2021年 · 第59卷第12期

A 58-year-old male was admitted to the hospital on October 31, 2019 mainly due to "a reducible mass in the right groin for half a month and a sudden massive mass in the right middle and upper abdomen for 5 h". Half a month ago, the patient developed a reversible mass in the right groin, accompanied by dull pain and discomfort, which was not diagnosed and treated. Five hours ago, there was a sudden tumor in the right middle and upper abdomen and it gradually increased, accompanied by severe pain. Past physical fitness. Physical examination: The right middle and lower abdomen is obviously raised, and a mass about 25 cm ×15 cm ×5 cm in size can be palpable (Figure 1), high tension and tenderness. Intestinal sounds decreased. The right scrotum is empty. Abdominal CT revealed right inguinal incarcerated hernia with small bowel obstruction (Figure 2）。 Preoperative diagnosis: right incarcerated indirect inguinal hernia with intestinal obstruction; Suspicious right side cryptorchidism. Preoperative preparation was performed according to incarcerated hernia, and emergency surgery was performed. An oblique incision extending upward along the right groin orientation reveals the hernial sac. The hernial sac and its contents protrude from the inner ring and then fold forward and upward between the external abdominal oblique muscle and the internal abdominal oblique muscle. When the hernia sac was opened, the incarcerated contents were small intestinal haptics about 50 cm long, which were obviously dilated and mostly dark red or purple-black. Quickly release the inner ring, see that the blood supply of the small intestine has improved, seal the mesenteric root and compress it with hot compress, and return it to the abdominal cavity after the blood supply is restored. The hernia sac was closed by continuous suture at the neck of the hernia sac. Bassini hernioplasty was performed after irrigation of the surgical area with iodophor and physiological saline. At the distal end of the spermatic cord, the testis was slightly atrophied, soft, and there was no passage between it and the scrotum, which confirmed the coexistence of right cryptorchidism. After consulting with the urology department and communicating with the family, it was not removed. Pathological examination revealed a massive neutrophil infiltration of the hernial sac. No complications occurred after surgery, and he was cured and discharged on the 8th day, without recurrence.

The patient, a 29-year-old male, was seen in our hospital on August 24, 2019 due to "tortuous dilatation of the right lower extremity vein for more than 3 years, recently aggravated". The patient was usually in good health, but denied the history of deep vein thrombosis and vascular malformation of the lower limbs, denied the history of trauma and surgery, and denied the family history of varicose veins of the lower limbs. Physical examination: Mild edema of the right lower limb, obvious tortuous dilatation of the superficial vein in the lower leg segment, large tension of the varicose mass, no induration, tenderness, no pulsatile sensation, and slightly increased skin temperature. No dermatitis, no pigmentation, no ulcers, pulsation of the dorsal pedis artery (+). Absence of varicose veins in the abdominal wall. Trendelenburg test (+), deep vein patency test (-) (Figure 1）。 The patient took a standing position and underwent total lower extremity venous hemodynamic assessment using dual-function ultrasound, including reflux source, vein diameter, reflux time, and peak reflux velocity. Routine examination of the crypto-femoral junction to judge the function of the terminal valve of the great saphenous vein showed that the terminal valve function was good, and no regurgitation was observed in the squeeze test and Valsalva action; The probe was moved to the upper and medial side of the crypto-femoral junction to the superficial inguinal ring, and then the patient was instructed to perform the Valsalva action. It was seen that the viniform venous plexus continued to reflux to the superficial inguinal vein, and finally merged into the main saphenous vein, resulting in reflux of the lower main saphenous vein and the calf branch veins (Figure 2）。 Diagnosis: varicose veins of right lower limb (grade C3, CHIVA Shunt type 4); Because the reflux source is the pelvic escape point, according to the Shunt classification theory proposed by Professor Claude Franceschi^［1］The patient was Shunt type 4.

The patient was a 59-year-old female. Due to sudden high fever and chills, he visited our hospital on September 21, 2020. The patient had nausea, anorexia, slight pain in the left upper abdomen since the onset of the disease, and lost 15 kg in weight in the last 6 months. The patient was diagnosed with type 2 diabetes 9 years ago and has been treated with insulin for 2 years. At present, his blood sugar control is acceptable. Physical examination after admission: body temperature 39.1 ℃, pulse 114 beats/min, blood pressure 107/71 mmHg (1 mmHg =0.133 kPa); There was obvious tenderness in the left upper abdomen, and the lower margin of the spleen could be palpable under the costs, and no obvious abnormalities in the heart and lungs were found. Relevant laboratory tests: White blood cell count 15×10⁹/L, carcinoembryonic antigen 1.2 μ g/L (reference range: 0.2-10.0 μ g/L), CA19-9 0.9 μ g/L (reference range: 0.6-2.5 μ g/L), alpha-fetoprotein 12 μ g/L (reference range: 0.6-25.0 μ g/L). Blood culture of Klebsiella pneumoniae. Chest CT findings suggest no nodules or other abnormalities. Echocardiography excludes endocarditis and atrial fibrillation. The results of abdominal CT examination showed unclear pancreatic tail and unclear boundary with splenic hilum; The spleen was significantly enlarged, irregular in shape, and there were multiple large and low-density lesions in the splenic parenchyma. The results of enhanced CT examination showed that the pancreatic tail occupied space, and the spleen lesions were not enhanced; The splenic arterial trunk is thin (Figure 1), no nodules or enlarged lymph nodes were seen in the liver, retroperitoneal and other parts. The initial diagnosis was a space-occupying lesion of the tail of the pancreas (considering malignancy), splenic abscess.

