2024年 · 第39卷第02期

The patient, a 65-year-old male, was admitted to hospital because "the skin sclera was found to be yellow for more than half a month". The patient was previously in good health. Preoperative MRI showed that the cancer of the lower common bile duct may be large, and pancreatoduodenectomy (PD) was performed. Intraoperative pancreatojejunostomy was performed using catheter to mucosa, and continuous anastomosis of bile and intestine was performed using absorbable sutures. The intraoperative bleeding volume was about 300 ml. Hemoglobin on postoperative day 1: 90.0 g/L. That night, without obvious inducement, the sudden blood pressure was low, 88/53 mm Hg, heart rate: 103 beats/min, soft abdomen, no tenderness and rebound pain, pale blood fluid was drawn from the abdominal drainage tube, and a small amount of dark blood fluid was drawn from the gastric tube. Emergency blood routine showed: hemoglobin: 69.0 g/L, and emergency CT showed: partial intestinal lumen dilation with high-density content. Considering the high possibility of bleeding in the transfusion haptics (Figure 1), the hemoglobin was reviewed after 1 h of conservative treatment: 58.0 g/L. Emergency surgery to explore hemostasis. There was no obvious effusion or infection in the abdominal cavity. First of all, the gastrointestinal anastomosis was opened, and a large amount of dark blood effusion and dark blood clots were found. There was no obvious bleeding point in the gastric cavity, and the bleeding was considered to come from the input loop. When the biliary enterostomy was opened, a large amount of blood and blood clots were seen in the input loop, but there was no obvious bleeding around the anastomosis and no bleeding in the biliary tract. The hemorrhage was judged to be in the input haptics, but the cause was unknown. The pancreaticojejunostomy was removed, no anastomotic bleeding was observed, the input loop was removed, and the input loop was incised at the opposite mesangial margin, showing an arterial wall with a long diameter of about 5 mm (Figure 2). According to the Child method, the pancreaticojejunostomy was reconstructed by Blumgart method, and a drainage tube was inserted into the pancreatic duct, but the catheter could not anastomose the mucosa. The drainage tube of the pancreatic duct was fixed with purses on both sides, and external drainage was performed in parallel. The biliary enterostomy was continuously anastomosed with 5-0 PDS line, and a T tube was inserted, and another hole was poked in the front of the hepatic duct with the long arm to lead out. Postoperative pathology showed that the mucosa was missing in some areas of the intestinal mucosa ligation, and local vascular tissue proliferation with degeneration, inflammatory exudation, hemorrhagic necrosis and massive inflammatory cell infiltration from the mucosal layer to the muscular layer of the missing area, proliferation of some surrounding intestinal mucosal glands, proliferation of submucosal fibers and vascular tissues with congestion, hemorrhage and inflammatory cell and lymphocyte infiltration; See also partial gastric mucosa. After operation, pancreatic fistula and delayed gastric emptying occurred without other complications, and he was successfully discharged from hospital on the 33rd day after the initial operation.

A 51-year-old male underwent "radical left hemicolectomy" in a foreign hospital in 2011 due to "malignant tumor of descending colon". Postoperative pathological examination: (left colon) moderately differentiated adenocarcinoma, cancerous tissue invading extraserous adipose tissue, no cancerous tissue remaining at surgical margin, lymph nodes (0/8), 8 cycles of XELOX regimen adjuvant chemotherapy after operation, regular review for 3 years without recurrence and metastasis. In February 2022, I saw a doctor for "intermittent upper abdominal distension for more than 5 months". Physical examination: The abdomen was flat, and a mass about 4cm ×4cm in size could be palpable in the left upper abdomen, which was hard in texture, with acceptable mobility and tenderness (+). Family history: father died of colon cancer, sister is still alive with colon cancer. Abdominal enhanced CT examination showed tumors near the liver flexure of the ascending colon and the small intestine, narrow intestinal lumen, and multiple swollen lymph nodes around it. Colon cancer with metastasis of the surrounding lymph nodes and small intestinal mass were considered (Figure 1). Electronic colonoscopy showed that an irregular mass protruding from the lumen in the transverse colon, with congestion and ulceration on the surface, easy bleeding at touch, circumferential, narrow lumen, and unable to pass through the lens body (Figure 2). Pathological examination: (colon) moderately differentiated adenocarcinoma. Laboratory test: Hemoglobin 75 g/L. The diagnosis was colonic malignancy, small intestinal mass, anemia. An exploratory laparotomy was performed, and a 6 cm ×5 cm mass was found in the ileocecal region during the operation, and the surrounding lymph nodes were palpable and enlarged; There was an 8 cm ×6 cm size mass in the jejunum 30 cm away from the Trigger's ligament, and the omentum was wrapped and adhered, and the range of mobility was acceptable. Radical right hemicolectomy and small intestine tumor resection were performed. Postoperative pathological examination: (right colon) moderately differentiated mucinous adenocarcinoma, some of which were tubular adenocarcinoma. The carcinoma tissue invaded the muscle layer of intestinal wall to the periphery, but not the serosa. No carcinoma tissue residual and lymph nodes were found at the surgical margin (0/13); (Small intestine) medium differentiated tubular adenocarcinoma, cancerous tissue invaded the whole thickness of the intestinal wall to the surrounding area, but did not invade the serosa, and no cancerous tissue remained at the surgical margin, lymph nodes (0/10) (Figure 3). Immunohistochemical examination showed: (right colon) CD56 (-), Syn (-); (Small intestine) CKp (+), CD56 (-), Syn (-), TP53 (wild type), MSH2 (-), MSH6 (-), MLH1 (-), PMS2 (-). Genetic testing: KRAS gene mutation, no MSH2, MSH6, MLH1, PMS2 gene mutation was detected.

A 54-year-old female was admitted with "10 d of right lower abdominal pain". The patient had previously undergone cesarean section in 1995. Physical examination: A cystic mass about 8 cm in size can be palpable in the right lower abdomen, with large mobility and mild tenderness. Laboratory test: blood routine: white blood cell count 3.53×10⁹/L. Pelvic magnetic resonance examination: Multilocular cystic mass in the right iliac fossa, about 6.6 cm ×6.0 cm ×7.8 cm in size, with internal septum, uniform intracapsular signal, and enhanced posterior capsular wall and septum enhancement (Figure 1). The initial diagnosis was a cystic tumor of appendix or right adnexal origin. Intraoperative exploration: the appendix was dark red with no mucus on the surface; There were multiple cystic foci outside the cecum and dorsal retroperitoneum, with thin cystic wall and clear cystic fluid, which was serous. Intraoperative rapid freezing pathological examination showed that there was no definite malignancy of ileocecal cystic lesions, which should be further diagnosed by routine sampling. Retroperitoneal lesion resection + appendectomy was performed by laparotomy. Postoperative pathological examination showed: (1) (appendectomy specimen): chronic appendicitis; (2) (Ileocecal mass): the small foci on the inner wall of the sac were covered with a single layer of cubic epithelial cells, which convex into the cavity in a shoe spike shape (Figure 2A); Immunohistochemical examination: Covered epithelial cells expressed CK5/6 (+) (Figure 2B), CK7 (+), CK20 (-), BAP1 (+), Calretinin (+), ER (-). The final diagnosis was benign peritoneal polycystic mesothelioma (benign multicystic peritoneal mesothelioma, BMPM).