Detailed Treatment Process
Male, 53 years old, admitted for gastric cancer surgery. The following is the specific content of the discharge summary. Department: General Surgery Admission date: July 28 Discharge date: November 27 Outpatient diagnosis: Gastric cancer Admission diagnosis: Gastric cancer Discharge diagnosis: Gastric cancer Main symptoms and signs on admission: Chief complaint: Recurrent dull upper abdominal pain and discomfort for more than one year Physical examination: Clear consciousness, normal breathing. No jaundice of skin or mucous membranes. Coarse breath sounds in both lungs, no dry or wet rales. Regular heart rhythm, strong heart sounds. Abdomen flat and soft, no tenderness, rebound tenderness, or muscle guarding. No palpable masses. Liver and spleen not palpable below the costal margin. No edema in both lower limbs, NS (-) Main laboratory results: 10/25 Blood routine - five-classification White blood cell count 9.70 × 10⁹/L, neutrophil% 56.4%, monocyte 6.90%, lymphocyte 35.20%, eosinophil 0.90%, basophil 0.60%, neutrophil absolute value 5.40 × 10⁹/L, monocyte absolute value 0.70 × 10⁹/L, lymphocyte absolute value 3.40 × 10⁹/L, eosinophil absolute value 0.10 × 10⁹/L, basophil absolute value 0.10 × 10⁹/L, red blood cell count 3.35 × 10¹²/L, hemoglobin 108 g/L, hematocrit 31.80%, mean red blood cell volume 95.1 fL, mean hemoglobin content 32.3 pg, mean hemoglobin concentration 340 g/L, red blood cell distribution width 16.6%, platelet count 240.00 × 10⁹/L, platelet hematocrit 0.22%, mean platelet volume 9.00 fL, platelet distribution width 16.1 fL 10/25 Liver function - emergency + renal function - emergency + sodium potassium chloride - emergency Sodium (dry slide method) 136.0 mmol/L, potassium (dry slide method) 3.40 mmol/L, chloride (dry slide method) 97.0 mmol/L, urea nitrogen (dry slide method) 3.0 mmol/L, creatinine (dry slide method) 35.5 umol/L, uric acid (dry slide method) 82.20 umol/L, bile acid 10.0 umol/L, alanine aminotransferase (dry slide method) 43.0 U/L, aspartate aminotransferase (dry slide method) 48.0 u/L, alkaline phosphatase (dry slide method) 130 U/L, GGT (dry slide method) 79 U/L, total bilirubin (dry slide method) 16.3 umol/L, direct bilirubin (dry slide method) 0.00 umol/L, total protein (dry slide method) 64 g/L, albumin (dry slide method) 30.2 g/L, albumin/globulin ratio 0.89 07/29 Blood cell five-classification White blood cell count 7.50 × 10⁹/L, neutrophil 61.2%, lymphocyte 28.00%, monocyte 7.70%, eosinophil 2.40%, basophil 0.70%, neutrophil absolute value 4.60 × 10⁹/L, monocyte absolute value 0.60 × 10⁹/L, lymphocyte absolute value 2.10 × 10⁹/L, eosinophil absolute value 0.20 × 10⁹/L, basophil absolute value 0.10 × 10⁹/L, red blood cell count 4.49 × 10¹²/L, hemoglobin 141 g/L, hematocrit 43.80%, mean red blood cell volume 97.7 fL, mean hemoglobin content 31.4 pg, mean hemoglobin concentration 321 g/L, red blood cell distribution width 13.8%, platelet count 212.00 × 10⁹/L, platelet hematocrit 0.19%, platelet distribution width 16.5 fL, mean platelet volume 9.10 fL 07/29 DIC full set Prothrombin time 10.50 s, prothrombin time INR 0.97, activated partial thromboplastin time 36.5 s, fibrinogen 3.05 g/L, thrombin time 13.60 s, D-dimer 0.13 mg/L, antithrombin activity assay 124%, fibrin (ogen) degradation products 0.70 mg/L 07/29 Pre-transfusion testing HIV initial screening test negative HCV-AB-IgG (-)0.02 s/co, TP-Ab (-)0.06 s/co 07/29 Renal function (no RBP) + sodium potassium chloride + GLU + liver function - inpatient Prealbumin 296.0 mg/L, bile acid 2.4 umol/L, alanine aminotransferase 19 U/L, aspartate aminotransferase 13 U/L, mitochondrial-AST 3 U/L, alkaline phosphatase 52 U/L, gamma-glutamyl transpeptidase 19.0 U/L, total bilirubin 11.0 umol/L, direct bilirubin 3.3 umol/L, total protein 65.7 g/L, albumin 39.7 g/L, albumin/globulin ratio 1.53, AST:ALT 0.68, BUN:CREA 0.11, sodium 142.0 mmol/L, potassium 4.10 mmol/L, chloride 106.0 mmol/L, glucose 5.12 mmol/L, urea nitrogen 7.56 mmol/L, creatinine 66 umol/L, uric acid 197 umol/L, glomerular filtration rate (MDRD) 109.51 ml/min per 1.75m² 07/29 PRO-BNP + myocardial infarction triple