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Female, 70 years old The following is the report of contrast-enhanced CT of the upper abdomen Radiological findings: A soft-tissue nodular lesion measuring approximately 2.2 cm × 2.0 cm is seen in the head of the pancreas. The lesion shows mild lobulation with ill-defined margins. Plain CT attenuation is about 46 HU with relatively homogeneous density. The lesion shows heterogeneous enhancement after contrast administration, which is less than that of normal pancreatic parenchyma. The pancreatic duct is dilated. The gallbladder is absent and the biliary tree is dilated. The liver is normal in morphology with a smooth surface. The lobes are in normal proportion and the parenchyma shows homogeneous density. No obvious widening of the fissures is seen. The spleen is normal in size with homogeneous density. A fat-density mass is seen in the left adrenal gland, measuring approximately 3.7 cm × 4.2 cm, with no obvious enhancement on contrast-enhanced scans. Multiple round-like low-density lesions are seen in both kidneys, with no enhancement on contrast-enhanced scans. No enlarged lymph nodes are seen in the retroperitoneum. No obvious ascites is present in the abdominal cavity. Radiological diagnosis: 1. Space-occupying lesion in the head of the pancreas, suspicious for malignancy, most likely pancreatic cancer, with pancreatic duct obstruction and dilatation. Further evaluation is recommended. 2. Absent gallbladder with biliary dilatation. 3. Space-occupying lesion in the left adrenal gland, most likely a lipoma. Follow-up is advised. 4. Multiple cysts in both kidneys. Review time: December 23
The following is the death summary Department: Hepatobiliary and Pancreatic Surgery Date of admission: December 22 Date and time of discharge: December 27 at 22:10 Outpatient diagnosis: Malignant tumor of the pancreatic head (uncinate process); status post cholecystectomy; Grade 2 hypertension (high risk); type 2 diabetes mellitus Admission diagnosis: Malignant tumor of the pancreatic head (uncinate process); status post cholecystectomy; Grade 2 hypertension (high risk); type 2 diabetes mellitus Discharge diagnosis: Malignant tumor of the pancreatic head (uncinate process, adenocarcinoma); adhesions after cholecystectomy; Grade 2 hypertension (high risk); type 2 diabetes mellitus Major symptoms and signs on admission: The patient had mild tenderness in the upper abdomen, no abdominal distension, no nausea or vomiting, and normal appetite. Bowel and bladder function were unremarkable. Physical examination: An old surgical scar about 10 cm long was noted below the right costal margin. The abdomen was soft and flat, with normal abdominal breathing. No abdominal wall varices. Mild tenderness in the upper abdomen. No obvious tenderness elsewhere in the abdomen, no muscle guarding or rebound tenderness. No palpable masses. Liver and spleen not palpable below the costal margin. No percussion tenderness over the liver or kidneys. Laboratory tests and major consultations (with dates and reference numbers): December 23, complete blood count + CRP + SAA: Red blood cells: 6.03 × 10¹²/L ↑; mean corpuscular volume: 66.5 fl ↓; mean corpuscular hemoglobin: 20.2 pg ↓; mean corpuscular hemoglobin concentration: 304 g/L ↓; white blood cells: 5.46 × 10⁹/L; neutrophils: 51.60%; lymphocytes: 38.10%; monocytes: 7.10%; eosinophils: 2.70%; basophils: 0.50%; neutrophils: 2.81 × 10⁹/L; lymphocytes: 2.08 × 10⁹/L; monocytes: 0.39 × 10⁹/L; eosinophils: 0.15 × 10⁹/L; basophils: 0.03 × 10⁹/L; hemoglobin: 122.0 g/L; hematocrit: 0.401; red cell distribution width: 15.4%; platelets: 225 × 10⁹/L; platelet distribution width: 16.5 fl; mean platelet volume: 11.6 fl; plateletcrit: 0.26; C-reactive protein: <0.50 mg/L; serum amyloid A: 6.48 mg/L; December 23, liver and kidney function with electrolytes: Alkaline phosphatase: 36.00 U/L ↓; creatinine: 