2023年 · 第61卷第02期

Patient 1, a 43-year-old female, was admitted to Ganzhou Cancer Hospital on October 19, 2021 due to "dull pain in the right upper abdomen for half a month". The patient had no other discomfort symptoms, previous history of hepatitis B, and no obvious positive signs were found on physical examination. HBV-DNA 6.8×10³U/mL, alpha-fetoprotein 17.9 μ g/L (normal range: 0-7 μ g/L), CA19-9 37.41 U/mL (normal range: 0-27 U/mL), and other laboratory results were normal. CT findings showed that the right liver occupied a space with a maximum diameter of 4.8 cm; Liver puncture biopsy reported poorly differentiated adenocarcinoma with a high possibility of cholangiocarcinoma. Antiviral therapy with oral entecavir. Nov 10, 2021 Skeletal dissection of common hepatic artery and hepatoduodenal ligament, right partial hepatectomy under general anesthesia. During the operation, several enlarged lymph nodes were found in the hepatoduodenal ligament, with medium texture and moderate liver sclerosis. The left liver was small in size, and the right liver could reach a mass with a maximum diameter of about 5 cm, with clear boundaries. Skeletal dissection was performed first, in which bile leakage occurred when it was swept up along the left edge of the common bile duct-common hepatic duct to the area below the left hepatic pedicle. After careful separation, it was found that there was a local bile duct with a diameter of 0.3 cm, and its anterior wall had been cut open, with bile overflowing. One end of the needle nose of a small round needle was extended through the bile duct fissure to explore, and the common hepatic duct could be entered to the right. The anterior wall of the common hepatic duct was jacked up and led to the caudate lobe to the left (Figures 1A and 1B). The anterior wall fissure of the bile duct was intermittently sutured with 6-0 non-absorbable thread (Figure 1C), and then the right partial hepatectomy was completed; The bile duct repair area was covered with the serous surface of the circular hepatic ligament with pedicle, the circular hepatic ligament and the surrounding tissue were sutured and fixed with 5-0 non-absorbable thread for several needles to prevent displacement, two abdominal drainage tubes were placed, the omentum was lifted up to cover the hepatic hilar area, and the abdomen was closed to end the operation. After operation, systemic support, liver protection and antiviral treatment were performed, and the recovery was smooth, without abnormalities such as biliary fistula. Pathological examination reported sarcomatoid hepatocellular carcinoma of right liver, and no metastasis was found in 13 lymph nodes. After 55 days after operation, CT examination showed that there was no dilatation of intrahepatic bile duct including caudate bile duct, and more swollen lymph nodes were seen in hepatoduodenal ligament and retroperitoneum; The skin and sclera appeared yellowing on 87 days after operation. The CT results showed that there was no recurrence or metastasis in the liver. The caudate lobe bile duct was not dilated, but the intrahepatic bile duct and common hepatic duct on both sides were significantly dilated. The hepatoduodenal ligament and retroperitoneal lymph nodes were enlarged compared with the previous ones. The patient abandoned the treatment of bile duct puncture and drainage.

A 60-year-old male patient went to Zhejiang Provincial People's Hospital on May 3, 2022 due to "skin sclera yellowing, deepening urine color and weight loss for more than 2 months". Two months ago, the patient developed skin sclera yellowing without obvious trigger, which was progressively aggravated, accompanied by deepening urine color, no abdominal distension, abdominal pain, and no fear of cold and fever. Percutaneous hepatic puncture biliary drainage was performed to reduce yellowing. The patient lost 10 kg of weight from the onset of the disease. New onset diabetes was found for 3 months and was not controlled by medication. No previous history of hepatobiliary disease, abdominal surgery, smoking or drinking. Physical examination: yellowing skin sclera, soft abdomen, no tenderness and rebound pain in the upper abdomen, no palpable abdominal mass, Murphy sign (-), Couassier sign (-), mobile voiced sound (-), and no percussion pain in both kidney areas. Laboratory tests: total bilirubin 301.1 μ mol/L, direct bilirubin 278.8 μ mol/L, glutamyl transpeptidase 373 U/L; Pancreatic amylase 224 U/L, total amylase 269 U/L; Carcinoembryonic antigen 10.2 μ g/L, CA19-9 8 791.0 U/ml. Abdominal enhanced CT examination showed that there was a lack of blood supply mass in the uncinate process area of the pancreatic head, with a size of 4.7 cm ×2.8 cm, and no mesenteric vascular involvement was observed (Figure 1). Abdominal enhanced MRI examination showed that the uncinate process of the pancreatic head occupied space, the size was 4.5 cm ×2.4 cm, with low signal in T1WI and high signal in T2WI, with dilatation of the biliopancreatic duct (Figure 2). PET-CT examination showed that the uncinate process of the pancreatic head occupied mass, the size was 5.0 cm ×3.9 cm, the maximum standardized uptake value (SUVmax) was 27.5, there were multiple lymph node metabolic increases around the lesion, the SUVmax was 6.0, and no distant metastasis was seen (Figure 3).