2024年 · 第39卷第03期

The patient, a 66-year-old male, was seen for "jaundice for more than 8 months". CA19-9: 281U/ml, abdominal enhanced CT showed low-density shadows on the head of the pancreas, with unclear boundaries, about 3.1 cm ×2.0 cm ×1.8 cm in size, and mild enhancement in the arterial phase; It was seen that the tumor invaded the common hepatic artery (CHA) without distant metastasis. Pancreatic ductal adenocarcinoma was reported by puncture pathology, which was considered to be locally advanced in combination with imaging examination. Albumin paclitaxel in combination with gemcitabine (AG) regimen (Albumin paclitaxel 125 mg/m²Gemcitabine 1 000 mg/m²The patients had no obvious discomfort and gained 5 kg during conversion therapy. After 6 cycles of treatment, CA19-9: 41.5 U/ml, CT showed that the tumor size shrank to 2.1 cm ×1.6 cm ×1.5 cm, but the CHA invasion did not change significantly compared with before (Figure 1). Hepatic artery embolization was performed before operation, and the anatomical variation of hepatic vessels was observed. CHA originated from the superior mesenteric artery (SMA). After coil embolization of CHA, multiple vessels compensated for hepatic blood flow supply (Figure 2). After embolization, the patient had no significant increase in aminotransferase, and underwent open pancreaticoduodenectomy on the second day, without reconstruction by CHA resection. The boundary between the tumor and the inferior vena cava and the aorta was clearly explored during operation. The common bile duct was severed sequentially, the CHA was severed 5 mm proximal to the confluence of the left and right branches, the stomach was severed, the pancreas was severed, and the CHA was severed 1 cm from the root (Figure 3), the lymph nodes were dissected, and the shark's mouth anastomosis was performed^［1］Digestive tract reconstruction was performed. The total surgical duration was 360 min, the blood loss was 200 ml, and no blood transfusion was performed. Postoperative pathology: Differentiated ductal adenocarcinoma of the pancreas with negative margins; The hepatic artery was involved, and no cancer was found at the broken end of the hepatic artery and the root margin of the hepatic artery. Aminotransferase was slightly elevated on day 1 after radical surgery and decreased to baseline levels 5 d later. The patient did not develop biliary fistula or pancreatic fistula, and the pancreatic-intestinal drainage was removed on the 7th day, and the patient was discharged on the 11th day. One month after surgery, the outpatient review recovered well, CA19-9 decreased to 17.2 U/L, and the liver function was stable. Follow-up chemotherapy with the original AG regimen for 4 to 6 cycles, and review regularly.

The patient, a 62-year-old male, went to the doctor for "6 days after rescue treatment of sudden cardiac death, chest tightness and asthma for 2 days", and had a history of coronary heart disease and diabetes. Cardiopulmonary resuscitation was performed in an external hospital due to sudden cardiac death 6 days ago. After successful resuscitation, coronary angiography showed myocardial infarction and coronary stent was placed. Cardiac ultrasound showed: ejection fraction 28%, left ventricular wall segmental motion abnormalities. Laboratory tests: serum high-sensitivity troponin 17.400 ng/ml, B-type aminoterminal natriuretic peptide>35 000 pg/ml; Blood routine: white blood cell count 15.77×10⁹/L, neutrophil percentage 84%. Off-pump coronary artery bypass grafting was performed 8 days after admission. Lower abdominal pain occurred on the 9th day after surgery. Emergency blood routine: white blood cell count 20.04×10⁹/L, the percentage of neutrophils was 91.6%. Abdominal CT examination revealed rectal dilatation with a large amount of contents in the cavity (Figure 1). On the 10th postoperative day, the patient had worsened lower abdominal pain and signs of hyperthermia and peritonitis. Abdominal CTA revealed severe stenosis at the initiation of the inferior mesenteric artery (Figures 2, 3). Emergency laparoscopic exploration revealed necrosis of the anterior wall of the upper rectum (Figure 4), and Hartmann's procedure (resection of the necrotic rectum, distal rectal closure, proximal colostomy) was performed. Postoperative pathological examination showed acute suppurative inflammation of rectal wall tissue and partial tissue necrosis. The patient developed multiple organ dysfunction after operation. After active treatment, he was cured and discharged on the 35th day after operation.