2015年 · 第53卷第03期

Female, 57 years old, was admitted on 03/03/2014 mainly for "3 months after surgery for thyroid cancer". The patient found a thyroid mass during physical examination 3 months ago, and went to another hospital. B-ultrasound showed a thyroid mass in the right lobe with cervical lymph node enlargement. Thyroid exploration was performed under general anesthesia. During the operation, two right lobe thyroid masses were found, located in the middle and lower part of the thyroid gland, with the size of 2.4 cm ×2.4 cm ×1.4 cm and 0.5 cm ×0.5 cm ×0.5 cm, respectively. They were solid and hard in texture, and adhered to the anterior cervical band muscle. swollen perithyroid lymph nodes; The left lobe did not reach the mass. The right lobe and isthmus were resected, and the right tracheoesophageal sulcus was dissected. Intraoperative frozen pathological examination showed malignant thyroid tumor with tumor infiltration around the thyroid gland and pretracheal lymph nodes. Postoperative pathological findings: medullary thyroid carcinoma; Anterior laryngeal lymph node 1/1, anterior tracheal lymph node 1/1, tracheoesophageal sulcus lymph node 0/4. Immunohistochemistry: carcinoembryonic antigen (+), calcitonin (+), chromogranin A (+), S – 100 (+), Tg (–). Three months after the operation, I came to our hospital for re-examination, and found that the lymph nodes in my right neck were swollen, and I was admitted to the hospital with suspicion of thyroid cancer metastasis.

Male, 36 years old, was admitted to hospital on 12 March 2012 due to "finding increased carcinoembryonic antigen for 4 years and swollen cervical lymph nodes for 2 years". The patient's physical examination 4 years ago found that the level of carcinoembryonic antigen was elevated, which was about twice the normal high limit. No obvious lesions were found by gastrointestinal endoscopy and abdominal CT. Regular re-examination was performed. During the follow-up, the level of carcinoembryonic antigen slowly increased, and cervical lymph node swelling occurred 2 years later. During this period, thyroid B-ultrasound was performed, and no obvious space-occupying lesions were found. The patient considered that there was distant metastasis of gastrointestinal tumor, so he abandoned any examination and active treatment. Recently, I felt that there was no obvious progress in my disease, so I came to our hospital for further diagnosis and treatment. Physical examination: conscious, general condition is good, body temperature and blood pressure are normal, and the skin and sclera have no yellowing stain. The neck is soft, the bilateral thyroid glands are not enlarged, and there is no mass. Several flat lymph nodes can be palpable on the lateral side of the left neck, the largest of which is about 1.0 cm ×1.5 cm in size and can be pushed. The heart and lungs are not special, the abdomen is flat and soft, there is no tenderness, and there is no mass. Digital rectal examination was negative. Freedom of movement of limbs, negative neurological examination. Auxiliary examination: carcinoembryonic antigen 37.09 mg/L (normal value<5.00 mg/L), thyroid function: free thyroxine 3 was 4.90 pmol/L (normal 2.63-5.70 pmol/L), free thyroxine 4 was 14.60 pmol/L (normal 9.01-19.04 pmol/L), thyrotropin 1.284 3 U/L (normal 0.350-4.940 U/L), anti-thyroid peroxidase antibody 0.23 U/ml (normal<5.61 U/ml), thyroglobulin antibody 0.66 U/ml (normal<4.11 U/ml) and calcitonin 332.55 ng/L (normal value 0.10-10.00 ng/L). B-ultrasound scan of thyroid showed that there was a hypoechoic area on the middle and lateral side of the left lobe, about 3.1 mm ×4.1 mm ×3.2 mm in size, irregular in shape, unclear in boundary, and no obvious blood flow signal was seen inside (Figure 1)； Several abnormal lymph nodes were found in the III and IV areas of the left cervix, which were located laterally and posteriorly to the internal jugular vein, respectively. The larger one of the IV areas posterior to the internal jugular vein was 13 mm ×8 mm in size (Figure 2), there is no mutual fusion between lymph nodes, the envelope is smooth, the boundary with the surrounding soft tissue is clear, the shape tends to be rounded, the lymphatic hilum of some lymph nodes disappears, and the internal lymph nodes show moderate echo, which is evenly distributed, and there is no obvious strong echo or no echo; Color flow imaging can show lymph node hilar vessels, which are more abundant. The enlarged lymph nodes in the left cervical area IV were examined by fine needle aspiration cytology under B-ultrasound localization. The results showed that the lymph node cancer metastasis may come from the thyroid gland. After admission, the relevant examinations were completed to exclude multiple endocrine tumors type 2. The patient had 49.5 ng/L of parathyroid hormone (normal 15.0-68.3 ng/L), 36.2 ng/L of norepinephrine (normal 19-121 ng/L) and 24.5 ng/L of epinephrine (normal 14-90 ng/L). Abdominal B-ultrasound: No obvious abnormalities were found in liver, gallbladder, pancreas, spleen, kidney and bilateral adrenal areas. CT of both lungs showed no obvious abnormalities. Preoperative diagnosis: Left medullary thyroid carcinoma with left cervical lymph node metastasis.

