2023年 · 第38卷第09期

The patient was a 63-year-old female. See a doctor for "wasting and fatigue for 4 years". Four years ago, the patient had no obvious inducement to lose weight, weakness, and no low back pain. Examination in the local hospital showed that the left kidney occupied space. CT showed: left retroperitoneal-left kidney malignant tumor, 12.0 cm ×6.6 cm ×16.7 cm; The right edge of the mass is adjacent to the abdominal aorta, surrounding the left renal artery, and the anterior edge is close to and pushing the left renal vein (Figures 1, 2). Laparoscopic radical nephrectomy was performed under elective general anesthesia in urology. During the operation, the mass was huge and tightly adhered to the surrounding tissues. Considering that it was difficult to completely strip the mass under laparoscopy, it was converted to open laparotomy. During the stripping of the mass, there was massive bleeding. After emergency hemostatic forceps clamping during the operation, 3-0 Prolene line suture was applied to stop the bleeding. After the peritoneum was explored after the tumor was completely resected, it was suspected that the abdominal aorta was mistakenly ligated. The distal abdominal aorta and femoral artery did not palpate obvious pulsation (Figure 3A). The intraoperative blood loss was about 4 000 ml. The abdominal aorta, superior mesenteric artery, and right renal artery were re-explored and blocked in turn. The abdominal aortic knot was cut off, and two ruptures in the anterior wall of the abdominal aorta with a size of about 0.5 cm ×0.5 cm were seen (Figure 3B). The intima of the posterior wall of the abdominal aorta was injured by cutting the rupture of the abdominal aorta. After fixing the posterior wall intima, the artificial blood vessel patch was cut to complete the abdominal aorta repair (Figure 3C). The abdominal aorta was occluded for about 34 min. After operation, the pulsation of superior mesenteric artery and renal artery could be palpable. No obvious intestinal ischemia and renal infarction were observed, and the pulsation of bilateral dorsal pedis artery could be palpable. Postoperatively, the patient was transferred to the intensive care unit for continued treatment. The patient was transferred to a local hospital for hospitalization on the 3rd postoperative day, and the patient died of pulmonary infection one week after the operation. Postoperative pathology: Malignant spindle cell tumor of the left kidney, considering sarcomatoid carcinoma.

The patient, a 45-year-old male, employee of an enterprise, was admitted to the hospital in June 2022 due to left low back pain for 1 d. A CT examination of the abdomen in a local hospital showed that the left renal vein was thickened, the density was unevenly increased, and renal vein thrombosis? Reexamination of renal artery CTA in our hospital showed venous thrombosis in the left renal vein-vena cava opening area, mild swelling of left kidney, with obvious perirenal exudation (Figures 1, 2). Laboratory test: D-dimer 480 ng/ml (normal range<243 ng/ml) and creatinine 116.9 μ mol/L (normal range 57-97 μ mol/L). Preoperative diagnosis: Nutcracker syndrome complicated by acute renal vein thrombosis. On the third day of admission, percutaneous left renal vein Angiojet catheter thrombolysis + renal vein balloon dilatation + left renal vein catheter thrombolysis + inferior vena cava filter placement + inferior vena cava and left renal venography were performed under local anesthesia (Figures 3 and 4). The intraoperative Angiojet catheter model was Poco Solent Omni, the balloon was Poco Charger 12 mm ×40 mm balloon, and the thrombolytic catheter was a multi-orifice thrombolytic catheter, positioned in the left renal vein. Postoperatively, urokinase was continuously pumped through the thrombolytic catheter for local thrombolytic therapy, and the local thrombolytic therapy lasted for 2 days. The dose of 300,000 U urokinase was mixed with 50 ml of normal saline, and the micropump pumping speed was 2 ml/h. The anticoagulant therapy was the same as before. The coagulation function was re-examined on the 4th day of admission: thrombin time (TT) 35.3 s (normal range 15.8-24.9 s), D-dimer 1 736 ng/ml. Renal function: Creatinine 104.7 μ mol/L. Reexamination of coagulation function on day 5 of admission: D-dimer 2 096 ng/ml. Renal function: Creatinine 101.9 μ mol/L, percutaneous left renal vein thrombectomy + inferior vena cava filter removal under local anesthesia (Figure 5). The coagulation function was re-examined on day 6 of admission: D-dimer 597 ng/ml. Renal function: Creatinine 99.7 μ mol/L. It indicated that the thrombus load was reduced, the renal function was improved compared with before, the anticoagulant and thrombolytic effect was acceptable, and the patient recovered and was successfully discharged on the 8th day of admission. After discharge, low molecular weight heparin was stopped, and rivaroxaban tablets 15 mg twice/d orally were changed, and rivaroxaban 20 mg once/d orally was changed after 3 weeks. One month after discharge, the patient's renal function was reviewed in the outpatient department of our hospital: creatinine was 117.5 μ mol/L, and D-dimer decreased to normal. Six months after discharge, the patient went to the local hospital for renal artery CTA, which showed no obvious abnormalities. Renal function was re-checked at the local hospital 8 months after discharge: creatinine 107 μ mol/L. Follow-up showed that creatinine was stable for a long time without aggravation. After discharge, the patient reported no obvious discomfort.

