2023年 · 第61卷第04期

The patient was a 38-year-old male. On April 20, 2021, he went to the Department of Hepatobiliary and Pancreatic Surgery of the People's Liberation Army General Hospital because of "edema of both lower limbs for 1 month, and the liver was found to occupy space for 1 week". The patient developed symmetrical edema of both lower limbs 1 month ago, progressively aggravated. One week ago, the results of abdominal ultrasonography, abdominal enhanced CT examination and PET-CT examination in outside hospital showed that the 6 segments of the liver occupied space with inferior vena cava tumor thrombus and left internal oblique muscle metastasis. Has a history of chronic hepatitis B for more than 10 years and has not received antiviral therapy; He denied the history of surgery, blood transfusion, and metallurgical travel, and the family history was not special. The abdominal ultrasonography after admission showed hypoechoic occupation in the right lobe of the liver, which was considered to be malignant. The results of abdominal enhanced CT examination showed: (1) space-occupying lesions in 6 segments of the liver, considering primary liver cancer; (2) The right hepatic vein, inferior vena cava and bilateral proximal renal veins are filling defects and obviously enhanced, considering tumor thrombosis; (3) Ascites (Figure 1). The results of PET-CT examination showed that: (1) the 6 segments of the liver occupied space, and the metabolism was significantly increased, considering primary liver cancer; (2) The whole filling defect of the inferior vena cava is accompanied by increased metabolism, and the formation of tumor thrombosis is considered; (3) The left internal abdominal oblique muscle (L3 level) shows nodular abnormal hypermetabolism, and metastasis is considered. Laboratory tests: hepatitis B surface antigen, e antibody and core antibody were all positive; Hepatitis B virus DNA was 1.12×10⁴U/ml; 376.5 U/L for AST and 106.3 U/L for ALT; Alpha-fetoprotein was 87.43 μ g/L. No obvious abnormalities were found in the remaining examinations. Diagnosis: (1) Primary liver cancer, China liver cancer staging (CNLC) -stage IIIB; (2) Chronic hepatitis B.

The patient, a 64-year-old male, was admitted to the Medical Department of Hepatobiliary and Pancreatic Surgery, PLA General Hospital on June 3, 2022 due to "liver space occupation found for 6 months". The patient underwent abdominal ultrasound in January 2022 and found uneven intrahepatic echoes, and no further diagnosis and treatment was made. In March 2022, he developed anorexia with weight loss, and lost 5 kg in weight within 2 months. In April 2022, he developed intermittent upper abdominal distension and pain, which was marked by the liver area and could be relieved by itself. An enhanced CT examination of the upper abdomen was performed in a local hospital, and the diagnosis of massive hepatocellular carcinoma of the right lobe of the liver was considered, with a size of approximately 14.2 cm ×10.2 cm. On April 29, 2022, transcatheter arterial chemoembolization was performed once. The postoperative efficacy evaluation showed that the lesion was partially necrotic and most of the blood supply was present, so the tumor survival was considered. Have a history of chronic hepatitis B for 30 years, and take oral antiviral drugs for 1 month; Has a history of diabetes for 8 years, with the highest blood glucose of 17 mmol/L. Oral treatment with metformin, acarbose and other drugs showed good blood glucose control. With a history of hypertension for more than 8 years, the highest blood pressure was 150/100 mmHg (1 mmHg =0.133 kPa), and the blood pressure was well controlled after oral enalapril maleate and indapamide tablets. There is no history of metallurgical travel and surgery, and there is no special family history. The admission physical examination was not special. Laboratory tests: alpha-fetoprotein>60 500 μ g/L; Hepatitis B surface antigen (+), surface antibody (-), e antigen (-), e antibody (+), core antibody (+), HBV DNA quantification<100 U/ml. The liver and kidney function and blood coagulation function were normal, the Child-Pugh grade of liver function was A (5 points), and the MELD score was 6 points. Abdominal enhanced MRI (2022-06-06): The right lobe of the liver occupied a huge mass, with a size of approximately 14.3 cm ×10.2 cm; After interventional surgery for right lobe lesions of the liver, most of the blood supply exists. PET-CT examination (2022-06-09): A large mixed low-density mass of 14.8 cm ×9.3 cm ×13.6 cm was seen in the right lobe of the liver, with increased heterogeneous radioactivity uptake, and the maximum standard uptake value was 18.2. Preliminary diagnosis: (1) Primary liver cancer, China liver cancer staging (CNLC) -stage IB; (2) Chronic hepatitis B; (3) Hypertension Grade 2 (very high risk); (4) type 2 diabetes; (5) The standardized remnant liver volume ratio (SRLVR) was 40.04%.

The patient, a 60-year-old male, came to our hospital on November 5, 2021 due to "cold sensation in both lower limbs for 5 years, aggravated cold sensation in left lower limb with intermittent claudication for 3 months". The patient reported fatigue in both lower limbs after walking about 10 m, which could be relieved after rest. Previous history: Hypertension for 20 years, blood pressure maintained at around 130/85 mmHg (1 mmHg =0.133 kPa) on metoprolol succinate and nifedipine. Diabetes for 20 years, insulin controls blood glucose, and fasting blood glucose is controlled at 8 mmol/L; He was diagnosed with coronary heart disease in July 2021 and underwent coronary artery stenting. He is currently in stable condition. Physical examination: the skin color of both lower limbs is pale, the calf is pigmented, the skin temperature is low, and the left calf is the one; The left dorsal pedis artery, left posterior tibial artery, and left femoral artery pulsed unpalpable, the right dorsal pedis artery pulsed OK, the right posterior tibial artery was unpalpable, and the right femoral artery pulsed palpable. There was no obvious abnormality in the sensory function of both lower limbs, and the movement was acceptable. There was no obvious abnormality in bilateral radial and carotid artery pulsation. CT angiography of lower extremity arteries showed: linear low-density shadow of left common iliac artery, involving left external iliac artery; Multiple soft and hard plaques in bilateral femoral arteries, partially occluded, with the left side. Echocardiogram showed that the size of each chamber of the heart was normal; Second, a small amount of tricuspid valve regurgitation; Decreased left ventricular myocardial compliance; Left ventricular systolic function was normal. Electrocardiogram showed: normal range electrocardiogram. The diameter of the patient's common iliac artery was 12.1 mm and the length of the occlusion section was approximately 34 mm (Figure 1), and the model of the endovascular device such as balloon and stent used in the operation was selected according to the measured artery diameter and occlusion length. The diagnosis was: arteriosclerosis obliterans of the lower extremities (intermittent claudication period); Hypertension Grade 3 (very high risk); Type 2 diabetes; Post-coronary stenting. After admission to the hospital, the relevant examinations were actively improved, and after no contraindications for surgery were found, the lower extremity arteriography, iliac artery balloon angioplasty and iliac artery stent implantation were performed with the assistance of a new universal endovascular interventional surgery robot (Figure 2) on November 7, 2021. The surgery was approved by the ethics committee of our hospital (batch number: AP-ROBIFA-01), and the patient signed the informed consent to the surgery.