test proBNP 59.76 pg/ml, myoglobin 19.00 ng/ml, CK-MB (mass) 1.0 ng/ml, troponin 0.000 ng/ml 07/29 General surgery tumor (male) Alpha-fetoprotein 4.71 ng/ml, carcinoembryonic antigen 5.40 ng/ml, prostate-specific antigen 1.06 ng/ml, free PSA 0.25 ng/ml, F-PSA/T-PSA 0.24, carbohydrate antigen CA-19-9 10.83 U/ml, carbohydrate antigen CA-125 1.75 U/ml, carbohydrate antigen CA-15-3 5.30 U/ml, carbohydrate antigen CA724 2.54 U/ml, carbohydrate antigen CA211 4.99 ng/ml, neuron-specific enolase 10.02 μg/L, SCC 0.60 ng/ml, CA242 5.75 U/ml 07/30 Hepatitis B and C panel (ward) HAV-IgM negative (-), HBsAg (-)0.02 IU/mL, HBsAb (-)0.23 mIU/mL, HBeAg (-)0.328 S/CO, HBeAb (-)2.06 S/CO, HBcAb (-)0.1 S/CO, HBcIgM (-)0.04 S/CO 07/30 Blood type antibody screening and identification (inpatient) ABO blood type A, RH blood type positive, antibody screening negative Special examinations and important consultations: 07/28 Examination diagnosis: Normal electrocardiogram 07/28 Chest X-ray posteroanterior digital radiography, examination diagnosis: No obvious active lesions in both lungs. 07/29 Cardiac color Doppler ultrasound, examination diagnosis: 1. Cardiac structures roughly normal at rest 2. Left ventricular systolic function normal 07/29 Axillary lymph node ultrasound, inguinal lymph node ultrasound, supraclavicular lymph node ultrasound, cervical lymph node ultrasound diagnosis: No obvious enlarged lymph nodes in retroperitoneum, bilateral neck, supraclavicular, axillary, or inguinal regions. 07/30 Abdominal dual-source CT enhanced scan with three-dimensional reconstruction and vascular three-dimensional reconstruction, diagnosis: Slight thickening of gastric wall on lesser curvature, please correlate with clinical findings (endoscopy). Small hepatic cyst. No obvious abnormalities in abdominal vessels. 08/06 Chest X-ray posteroanterior digital radiography, examination diagnosis: Increased lung markings in both lungs, please correlate with clinical findings. 08/06 Abdominal CT plain scan ≥64 rows, examination diagnosis: Post-gastric surgery status, local abdominal drainage tube in place, free gas visible in left upper abdomen, please correlate with clinical findings. 08/06 Pleural effusion B-ultrasound examination and localization, examination diagnosis: Left pleural effusion. No obvious effusion in right pleural cavity. 08/11 Electronic gastroduodenoscopy, examination diagnosis: Post-gastric surgery changes, anastomotic bleeding, endoscopic treatment ineffective, recommend surgical treatment. 09/10 Abdominal CT enhanced scan ≥64 rows with vascular three-dimensional reconstruction, examination diagnosis: Changes after “gastric CA surgery and splenic artery DSA”, mild dilatation of left intrahepatic bile duct with low-density shadow in left lateral lobe, small amount of abdominal fluid, gallbladder effusion. Please correlate with clinical history and other examinations. Abdominal CTA shows atherosclerotic changes in abdominal aorta. High-density shadows in common hepatic artery, splenic artery and their branches. Bilateral pleural effusions noted, more pronounced on left, with poor expansion of left lower lung. 09/01 Chest X-ray posteroanterior digital radiography, examination diagnosis: Increased lung markings in both lungs, blurred markings in left lower lung, please correlate with clinical findings. Abdominal CT plain scan ≥64 rows, examination diagnosis: Manifestations after “gastric cancer surgery and splenic artery DSA”, slight dilatation of intrahepatic bile duct and low-density shadow in left lateral lobe of liver, gallbladder effusion, roughly similar to previous images from 09/10 (as in original). Low-density mass beside pancreatic tail, multiple high-density shadows in liver, recommend correlation with clinical findings and further examination if necessary. Paraffin pathology (11879): “Gastric angle” tubular adenocarcinoma, grade II, with perineural invasion, infiltrating into surrounding adipose tissue. No cancer involvement at either resection margin or additional anastomotic margin. No cancer metastasis in 0/4 lesser curvature lymph nodes, 0/8 greater curvature lymph nodes, or 0/1 greater