The patient, a 53-year-old female, was admitted to the hospital due to fatigue and discomfort for more than 1 month with intermittent vaginal bleeding. Abdominal CT performed at the local hospital 1 month before admission showed an exophytic mass in the neck of the pancreas, which was not clearly distinguished from the medial margin of the liver, and was considered a neuroendocrine tumor. Blood routine: low platelets. Bone marrow puncture: immune thrombocytopenia with iron deficiency anemia is not excluded. Total abdominal enhanced CT + three-dimensional analysis (Figure 1) showed that the liver-stomach space occupied space, considering giant lymph node hyperplasia. Initial diagnosis: abdominal tumor, anemia, thrombocytopenia. After symptomatic treatment and exclusion of contraindications, the patient underwent laparoscopic exploration. Intraoperative exploration was visible (Figure 2). A gray-yellow mass with a size of about 6 cm ×4 cm was visible under the liver and the upper margin of the pancreas, with unclear boundaries, and the mass was completely removed. A tumor of about 2 cm ×1.5 cm in size was seen in the liver-stomach space, which was resected by the same method. Postoperative gross specimen: The resected specimen consisted of a piece of grayish-yellow tissue 6 cm ×5 cm ×3.5 cm and a fibroadipose fragment containing 2 cm ×1.5 cm ×1 cm. The mass was wrapped, with an off-white cut, surrounded by irregular, light-colored areas of 1 cm in diameter. Postoperative pathological diagnosis: Castleman disease (CD), plasma cell type. The patient was reviewed regularly and recovered well without recurrence.

A 34-year-old woman came to the clinic for "5 d of paroxysmal pain under the xiphoid process after a meal". Deep tenderness in the middle of the upper abdomen at admission. Imaging examination: Upper abdominal enhanced CT (Figure 1): A massive soft tissue density shadow was seen on the head of the pancreas, showing uneven enhancement with poor boundary, and the maximum cross section was about 59 mm ×49 mm. Considering the possibility of neuroendocrine tumor, enlarged lymph nodes were seen in the hilar region, with a diameter of about 19 mm. Pancreatic head duodenectomy is proposed. During the operation, a 6 cm ×5 cm hard mass could be palpable in the head and neck of the pancreas, invading the posterior wall of the stomach. Multiple hard masses about 1 cm in diameter were seen in the body and tail of the pancreas. The tumors of the head and body of the pancreas were removed and frozen during the operation, respectively, showing: (pancreas) spindle cell malignant tumor, mitotic image is easy to see, and the morphology tends to be mesenchymal. After further communication with family members, total pancreatectomy + duodenectomy was decided. The operation went smoothly with about 600 ml of intraoperative bleeding. Postoperative pathology: A gray-white gray-red swelling, about 65 mm ×50 mm, soft, semi-gelatinous, and swollen lymph nodes around the pancreas, about 22 mm in diameter, were seen on the section (under the naked eye). Histopathology (Figure 2): (Pancreas) spindle cell mesenchymal malignant tumor. The tumor is composed of alternately distributed cell-rich areas and sparse areas, with angioperithelioma-like, wavy and bundle-like areas. The tumor cell density is high, abnormality is obvious, and mitotic images are easy to see (hot spots can reach 6/HPF). The morphology first tends to be malignant solitary fibrous tumor (SFT), invading the pancreatic envelope, invading the serous layer of the stomach and duodenum. Satellite nodules (3, about 16 mm in diameter) are seen around the pancreas, and the resection margins of the duodenum, stomach, pancreas and bile duct are not involved. No tumor metastasis was found in the lymph nodes submitted for examination. Immunohistochemistry: CD31 (+), CD34 (-), Ki-67 (+, ~50%), STAT6 (-), Bcl-2 (-), CD99 (-), S100 (-), CD117 (-), CD21 (-), SMA (-), Dog-1 (-), TLE1 (-), pan-TRK (-), CKpan (-), ALK (5A4) (-), HMB45 (-), Fli-1 partially weak (+), ERG scattered weak (+). The patient was followed up for 16 months with regular medication, and the patient recovered well.

