2024年 · 第62卷第01期

The patient, a 48-year-old female, came to our hospital on September 17, 2018 due to "persistent epigastric pain with acid reflux for 3 months". The patient developed postprandial acid reflux, middle and upper abdominal pain without obvious trigger 3 months ago, with a digital pain score of 5 to 6 points, no back radiation pain, accompanied by vomiting, and the abdominal pain could be slightly relieved after vomiting, without fever, yellowing of skin and sclera, and normal exhaust and defecation. There was no significant weight loss. No previous history of chronic diseases such as hypertension, diabetes, and coronary heart disease; No history of infectious diseases; There was no history of major surgery, trauma and blood transfusion. Physical examination: Body temperature 36.2 ℃, pulse 64 beats/min, respiratory rate 19 beats/min, blood pressure 125/76 mmHg (1 mmHg =0.133 kPa). There was no yellowing stain on the skin and sclera of the whole body, obvious swelling of the superficial lymph nodes without palpation, soft abdomen, deep tenderness in the right upper abdomen, no rebound pain, subcostal and xiphoid process of the liver and spleen, and Murphy's sign (-). Laboratory test: white blood cell count 4.17×10⁹/L, neutrophil percentage 66.3%, hemoglobin 143 g/L; Glutamine transpeptidase 11 U/L, albumin 42 g/L, total bilirubin 13.8 μ mol/L; tumor marker CA19-9 108 U/ml; The coagulation test results were normal. The results of abdominal enhanced CT, pancreatic CT thin-section scan and three-dimensional reconstruction showed that the cystic mass of the head of the pancreas was occupied, and intraductal papillary mucinous neoplasm (IPMN) was possible, with a size of about 1.7 cm ×1.8 cm; The cyst wall is thick with enhancement, and malignant transformation is not excluded. The lesion is close to the root of the superior mesenteric vein, and the lumen is slightly narrow. Multiple tortuous arterial shadows around the lesion, originating from the superior mesenteric artery; Severe stenosis at the beginning of the celiac trunk, possibly due to compression of the middle arch ligament (Figure 1). The results of PET-CT examination showed that the cystic low-density shadow in the pancreatic head area, about 1.6 cm ×1.4 cm in size, seemed to communicate with the pancreatic duct, and the uneven radioactive uptake of the cyst wall was increased. The maximum standard uptake value (SUVmax) was 2.3, and the SUVmax after delayed imaging was 3.2; The pancreatic duct was dilated, and no other abnormal radioactive uptake increased. The results of abdominal vascular ultrasonography showed that the blood flow in the initial segment of the celiac trunk was obviously thinner and disordered, with an inner diameter of about 0.16 cm, the blood flow velocity in the peak systolic period was 249 cm/s, the lumen of hepatic artery and splenic artery was not obviously narrowed and dilated, and the blood flow direction was normal. Stenosis at the beginning of the celiac trunk and median arcuate ligament syndrome (MALS) are more likely. The results of electronic endoscopic ultrasound showed that the pancreatic head had a cystic structure, about 3.1 cm ×1.8 cm in size, and the cyst wall was thick and irregular; The pancreatic duct was dilated, 5-7 mm in diameter; Puncture of cystic lesion was unsuccessful.

The 58-year-old male patient was admitted to the Department of Hepatobiliary and Pancreatic Surgery of Leshan People's Hospital on October 9, 2022 due to "repeated upper abdominal dull pain and discomfort for 2 years". After admission, the relevant examinations were completed: hemoglobin 148 g/L, platelet count 217×10⁹/L, ALT 105 U/L, AST 246 U/L, total bilirubin 30.2 μ mol/L, direct bilirubin 14.8 μ mol/L, albumin 40.2 g/L, CA19-9 52.37 U/ml, normal coagulation function, negative results of related tests before transfusion, no obvious abnormalities in cardiopulmonary function tests, and Child-Pugh grade of liver function A; The results of epigastric enhanced MRI and magnetic resonance cholangiopancreatography showed that the 3 segments of the liver were significantly dilated with intraductal stones, and the 3 segments of the liver were mildly atrophied (Figure 1A); Gallbladder stones with significant enlargement; A filling mild defect with a maximum diameter of about 0.6 cm and mild enlargement of the diameter of the common bile duct was seen in the common bile duct, considering the possibility of common bile duct stones (Figure 1B). Preliminary diagnosis: (1) intrahepatic and extrahepatic bile duct stones with 3-segment liver atrophy; (2) Gallbladder stones with chronic cholecystitis. Considering that the patient's common bile duct stones are small and the inner diameter of the bile duct is not obviously enlarged, we first performed endoscopic retrograde cholangio-pancreatography (ERCP) to remove the bile duct stones, followed by endoscopic nasobiliary drainage (ENBD) (Figure 1C). After ERCP, the patient recovered smoothly, and the retention rate of indocyanine green (ICG) was examined for 15 minutes after stone removal, and the result was 2.4%. After general practice discussion, patients were considered: (1) mild elevation of CA19-9; (2) Localized dilation of hepatobiliary duct with stone incarceration; (3) The drained liver segment corresponding to the dilated bile duct tends to atrophy; (4) There were no obvious abnormalities in preoperative cardiopulmonary function and liver function. Therefore, the treatment plan of "fluorescence laparoscopic anatomical 3-segment liver resection + cholecystectomy" was formulated for the patient on the third day after ERCP.