Male, 61 years old, went to our hospital on September 16, 2014 because of "multiple tumors in the neck 1 month after radical thyroidectomy". On July 28, 2014, the patient found thyroid nodules during physical examination in a local hospital. Ultrasound examination showed a solid mass of about 5.2 cm ×3.2 cm in the left lobe of the thyroid gland, with clear boundaries, irregular shape, heterogeneous echo, accompanied by scattered strong echo spots and abundant blood flow signals; Multiple enlarged lymph nodes in both necks, the size of the larger one on the left side was 5.2 cm ×3.2 cm, and the size of the larger one on the right side was 2.6 cm ×1.4 cm; Consider multiple solid masses in the left lobe of the thyroid gland, which are likely to be malignant, with enlarged lymph nodes in both necks and metastatic cancer. On July 31, 2014, the patient went to a tertiary hospital for treatment. The initial thyroid ultrasound showed that multiple heterogeneous echoic masses and nodules were seen in the left lobe. The largest one was 4.8 cm ×3.7 cm ×4.6 cm in size, with clear boundary and regular shape. Small patches of anechoic areas were seen inside, and a few blood flow signals were seen in color blood flow imaging. There were no obvious abnormal lymph nodes in both necks, multiple heterogeneous echoes and nodules in the thyroid gland, and the possibility of benignity was high. Reexamination of thyroid ultrasound showed that the left lobe of thyroid gland was morphologically abnormal, and heterogeneous echo mass was visible, about 4.9 cm ×3.7 cm ×4.7 cm in size, with clear boundaries and regular shape; Multiple hypoechoic nodules can be seen in the left neck, the largest of which is about 4.0 cm ×3.7 cm ×2.0 cm in size, with clear boundaries and irregular shape. Multiple patchy strong echoes can be seen inside, and no abnormal lymph nodes can be seen in the right neck. Heterogeneous echoic mass in the left lobe of the thyroid gland, considering cancer is not excluded; There were multiple hypoechoic nodules in the left neck, and metastasis of enlarged lymph nodes was not excluded. On August 7, 2014, the patient underwent "radical thyroidectomy" in this tertiary hospital. According to its description, only the left lobe + isthmus was resected. No enlarged lymph nodes were detected during the exploration of the left carotid artery sheath during the operation, and no lateral and central lymph node dissection was performed. Postoperative pathological results: (left lobe + isthmus) papillary thyroid carcinoma, the largest was 5.0 cm ×4.0 cm ×4.0 cm in size, and the smaller was 1.5 cm ×1.3 cm ×1.0 cm in size. One lymph node metastasis was found around the isthmus tumor. Postoperatively, oral replacement therapy with levothyroxine 75 μ g was given. On September 9, 2014, I went to the original first hospital for a follow-up visit. Thyroid ultrasound showed that after thyroid operation, there was a mass in the left lobe surgical area; Multiple lymph node metastatic carcinoma of both necks. CT of the neck showed multiple lymph node enlargement in both necks, bilateral supraclavicular, suprasternal fossa and superior mediastinal lymph node metastases. There was no significant change in cervical lymph nodes compared with the preoperative ultrasound findings. The patient went to our hospital for treatment.

With the emphasis on intra-abdominal pressure (IAP), a large number of studies have begun to focus on intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). The abdominal compartment society (WSACS) put forward The expert consensus of IAH and ACS in 2006, published The diagnosis and treatment guidelines in 2007, and defined The recommended direction of disease-related research in 2009. In 2013, WSACS released new IAH and ACS expert consensus and diagnosis and treatment guidelines. The guidelines were developed with the participation of multi-disciplinary experts, mostly surgical specialists and critical care specialists. Experts first identified 24 IAH and ACS issues that clinicians are concerned about, and then conducted a systematic and orderly documentation.