The patient was an 81-year-old male who was admitted to the hospital on 24 September 2020 mainly due to "pulsatile sensation in the abdomen for half a year, aggravated with abdominal pain for 1 month". The patient discovered an abdominal aortic aneurysm 17 years ago and underwent abdominal aorta-iliac artery Y-shaped artificial blood vessel replacement. Six months ago, he experienced abdominal compression and pulsation of the mass. In the past month, his symptoms worsened, accompanied by dull abdominal pain, so he went to the outpatient department of our hospital and was admitted to our department for further diagnosis and treatment. Physical examination: soft abdomen, palpable pulsatile mass around the umbilicus and on the umbilicus, about 10 cm ×15 cm in size, mild tenderness, palpable pulsation of both femoral arteries. Laboratory tests: creatinine 112.87 μ mol/L, urea 8.17 mmol/L. CT angiography showed aneurysmal dilatation of the abdominal aorta 2 cm below the superior mesenteric artery, the neck angle of the tumor was about 90°, the maximum diameter of the tumor was about 12 cm, the tumor was ruptured and partially wrapped, and there was no extravasation around the wrapping. Both renal arteries were located in the tumor body, and the initial segment of both renal arteries was narrowed by about 70%. Y-shaped artificial blood vessels were visible at the distal end of the abdominal aorta and both common iliac arteries, and the lumen was normal (Figure 1）。 The patient had a history of hypertension and coronary heart disease for more than 10 years. Admission diagnosis: (1) ruptured abdominal aortic aneurysm, after artificial blood vessel replacement of abdominal aortic aneurysm; (2) stenosis of both renal arteries; (3) Chronic renal insufficiency; (4) Grade 2 hypertension; (5) Coronary heart disease.

The patient, a 62-year-old male, was admitted to the hospital on 25-Apr-2021 mainly due to "20 d postoperative for thoracic vertebral fracture and 10 d sensorimotor disorders of both lower limbs". One month ago, the patient fell and caused T₁₂The vertebral fracture was seen in the local hospital and performed T on April 3, 2021₁₂Vertebroplasty (Figure 1), the waist pain is relieved after surgery, and you can get out of bed with a brace. 10 days after surgery, the patient's low back pain gradually worsened, accompanied by symptoms such as weakness of both lower limbs, hypoesthesia, and defecation retention. He went to the local hospital again for symptomatic treatment such as analgesia and indwelling catheterization, but the effect was not good. He came to our hospital for further diagnosis and treatment. Admission physical examination: wheelchair pushed into the ward, body temperature 37.3 ℃; The visual analog score of low back pain was 5 points, tenderness and percussion pain in the thoracolumbar segment of the spine, limited pain, and low local skin temperature; The sensation in the sellar area basically disappeared, the cremastis reflex was not drawn out, the anal sphincter muscle contracted weakly, and the sensation of the skin distal to the bilateral buttocks and bilateral inguins was obviously reduced; Bilateral iliopsoas, quadriceps, tibialis anterior, gastrocnemius, dorsal extensor and plantar flexor were grade 3. The right side was slightly weaker than the left side, and the bilateral Achilles tendon reflex and knee reflex were weakened. Imaging examination: X-ray film of thoracolumbar spine showed that the thoracolumbar spine was T₁₂The vertebrae is kyphosis, and the height of the anterior column of the vertebral body is partially lost. MRI images showed T₁₂~ L₁Fusiform T2WI long signal mass at the posterior edge of the vertebral body, about 8 mm thick, spinal cord nerve compression at the same level, spinal cord signal unchanged, MRI enhancement scan showed edge enhancement of the mass (Figure 2）。 Laboratory tests: erythrocyte sedimentation rate 35 mm/1h, high sensitivity C-reactive protein 120 mg/L, white blood cell count 10.07×10⁹/L, neutrophil ratio 0.87. The patient had a previous history of diabetes for 5 years. Preoperative diagnosis: (1) T₁₂~ L₁Local mass in the horizontal spinal canal: hematoma? Abscess? (2) Cone-cauda equina syndrome (ASIA grade D); (3) T₁₂After vertebroplasty; (4) Type 2 diabetes.