omentum lymph nodes. Disease course and treatment outcome: The patient completed relevant examinations after admission. On 07/31, radical gastrectomy for gastric cancer (D2, Billroth I) was performed under general anesthesia. Intraoperatively, the tumor was located on the lesser curvature at the gastric angle, measuring approximately 2.5 × 2.2 cm, without serosal invasion, ulcerative type. Enlarged lymph nodes were palpable around the stomach. Intraoperative blood loss was about 100 ml, no transfusion. Postoperatively, cephalosporin was given for infection prevention, acid suppression, and intravenous nutritional support. On the evening of 08/11, the patient suddenly vomited blood. Emergency gastroscopy showed anastomotic bleeding. Endoscopic hemostasis was ineffective, so emergency laparotomy with abdominal adhesiolysis and suturing of the gastro-duodenal anastomosis for hemostasis was performed immediately under general anesthesia. Intraoperatively, upper abdominal postoperative adhesions were noted, with about 100 ml of light-yellow ascites in the abdominal cavity. After adhesiolysis, the residual stomach and duodenum Billroth I anastomosis was identified. The residual stomach had high tension, and small intestine and colon were distended with gas. A 3 cm incision was made on the anterior wall of the residual stomach, revealing about 250 ml of old blood clots in the gastric cavity. After suction, a pulsating bleeding point was seen on the posterior wall of the original gastro-duodenal anastomosis. It was ligated with 4-Prolene suture. The anterior gastric wall incision was closed intermittently. Drainage tubes were placed in the splenic fossa, below the pancreas, and beside the anastomosis. A gastric tube was left in place with its distal end in the duodenal lumen. Intraoperative blood loss was about 400 ml, no transfusion reaction. The patient was transferred to SICU postoperatively. On the morning of 08/27, the patient vomited fresh blood again, about 200 ml. He received 6 units of red blood cells and 400 ml of plasma transfusion, with no transfusion reaction. Treatments included gastrointestinal decompression, hydroxyethyl starch for volume expansion, red blood cells and plasma to correct anemia, etc. Emergency DSA abdominal vascular angiography showed no obvious bleeding signs. Gastrointestinal decompression, hydroxyethyl starch volume expansion, enteral and parenteral nutritional support, and other treatments were continued. On 09/01, fresh red blood was seen draining from the gastric tube and gastrostomy tube. Emergency DSA abdominal vascular angiography revealed contrast extravasation and bleeding at the origin of the splenic artery, which was embolized for hemostasis. Postoperatively, transfusion, volume expansion, and supportive treatment were continued. On 09/18, fresh red blood was seen from the abdominal drainage tube, suggesting recurrent abdominal bleeding. Emergency DSA abdominal vascular angiography showed contrast extravasation and bleeding from the main trunk of the hepatic artery, which was embolized for hemostasis. After the procedure, the patient’s condition gradually stabilized. He received blood transfusions and enteral/parenteral nutritional support, then gradually resumed a semi-liquid diet. The gastrostomy tube and jejunostomy tube were removed successively. The patient is now in acceptable general condition and is being discharged. Complications: Anastomotic bleeding, splenic artery bleeding, and common hepatic artery bleeding after gastric cancer surgery Condition at discharge: Clear consciousness, stable vital signs, clear breath sounds in both lungs, no obvious rales, regular heart rhythm, no murmurs, abdomen flat and soft, no obvious tenderness or rebound tenderness, abdominal incision healing well. Including the initial gastric cancer surgery, the patient underwent a total of 5 operations during the entire hospitalization. Total hospitalization cost was $430,000, of which medical insurance paid $300,000. The patient’s out-of-pocket portion included approximately $27,000 in classified co-payments and $50,000 self-pay, totaling about $130,000 out of pocket.