Bronchoplasty/angioplasty is one of the surgical resection methods of central non-small cell lung cancer, which can not only ensure the resection of tumor, but also maximize the preservation of lung function of patients. It is often used in patients with poor lung function and cannot tolerate total pneumonectomy. With the advancement of completely video-assisted thoracoscopic surgery (C-VATS), bronchoplasty/angioplasty for central lung cancer can also be performed through C-VATS, thus avoiding trauma to the body caused by thoracotomy. However, due to the high difficulty of this technique, this kind of report is rare for many years, and all of them are small sample case series studies^[1,2,3]。

Primary trigeminal neuralgia often occurs in middle-aged and elderly people, and its specific etiology is not completely clear. Domestic and foreign scholars based on the changes of vascular compression and demyelination in the area of trigeminal nerve root entering the brainstem^[1]Microvascular decompression was performed with satisfactory therapeutic results. However, due to the high risk of craniotomy in elderly patients and patients with severe systemic diseases, the compliance of patients who need secondary surgery is not high, so percutaneous foramen ovale puncture of semilunar ganglion radiofrequency surgery has become an ideal alternative treatment for such patients. In this method, Hartel anterior approach is generally used for foramen ovale puncture^[2]The literature reports that the puncture method has a failure rate of 4% and a high long-term recurrence rate^[3,4]。 We treated trigeminal neuralgia with percutaneous mandibular angle approach foramen ovale puncture for semilunar ganglion selective target radiofrequency surgery, which is reported below.

Female, 38 years old, was admitted to hospital on April 1, 2014 mainly due to "bilateral knee pain for 7 months after parathyroid surgery, aggravated for 1 week". The patient had repeated pancreatitis since 2010, and was diagnosed as chronic pancreatitis with pancreatic duct stones in another hospital. The symptoms were relieved after extracorporeal lithotripsy. During hospitalization, it was found that the blood calcium level was increased (>3.00 mmol/L, normal value 2.00~2.75 mmol/L). After further examination, he was diagnosed as right parathyroid adenoma and underwent surgical treatment. The right parathyroid tumor was found to adhere to the thyroid gland during the operation, and right parathyroid gland + right thyroid lobectomy was performed. Postoperative pathology showed parathyroid adenoma, but immunohistochemistry showed that the Ki-67 index was as high as 50%; The serum calcium and parathyroid hormone (PTH) returned to normal levels after operation. In 2012, the patient self-palpated bilateral neck subcutaneous nodules. Since 2013, the patient has polydipsia and bilateral knee joint pain, which is aggravated when walking. He came to our hospital for further surgical treatment in April 2014. Physical examination: poor general condition, lethargy, mild dehydration, body mass index 19.98 kg/m²； An old surgical scar can be seen in the anterior cervical area, and a subcutaneous nodule can be palpable at the level of thyroid cartilage in the left cervical area, which is hard in texture and measures 3.5 cm ×2.2 cm in size. A hard nodule with a maximum diameter of 1.5 cm was palpable on the lateral side of the right end of the neck incision (Figure 1)。 Laboratory tests: Blood calcium 3.49 mmol/L, PTH 2 944.10 ng/L (normal 15.0-68.3 ng/L), alkaline phosphatase 206 U/L (normal 38-126 U/L), 25 hydroxyvitamin D 17.56 nmol/L (normal>50 nmol/L). B-ultrasound of the neck showed: cystic-solid nodules in the left lobe of the thyroid gland (size 0.9 cm ×0.6 cm), solid nodules in the subcutaneous soft tissue of the left neck (size 2.0 cm ×1.5 cm), and solid nodules in the right thyroid region, considered to be derived from the parathyroid gland; Enhanced CT scan of the chest showed multiple metastatic nodules in the lung (Figure 1)；⁹⁹Tc^mmethoxyisobutylisonitrile (MIBI) imaging showed radioactive concentration of right thyroid region, left neck subcutaneous nodules, and lung nodules (Figure 2)； There were no other abnormal metabolic lesions except neck and lung in PET.

The donor was a 34-year-old male. Height 173 cm, weight 73 kg, body mass index 24.4 kg/m², Blood Type B. Liver CT interpretation and analysis system was used to evaluate the donor liver before operation (Figure 1), showing a whole liver volume of 1 387 cm³The volume of the left lateral lobe of the liver was 181 cm³There was no variation in the hepatic artery, 4 segments of the hepatic artery originated from the right hepatic artery, the portal vein was classified as type I according to Kyoto University, and the biliary tract was classified as type IV by Nakamura^[2]That is, the right posterior branch originates from the left hepatic duct. Recipient female, 10 months. Height 64 cm, weight 9.5 kg, blood type B. The preoperative estimated graft to recipient weight ratio (GRWR) was 1.9%.

