intermuscular and serous surface, and the blood vessels on the serous surface were obviously dilated and congested (Figure 3).

A 21-year-old male was admitted for "gastric mass found on physical examination for 5 d". Physical examination showed no abnormalities. Serum tumor markers: CEA, CA19-9 normal, CA72-4 elevated (22.90 IU/ml). Abdominal enhanced MRI examination showed that cystic hyperintensity shadows could be seen in the spleen-stomach space and the large curvature of the stomach body, the larger one was about 9.0 cm ×6.4 cm, and the enhanced scan did not enhance (Figure 1). Enhanced CT examination of the abdomen showed that there was one cystic low density lesion on the large curvature side of the stomach body and the spleen-stomach space, with the size of 2.7 cm ×3.4 cm and 9.6 cm ×6.8 cm, respectively (Figure 2). Preliminary diagnosis: gastric cystic mass occupation (gastric duplication malformation?). Exploratory laparotomy was performed. Intraoperative exploration showed that there was a mass about 4 cm ×3 cm ×3 cm in size on the large curved side of the antrum of the stomach, and a mass about 10 cm ×9 cm ×8 cm in size on the large curved side of the bottom of the stomach. The serous layer migrated with the normal stomach, and the cystic cavity was not communicated with the gastric cavity (Figures 3 and 4). Partial gastrectomy was performed. Postoperative pathological examination showed: (1) gastric antrum mass, cyst wall lined with gastric mucosal tissue, consistent with gastric duplication deformity (Figure 5); (2) Gastric fundus mass, cyst wall lined with ciliated columnar epithelium, consistent with gastric cyst (Figure 6). The patient was followed up for 18 months and recovered well.

A 65-year-old male complained of "hematochezia for 3 months". Colonoscopy showed low rectal cancer, the tumor was located in the left rectal wall, 3 cm in diameter, and the lower edge was 1 cm away from the dentate line. Biopsy pathology showed adenocarcinoma. MRI showed cT3N0M0. The XELOX regimen was performed for 3 cycles of neoadjuvant chemotherapy. Single-port +1 (SILS +1) trans-intersphincterectomy was performed in June 2022. Procedure: A 3 cm transverse incision of the right flat umbilicus was taken, and a single-hole multi-channel PORT was placed for placement of the lens, master surgeon aids and assistant aids, and a 12 mm cannula was placed as the main operating hole for right lower abdominal puncture (Figure 1). First, the sigmoid colon and rectum were dissociated according to the principle of total mesorectal resection (Figures 2 and 3). After reaching the plane of levator ani muscle, it enters the internal and external sphincter spaces from the left and right rear sides, and cuts off the rectococcygeal ligaments. When the varicose vascular plexus is seen, it indicates that it has been separated to the level of the dentate line, and the anterior and lateral sphincter spaces of the rectum are separated in the same way (Figure 4). The rectum was flushed with diluted iodophor, and the anal margin was retracted with a Lone-Star disc-shaped hook under direct vision. An annular pre-tangent line was burned at 1.5 cm from the lower margin of the tumor with an electric knife, and the incision was made layer by layer, and it entered the separated internal and external sphincter space under pneumoperitoneum. After the upper and lower meeting, the rectum was dragged out through the anus, and the intestinal tube was cut off to remove the specimen. Flush again, adjust the proximal colon broken end and the full-thickness intermittent suture of the anal canal to complete the reconstruction, and finally perform prophylactic terminal ileostomy with the incision at the single PORT, and place a pelvic drainage tube through the main operating hole of the right lower abdomen. The operation time was 230 min, the intraoperative bleeding was 50 ml, there were no surgical complications, and the hospital was discharged 7 days after the operation. The postoperative pathological examination showed moderately differentiated adenocarcinoma, ypT2N0M0, with negative resection margin. Stoma reduction was performed 3 months after surgery, and the patients were followed up 6 months after surgery with good stool control ability, and stools were performed 3~4 times a day.

A 40-year-old female was seen for 3 weeks due to right carotid artery dissection caused by a fall. The patient went to a local hospital due to falling and hitting a foreign object in his right neck. The main manifestation was pain in his right neck. At that time, he was unconscious, vague speech and impaired limb movement. CT examination in another hospital showed that the middle segment of the right common carotid artery was dissected. For further treatment, he went to our hospital. The past history was no different, he denied the history of hypertension, diabetes, coronary heart disease, etc., and there were no obvious positive signs in the neurological examination. The outpatient was given aspirin enteric-coated tablets 0.1g once a day and sulodite soft capsule 1 oral treatment twice a day. Three weeks later, the reexamination of the cervical CTA in our hospital showed that the proximal lumen of the right common carotid artery was severe stenosis, and the proximal vessel of the stenosis showed a local double-lumen shadow, suggesting the progression of right carotid artery dissection. The drug was adjusted to aspirin enteric-coated tablets 0.1g combined with rivaroxaban 10 mg once daily oral therapy. Preoperatively, neck CTA, head and neck vessel wall MR enhancement and carotid angiography were performed to confirm right carotid artery dissection (Figure 1). After excluding surgical contraindications, right carotid artery endarterectomy and patch plasty were performed under general anesthesia. During the operation, right carotid artery endarterectomy and local thrombosis were seen (Figure 2). Dissecting partial endarterectomy and in situ patch enlargement were performed, and the operation was smooth. Postoperatively, aspirin enteric-coated tablets 0.1 g and clopidogrel bisulfate tablets 75 mg were given oral double antiplatelet therapy once a day. Follow-up cervical CTA at 1 and 6 months after operation showed: postoperative changes of proximal right common carotid artery dissection, local fusiform enlargement of the lumen, and the original stenotic vessel returned to normal thickness. The patient recovered well after operation, did not complain of obvious discomfort, and lived normally.