42.90 µmol/L ↓; glucose: 7.20 mmol/L ↑; total protein: 59.90 g/L ↓; myoglobin: 10.4 ng/ml ↓; total bilirubin: 14.70 µmol/L; indirect bilirubin: 10.40 µmol/L; direct bilirubin: 0.00 µmol/L; alanine aminotransferase: 31.00 U/L; aspartate aminotransferase: 15.00 U/L; γ-glutamyl transferase: 21.00 U/L; urea: 4.89 mmol/L; uric acid: 390.90 µmol/L; albumin: 38.30 g/L; globulin: 21.60 g/L; albumin/globulin ratio: 1.77; total cholesterol: 3.43 mmol/L; carbon dioxide: 22.90 mmol/L; potassium: 3.96 mmol/L; sodium: 137.10 mmol/L; chloride: 103.70 mmol/L; calcium: 2.12 mmol/L; phosphorus: 1.39 mmol/L; amylase: 60 U/L; troponin I: 0.002 ng/ml; creatine kinase isoenzyme: 0.80 ng/ml; cholinesterase: 6090 U/L; December 23, B-type natriuretic peptide: 30.0 pg/ml; December 23, coagulation profile: Prothrombin time: 13.0 seconds ↑; INR: 1.13; prothrombin activity: 100.6%; thrombin time: 16.6 seconds; activated partial thromboplastin time: 24.9 seconds; fibrinogen: 2.76 g/L; D-dimer: 0.35 µg/ml; antithrombin III: 90.1%; fibrin degradation products: 1.10 µg/mL; anti-Xa activity: 0.000; December 23, tumor markers (CEA, AFP, CA19-9 chemiluminescence): Carcinoembryonic antigen (CEA): 19.66 ng/ml ↑; carbohydrate antigen 19-9 (CA19-9): 96.57 U/ml ↑; alpha-fetoprotein (AFP): 1.27 ng/ml; December 23, hepatitis B/C, syphilis, HIV: Hepatitis B surface antibody (HBsAb): 56.77 (+) mIU/ml ↑; hepatitis B e antibody (HBeAb): 0.55 (+) S/CO ↓; hepatitis B core antibody (HBcAb): 4.67 (+) S/CO ↑; HIV Ag/Ab: negative; hepatitis B surface antigen (HBsAg): 0.01 (-) IU/ml; hepatitis B e antigen (HBeAg): 0.305 (-) S/CO; hepatitis B core IgM antibody: 0.06 (-) S/CO; Treponema pallidum antibody (TP): 0.09 (-) S/CO; TRUST: negative; TRUST titer: negative; hepatitis C antibody: 0.08 (-) S/CO; December 23, thyroid function: T3: 1.37 nmol/L; T4: 101.40 nmol/L; free T3: 3.57 pmol/L; free T4: 15.90 pmol/L; TSH: 3.00 µIU/ml; thyroglobulin antibody: 13.36 IU/ml; thyroglobulin: 4.96 ng/ml; TSH receptor antibody: 1.08 IU/L; thyroid peroxidase antibody: 10.06 IU/ml; calcitonin: <0.50 pg/ml; December 23, lipids: HDL cholesterol: 1.12 mmol/L ↓; apolipoprotein A-I: 0.92 g/L ↓; total cholesterol: 3.76 mmol/L; triglycerides: 1.07 mmol/L; LDL cholesterol: 2.16 mmol/L; small dense LDL cholesterol: 24.7 mg/dl; apolipoprotein B: 0.78 g/L; apolipoprotein E: 3.23 mg/dl; lipoprotein(a): 234 mg/L; free fatty acids: 0.27 mmol/L; December 23, other viral serology (hepatitis B large protein): Hepatitis B large protein: 0.98 (-); December 23, hepatitis B virus pre-S1 antigen: Pre-S1 antigen: 0.05 S/CO; December 23, IL-6: 26.75 pg/ml ↑; procalcitonin: 0.050 ng/ml; December 23, thromboelastography (TEG): R (coagulation factor activity): 4.9 min (enhanced) ↓; Angle (fibrinogen function): 52.8 deg (reduced) ↓; K (fibrinogen function): 1.9 min (normal); MA (platelet function): 61.6 mm (normal); CI (coagulation index): -0.2 (normal); EPL (fibrinolysis): 0.1% (normal); LY30 (fibrinolysis): 0.1% (normal); December 24, ABO and Rh blood typing: Blood type A; Rh(D) positive; December 24, ABO/Rh typing and antibody screen: Blood type A; Rh(D) positive; antibody screen: negative; December 22, electrocardiogram: Sinus rhythm; low voltage in limb leads; mild left axis deviation of QRS; tall peaked T waves (please correlate clinically); December 22, chest CT (lungs, mediastinum, chest wall) plain scan: 1. Ground-glass opacity in the anterior segment of the right upper lobe; tiny solid nodules in the anterior basal segment of the left lower lobe, posterior segment of the right upper lobe, and medial segment of the right middle lobe—follow-up recommended. 2. Linear opacity in the medial segment of the right middle lobe; bulla in the right lower lobe—follow-up advised. 3. Calcifications in both breasts—mammography if indicated. 4. Probable hemangioma in T9 vertebra. 5. Calcified plaques in the aorta and coronary arteries. 