A 20-year-old male was admitted to the hospital on 21 August 2012 with "intermittent headache for 4 years, progressive exacerbation for 2 months with one generalized convulsive attack". The patient intermittently experienced dull pain in the head 4 years ago, which was considered to be caused by learning fatigue and did not care; The pain worsened after bed rest 2 months ago, and severe headache, seizure and unconsciousness occurred 1 day ago. Physical examination: Left side hypoolfactory, no obvious neurological positive signs were observed. CT examination showed that mixed density occupied space in the anterior horn of the proximal ventricle of the left frontal lobe. Further MRI examination showed that a space-occupying lesion with a size of 3.4 cm ×2.6 cm ×5.0 cm was found in the left anterior and middle cranial fossa floor. T1WI showed isometric and low signal, T2WI showed high and low mixed signal, water and lipid pressure images showed isometric and low signal, and the enhancement showed uneven enhancement. Adjacent brain tissues showed patchy T1WI low signal and T2WI high signal, but the enhancement was not enhanced. Bilateral ventricles and third ventricles were enlarged, and the midline structure was slightly displaced to the right posterior side. The diagnosis was considered as a schwannoma. Six days after admission, the tumor was resected by left frontal craniotomy with coronary incision under general anesthesia. During the operation, the tumor was located at the left anterior cranial fovea floor, involving the anterior clinoid process backward, and had a little adhesion to the dura mater of the anterior cranial fovea floor. The local dura mater was obviously compressed and damaged. The tumor was clearly bounded, gray-red, enveloped, surrounded by arachnoid, medium in texture, rich in blood supply, and cystic necrosis in the center. The tumor was completely resected in blocks. No left olfactory bulb and olfactory nerve were seen during the operation. The damaged dura mater was repaired with artificial dura mater. The postoperative pathological diagnosis was olfactory sheath cell tumor (olfactory ensheathing cell tumor, OECT). HE staining showed that the tumor cells were spindle-shaped, arranged in dense fibrous strips or bands, a few cells were arranged in wheel shape, and the matrix was mature collagen fibers, running parallel to the long axis of the cells. Immunohistochemistry: Ki-67 (+<3%), GFAP (–), Vimtin (+), S-100 (+), leu-7 (–), EMA (–). The symptoms of headache disappeared after operation and recovered well, but left anosmia was left. After 1 year and 6 months of follow-up, the patient was in good general condition, but his sense of smell did not recover, and there was no tumor recurrence on MRI (Figure 1、Figure 2、Figure 3、Figure 4、Figure 5)。

Male, 50 years old, was admitted to the hospital on August 5, 2013 due to "discovery of left kidney stones for 12 years and intermittent full-course macroscopic hematuria for 2 months". Physical examination: The abdomen was flat and soft, without tenderness and rebound pain, and mild percussion pain in the left kidney area. Intravenous pyelography showed cast stone in the left kidney, left hydronephrosis and horseshoe kidney malformation. CT scan and urography showed left lower kidney stones with accumulation of water, left lower renal pelvic ureteral junction stenosis, bilateral duplicate kidney with horseshoe kidney malformation (Figure 1、Figure 2、Figure 3)。 Cystoscopy showed no new organisms and stones in the bladder, and blood sprayed from the left ureteral opening. Preoperative preparation was performed and laparoscopic left inferior pyelolithotomy + pyeloplasty was performed on 11 August 2013 under general anesthesia. The paracolonic sulcus and splenorenal ligament were opened, and the left kidney was revealed. Exploration showed that the left kidney was poorly rotated, the renal hilum faced forward, the duplicate kidney combined with horseshoe kidney malformation, the isthmus was thin, located in front of the abdominal aorta, and the left ureter passed through the front of the renal pelvis. The left inferior renal pelvis was incised with an arc incision of about 3 cm, see stenosis of the left inferior renal pelvis ureteral junction, and the cast stone was removed completely and the lithotripsy within the visual field was cleared. Cut the renal pelvis and perform disconnected pyeloplasty. First, the stenotic segment is removed, the dilated left lower renal pelvis is trimmed, the posterior and anterior walls of the renal pelvis are sutured in turn, and an inlet double J tube is placed in the left lower renal pelvis and ureter to support drainage. The operation was smooth and the postoperative recovery was good, and the double J tube was removed under cystoscopy 2 months after the operation. After 6 months of reexamination, the patient had no symptoms such as hematuria and low back pain, no urinary stones were found on abdominal X-ray film, and no obvious hydrophosis was found on kidney B-ultrasound examination.