Detailed Treatment Process
Female, 70 years old The following is the upper abdominal contrast-enhanced CT report
Radiological findings: A soft tissue nodular lesion approximately 2.2cm * 2.0cm in size is seen in the head of the pancreas. The lesion shows shallow lobulation, with ill-defined borders. Plain CT value is about 46HU, with relatively uniform and solid density. After enhancement, the lesion shows heterogeneous enhancement, lower than that of normal pancreatic tissue, with pancreatic duct dilatation; the gallbladder is absent, and the biliary tract shows visible dilatation. The liver has a regular morphology, smooth surface, and normal proportions of each lobe, with uniform parenchymal density and no obvious widening of the interlobar fissures. The spleen is normal in size with uniform parenchymal density. A fat-density mass is seen in the left adrenal gland, measuring approximately 3.7 * 4.2cm, with no obvious enhancement on contrast-enhanced scan. Multiple rounded low-density shadows are seen in the parenchyma of both kidneys, with no enhancement on contrast-enhanced scan. No enlarged lymph nodes in the retroperitoneum. No obvious fluid accumulation in the abdominal cavity.
Radiological diagnosis: 1. Space-occupying lesion in the head of the pancreas, considered likely malignant tumor, most probably pancreatic cancer, with pancreatic duct obstruction and dilatation. Further examination is recommended. 2. Absent gallbladder with biliary dilatation. 3. Space-occupying lesion in the left adrenal gland, considered most probably a lipoma. Follow-up is recommended. 4. Multiple cysts in both kidneys.
Review time: December 23
The following is the death summary Department: Hepatobiliary and Pancreatic Surgery Admission date: December 22 Discharge date and time: December 27 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
Main symptoms and signs on admission: The patient had mild tenderness in the upper abdomen, no abdominal distension, no nausea or vomiting, and fair appetite, with no special findings in bowel or urinary habits. Physical examination: An old surgical scar about 10cm long was seen under the right costal margin. The abdomen was flat and soft, with abdominal breathing present. No abdominal wall varices. Mild tenderness in the upper abdomen. No obvious tenderness in the rest of the abdomen, no muscle guarding or rebound tenderness. No palpable masses. Liver and spleen not palpable below the costal margin. No percussion tenderness in the liver area. No percussion tenderness in both kidney areas.
Laboratory tests and main consultations (with dates and test numbers noted): December 23 blood routine + CRP + SAA: Red blood cells: 6.03 × 10¹²/L↑; mean corpuscular volume: 66.5fl↓; mean corpuscular hemoglobin: 20.2pg↓; mean corpuscular hemoglobin concentration: 304g/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: 122.0g/L; hematocrit: 0.401; red blood cell distribution width: 15.4%; platelets: 225 × 10⁹/L; platelet distribution width: 16.5fl; mean platelet volume: 11.6fl; plateletcrit: 0.26; C-reactive protein: <0.50mg/L; serum amyloid A: 6.48mg/L; December 23 liver and kidney function electrolytes: Alkaline phosphatase: 36.00U/L↓; creatinine: 42.90umol/L↓; glucose: 7.20mmol/L↑; total protein: 59.90g/L↓; myoglobin: 10.4ng/ml↓; total bilirubin: 14.70umol/L; indirect bilirubin: 10.40umol/L; direct bilirubin: 0.00umol/L; alanine aminotransferase: 31.00U/L; aspartate aminotransferase: 15.00U/L; γ-glutamyl transferase: 21.00U/L; urea: 4.89mmol/L; uric acid: 390.90umol/L; albumin: 38.30g/L; globulin: 21.60g/L; albumin/globulin: 1.77; total cholesterol: 3.43mmol/L; carbon dioxide: 22.90mmol/L; potassium: 3.96mmol/L; sodium: 137.10mmol/L; chloride: 103.70mmol/L; calcium: 2.12mmol/L; phosphorus: 1.39mmol/L; amylase: 60U/L; troponin I: 0.002ng/ml; creatine kinase isoenzyme: 0.80ng/ml; cholinesterase (dry): 6090U/L; December 23 B-type natriuretic peptide: 30.0pg/ml; December 23 coagulation function: 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: 