2019年 · 第57卷第10期

Male, 72 years old, was admitted to our center for treatment on February 7, 2018 due to "intermittent fever for more than half a year". Six months ago, the patient had no obvious trigger of fever, the maximum body temperature was 38.5℃, no chills, jaundice and digestive symptoms, and the symptoms were relieved after self-medication. A few days later, the patient had fever again, and the local hospital planned to diagnose it as "malaria". After oral antimalarial drugs, the symptoms improved. Five months later, the patient had fever again, accompanied by right upper abdominal pain, accompanied by yellowing of the skin and sclera, deepening of urine color, clay-colored stool, and obvious weight loss. Color ultrasound and enhanced liver CT examination were performed in the local hospital, which showed "common bile duct stones". For further diagnosis and treatment, they were transferred to our center. The patient's past history and personal history were not special. Admission physical examination: skin sclera yellowing, right upper abdomen tenderness, Murphy sign positive. Laboratory tests: ALT 118.0 U/L, AST 108.0 U/L, alkaline phosphatase 454.0 U/L, gamma-glutamyltransferase 969.0 U/L, total bilirubin 182.45 μ mol/L, conjugated bilirubin 87.83 μ mol/L, CA19-9 395.7 U/ml. Abdominal ultrasound examination: the intrahepatic and extrahepatic bile ducts were dilated, the inner diameter of the upper segment of the extrahepatic bile duct was 1.4 cm, and an isoechoic mass with a range of about 3.5 cm ×1.1 cm could be seen within it; Phase III enhanced CT of liver (Figure 1) Examination: the wall of the common bile duct was thickened, and two low-density masses were seen, accompanied by low biliary obstruction and intrahepatic and extrahepatic bile duct dilation; Magnetic resonance hydrography of the cholangiopancreas (Figure 2) Examination: Filling defect was seen in the common hepatic duct area, and intrahepatic and extrahepatic bile duct dilatation with gallbladder enlargement; Endoscopic retrograde cholangiopancreatography: intrahepatic bile duct and common hepatic duct were dilated, with a diameter of about 1.5 cm at the widest point; One 2.8 cm long centripetal stenosis was seen in the upper segment of the common bile duct, and two irregular eccentric stenoses were seen in the middle and lower segments, of which the longer one was about 2.0 cm long. Cell brushing examination was performed, and a small number of abnormal cells were reported by pathological examination. Tumor local tomography (Figure 3) Examination: Choledochoduodenal upper pancreatic lesions with elevated glucose metabolism, considering that the lesions have a malignant tendency. Combined with the patient's past history of fever, abdominal pain, jaundice, right upper abdominal tenderness, positive Murphy's sign, and the results of imaging and pathological examinations, the patient was considered to have multiple bile duct tumors with acute obstructive suppurative cholangitis as the first symptom, and the initial diagnosis was multiple bile duct tumors, acute obstructive suppurative cholangitis, and obstructive jaundice.

Female, 31 years old, with intermittent pain in the upper abdomen for more than 1 year. The examination found that the abdominal cavity occupied space for more than 1 month as the main complaint and was admitted to hospital on March 25, 2017. The patient experienced intermittent pain in the upper abdomen more than 1 year ago, with intermittent attacks, which were not examined and treated. A mass was palpable in the right upper abdomen 1 month ago, progressively enlarged, soft in texture and poorly mobile. MRI findings after admission (Figure 1): A huge mass shadow was seen in the right lobe of the liver and abdominal cavity, with unclear boundaries and multiple partitions, high signal in T1WI, high and low mixed signal in T2WI, high or slightly high signal in DWI, and the maximum cross section was about 251 mm ×313 mm ×245 mm. The liver and right kidney were pressed and displaced forward. The pathological examination results of puncture biopsy suggested teratoma. The patient had a huge tumor and obvious compression symptoms, so it was decided to undergo surgery first.

Acute pancreatitis is a common digestive tract emergency, which is a local inflammatory reaction of the pancreas caused by the activation of pancreatic enzymes in the pancreas. systemic inflammatory response syndrome (SIRS) or even organ failure may occur in severe cases^[1]。 The mortality rate of patients with severe acute pancreatitis (SAP) combined with aseptic necrosis and organ failure was 19.8%, while the mortality rate of patients with pancreatic necrosis combined with organ failure was 35.2%^[2]。 With the further understanding of the pathogenesis of acute pancreatitis, the treatment philosophy of multi-disciplinary team (MDT) has gained consensus^[3,4]。 Surgical treatment is an important part of MDT in acute pancreatitis. Some scholars have proposed a step-up approach for surgical intervention^[5]。 Because the treatment purpose of acute pancreatitis is different in different stages, it is extremely important to choose the appropriate time and appropriate way to perform surgical intervention according to the individual situation of patients. Wrong surgical intervention may lead to poor prognosis.

A 47-year-old female was admitted to the hospital mainly because "nodules in the right upper lung were found on physical examination for more than 3 months". Chest CT examination after admission showed: 9 mm ×7 mm nodules in the posterior segment of the left upper apex, a few solid components in the mediastinal window, and the tumor location in the three-dimensional reconstruction image (Figure 1）。 The preoperative evaluation of cardiopulmonary function was normal, without distant metastasis, and it was proposed to perform localized puncture biopsy of pulmonary nodules guided by magnetic navigation + thoracoscopic posterior left upper apical segment resection. Intraoperatively, 0.1 ml of indocyanine green stock solution was injected at 0.4 cm periphery of the tumor in the recumbent position under the guidance of magnetic navigation (Figure 2）； After turning to the right lateral decubitus position, the fourth intercostal of the left anterior axillary line was taken into the chest, and a patchy fluorescent stained area in the posterior segment of the left upper lung apex was seen under fluoroscope (Figure 3）。 After the blood vessels and trachea were dissected, the boundary was judged by ventilation collapse method to remove the specimens (Figure 4，Figure 5）； Intraoperative frozen pathological examination showed that it was necessary to differentiate between adenocarcinoma in situ and minimally invasive carcinoma, and then the lymph nodes of groups 5, 7, 10 and 12 were biopsied. The results of postoperative pathological examination showed that the left upper lung nodule was in line with adenocarcinoma in situ with small focal interstitial invasion, and no lymph node metastasis was found.