6. Left adrenal mass with fatty components, suggestive of myelolipoma—further contrast-enhanced imaging recommended. December 22, basic cardiac ultrasound: Aortic valve calcification with mild regurgitation; left ventricular systolic function normal. December 23, upper abdominal CT (focused on diffuse liver disease) plain + contrast: 1. Space-occupying lesion in the pancreatic head, most likely malignant (pancreatic cancer probable), with pancreatic duct obstruction and dilation—further evaluation recommended. 2. Absent gallbladder with biliary dilation. 3. Left adrenal mass, most likely lipoma—follow-up advised. 4. Multiple renal cysts. December 24, ultrasound-guided percutaneous transhepatic biliary drainage (PTCD): Ultrasound-guided percutaneous transhepatic biliary catheter placement. Course and treatment outcome (including surgery name, date, transfusion, and resuscitation details): After admission, the patient completed relevant examinations and received liver protection, gastric protection, and nutritional support. Once surgical contraindications were ruled out, radical pancreaticoduodenectomy was performed on December 27, 2021. Laparoscopic exploration showed no obvious metastatic lesions in the peritoneal cavity. There were postoperative adhesions between the liver and diaphragm, changes after cholecystectomy with omental adhesions at the gallbladder bed. No obvious abnormalities on the abdominal wall, small bowel, colon, or bladder surface. No ascites. The mass was located in the uncinate process of the pancreas, about 3.5 cm in diameter and firm. The common bile duct was mildly dilated. The hepatic artery and gastroduodenal artery were not involved by tumor. Dissection of the uncinate process was difficult laparoscopically, so a midline upper abdominal incision was made. Open exploration revealed that the uncinate tumor had invaded the superior mesenteric vessels and portal vein. The portal vein was encased by tumor over a length of about 5 cm. Tumor invasion was visible on the right wall of the superior mesenteric artery. The roots of the splenic artery and vein were also encased. During dissection of the portal vein and uncinate tumor, bleeding occurred from the portal vein sidewall. After portal vein clamping, the splenic vessels were divided and ligated, the pancreas was transected at the neck, the encased segment of portal vein was resected, and the uncinate tumor was removed along with the right lateral wall of the superior mesenteric artery. Portal vein reconstruction with an artificial vascular graft was then performed. Significant bleeding occurred during the procedure. The patient received 4 units of red blood cell suspension (600 ml total), 4 units of plasma (400 ml total), and 80 g of albumin. Oozing from the surgical field persisted. During hemostasis, the patient suddenly experienced cardiac arrest. Continuous chest compressions were started immediately, along with continuous intravenous epinephrine and defibrillation. Spontaneous heartbeat was restored. The operation was completed, the abdomen was closed, and the patient was transferred intubated to the surgical intensive care unit for further monitoring. At 19:20 the patient was moved to the thoracic surgery CCU, where mechanical ventilation and dopamine were used to support blood pressure. At 20:50, cardiac arrest occurred again. Chest compressions, defibrillation, and intravenous epinephrine were administered immediately. The family was informed of the critical condition. Around 22:10, spontaneous heartbeat and respiration ceased, central pulses disappeared, pupils were fully dilated, and the ECG showed a flat line. Clinical death was declared. Complications: None Treatment outcome: Death
Preoperative imaging showed pancreatic duct dilation, but did not reveal encasement or invasion of the superior mesenteric vessels or portal vein by the tumor. This was discovered only in the surgical field.