2.76g/L; D-dimer: 0.35ug/ml; antithrombin III: 90.1%; fibrin degradation products: 1.10ug/mL; anti-Xa activity: 0.000; December 23 cancer antigen assay (CEA), alpha-fetoprotein assay (AFP), carbohydrate antigen assay CA19-9 (chemiluminescence): Cancer antigen (CEA): 19.66ng/ml↑; carbohydrate antigen 19-9 (CA19-9): 96.57U/ml↑; alpha-fetoprotein (AFP): 1.27ng/ml; December 23 hepatitis B and C, syphilis, HIV: Hepatitis B virus surface antibody (HBsAb): 56.77(+)mIU/ml(-)↑; hepatitis B virus e antibody (HBeAb): 0.55(+)S/CO(-)↓; hepatitis B virus core antibody (HBcAb): 4.67(+)S/CO(-)↑; human immunodeficiency virus (HIV) Ag/Ab: negative(-); hepatitis B virus surface antigen (HBsAg): 0.01(-)IU/ml(-) none; hepatitis B virus e antigen (HBeAg): 0.305(-)S/CO(-) none; hepatitis B virus core antibody IgM (HBcAb-IgM): 0.06(-)S/CO(-) none; Treponema pallidum antibody (TP): 0.09(-)S/CO(-) none; toluidine red unheated serum test for syphilis (TRUST): negative(-) none; toluidine red unheated serum test for syphilis (titer) (TURST DIL): negative(-); hepatitis C virus antibody (HCVAb): 0.08(-)S/CO none; December 23 thyroid function: Triiodothyronine (T3): 1.37nmol/L; thyroxine (T4): 101.40nmol/L; free triiodothyronine (FT3): 3.57pmol/L; free thyroxine (FT4): 15.90pmol/L; thyroid-stimulating hormone (TSH): 3.00uIU/ml; thyroglobulin antibody (TGAb): 13.36IU/ml; thyroglobulin (TG): 4.96ng/ml; thyroid-stimulating hormone receptor antibody (TRAb): 1.08IU/L; anti-thyroid peroxidase antibody (TPOAb): 10.06IU/ml; calcitonin (CT): <0.50pg/ml; December 23 blood lipids: High-density lipoprotein cholesterol: 1.12mmol/L↓; apolipoprotein AI: 0.92g/L↓; total cholesterol: 3.76mmol/L; triglycerides: 1.07mmol/L; low-density lipoprotein cholesterol: 2.16mmol/L; small dense low-density lipoprotein cholesterol: 24.7mg/dl; apolipoprotein B: 0.78g/L; apolipoprotein E: 3.23mg/dl; lipoprotein(a): 234mg/L; free fatty acids: 0.27mmol/L; December 23 serological diagnosis of other viruses (hepatitis B large protein): Hepatitis B large protein (LHBs): 0.98(-); December 23 hepatitis B virus envelope protein pre-S1 antigen assay: pre-S1 antigen (Pre-S1Ag): 0.05S/CO; December 23 IL-6: 26.75pg/ml↑; procalcitonin: 0.050ng/ml; December 23 thromboelastography (TEG): R (coagulation factor activity): 4.9 enhanced min↓; Angle (fibrinogen function): 52.8 weakened deg↓; K (fibrinogen function): 1.9 normal min; MA (platelet function): 61.6 normal mm; CI (comprehensive coagulation index): -0.2 normal; EPL (fibrinolysis status): 0.1 normal%; LY30 (fibrinolysis status): 0.1 normal%; December 24 ABO blood type identification, Rh blood type identification: Blood type identification: Type A; RH(D) blood type identification: positive(+); December 24 ABO blood type identification, Rh blood type identification, blood type specific antibody identification (antibody screening): Blood type identification: Type A; RH(D) blood type identification: positive(+); blood type antibody screening test: negative(-) none; December 22 electrocardiogram: Sinus rhythm; low voltage in limb leads; mild left axis deviation of QRS; tall peaked T waves (please correlate with clinical findings); December 22 chest (both lungs, mediastinum, chest wall) CT plain scan: 1. Ground-glass density shadow in the anterior segment of the right upper lobe, solid tiny 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 is recommended. 2. Cord-like lesion in the medial segment of the right middle lobe, pulmonary bulla in the right lower lobe. Follow-up is recommended. 3. Calcifications in both breasts. Mammography is recommended if necessary. 4. Possible hemangioma in the T9 vertebral body. 5. Calcified plaques in the aorta and coronary arteries. 6. Left adrenal mass with fatty components, possibly myelolipoma. Further contrast-enhanced examination is recommended. December 22 heart (basic package), echocardiography: Aortic valve calcification with mild regurgitation; left ventricular systolic function normal December 23 upper abdominal (mainly for diffuse liver lesions) CT plain scan + CT enhancement: 1. Space-occupying lesion in the head of the pancreas, considered likely malignant tumor, most probably pancreatic cancer, with pancreatic duct obstruction and dilatation. Further examination is recommended. 