A 65-year-old female was admitted with intermittent right upper abdominal pain for 48 h. The right upper abdomen showed intermittent distension and pain, with obvious symptoms after eating, accompanied by nausea and no vomiting. He underwent cholecystectomy for gallstones in 2008 and pancreaticoduodenectomy in our hospital in 2011 for duodenal ampullary cancer. Physical examination: 20 cm old surgical scar was seen in the middle and upper abdomen, tenderness in the right upper abdomen, no rebound pain, no muscle guard, and normal intestinal sounds. Blood routine: white blood cell count 7.93×10⁹/L, neutrophil percentage 80.4%, C-reactive protein 24.09 mg/L. Liver function : ALT 68 U/L. Abdominal CT plain scan + enhancement: changes after pancreaticoduodenectomy, partial intestinal dilatation and gas accumulation, local density of the dilated intestinal tube, and blurred surrounding fat space; Intrahepatic bile duct dilatation and pneumatosis (Figure 1). Clinical diagnosis: obstruction of input haptics after pancreaticoduodenectomy. After 9 days of fasting, anti-infection, antispasmodic and other treatments, the symptoms were not relieved. Laparotomy showed that the right upper abdomen was widely adhered to the abdominal wall and separated. The hepatic flexure of the transverse colon and its mesangium were dissected in turn. There was no stenosis at the point where the input loop penetrated the transverse mesangium, and it freed proximally along the intestinal wall of the input loop to the upper region of the transverse colon. The jejunal bridge loop at the biliary intestine and pancreatic intestine anastomosis was dilated, congested and edema. A hard mass could be palpable in the small intestine about 10 cm away from the enterointestinal anastomosis, which could be moved by pushing. It was judged as a stone. The distal intestinal tube of the stone was relatively narrow, so it was pushed distally, away from the biliary intestinal anastomosis. Then, the intestinal wall was longitudinally incised, and the stone was removed. Choledochoscopy was used to explore the intrahepatic bile duct and intestinal loop through the intestinal incision. No stones remained. The intestinal incision was sutured transversely, and a drainage tube was placed to close the abdomen. Intraoperatively, a nutrition tube was placed into the output loop through nasal and gastrointestinal anastomosis. He was treated with early enteral nutrition and anti-infection after operation, and was discharged after successful recovery.

A 27-year-old male was admitted to the hospital due to "intermittent hematochezia for 5 years and recurrence for 1 d". Abdominal CT examination showed that the ileocecal intestinal wall was thickened, the surrounding fat density was increased, and there were multiple small mesangial lymph nodes. The patient had undergone appendectomy 10 years ago, and had undergone gastroscopy in our hospital at the first onset 5 years ago. No abnormalities were found. Colonoscopy showed that there was a lobulated polypoid bulge in the cecum about 2.0 cm ×1.0 cm in size, with rough surface, deep depression in the base, and edema of the peripheral mucosa. Pathology suggested chronic mucositis. Colonoscopy after admission revealed ulcerative lesions in the cecum, which were larger than 5 years ago, with a maximum diameter of about 3 cm (Figure 1). Pathological examination revealed chronic mucositis. Surgical treatment was performed. During the operation, a local hard mass, about 3.0 cm ×3.0 cm in size, was seen in the initial part of the cecum. Then, the intestinal wall was incised, and an ulcerative mass was seen, which was soft in texture. The mass was removed along the normal tissue at the edge of the mass, and no tumor lesions were found after rapid freezing pathological examination. The full-thickness suture of the cecum wound + seromuscular suture was further confirmed by pathological examination after operation as gastric mucosal ectopia (Figure 2).