2. Absent gallbladder with biliary dilatation. 3. Space-occupying lesion in the left adrenal gland, considered most probably a lipoma. Follow-up is recommended. 4. Multiple cysts in both kidneys. December 24 ultrasound-guided biliary puncture and catheter drainage (PTCD), interventional: Ultrasound-guided percutaneous transhepatic biliary drainage
Course and treatment outcome (with surgical names, surgical dates, blood transfusions, and resuscitation details noted): After admission, the patient completed relevant examinations and received liver protection, stomach protection, nutritional support and other treatments. After surgical contraindications were ruled out, radical pancreaticoduodenectomy was performed on 2021-12-27. Laparoscopic exploration showed no obvious metastatic lesions in the abdominal cavity, adhesions between the liver and diaphragm from previous surgery, changes after cholecystectomy, omental adhesions at the gallbladder bed, and no obvious abnormal lesions on the surfaces of the abdominal wall, small and large intestines, or bladder. No ascites. Exploration revealed a mass in the uncinate process of the pancreas, about 3.5cm in diameter and hard in texture. The common bile duct was mildly dilated. The hepatic artery and gastroduodenal artery were not involved by the tumor. Separation of the uncinate process was difficult under laparoscopy, so a midline upper abdominal incision was made to open the abdomen. Exploration showed that the uncinate tumor invaded the superior mesenteric vessels and portal vein. The portal vein was encased by the tumor for about 5cm. Tumor invasion was visible on the right wall of the superior mesenteric artery. The roots of the splenic artery and vein were encased within the tumor. During separation of the portal vein and uncinate tumor, bleeding occurred from the portal vein sidewall. After portal vein clamping, the splenic vessels were dissected and divided, the pancreas was transected at the neck, the entire encased segment of the portal vein was resected, and the uncinate tumor was excised at the level of the right wall of the superior mesenteric artery. Portal vein reconstruction with an artificial vascular graft was then performed. There was significant bleeding during the operation. Intraoperatively, 4 units of red blood cell suspension (total 600ml), 4 units of plasma (total 400ml), and 80g of albumin were transfused. Diffuse oozing from the wound surface persisted. During hemostasis, the patient suddenly developed cardiac arrest. Continuous chest compressions were immediately performed along with continuous intravenous epinephrine and defibrillation. The patient regained spontaneous heartbeat. The operation was completed. After abdominal closure, the patient was transferred to the surgical intensive care unit with endotracheal intubation for further monitoring of vital signs. The patient was transferred to the thoracic surgery CCU at 19:20, receiving ventilator support and dopamine to maintain blood pressure. At 20:50, the patient experienced another cardiac arrest. Immediate chest compressions, defibrillation, and other resuscitation measures were performed, along with intravenous epinephrine. The patient's family was informed of the critical condition. Around 22:10, spontaneous heartbeat and respiration ceased, major arterial pulsation disappeared, pupils were dilated to the edges, and the electrocardiogram showed a flat line. Clinical death was declared.
Complications: None Treatment outcome: Death
Preoperative imaging showed pancreatic duct dilatation, but did not reveal encasement or invasion of the superior mesenteric vessels and portal vein by the tumor. This was discovered during the surgical field exploration.