After surgery, some venous blood would not pass through the liver. The lack of metabolic reactions was the main cause of hepatic encephalopathy.
That was also why he had used two stents to narrow the inner radius of the outflow tract.
They could remove the second stent only after the patient adjusted to it, significantly reducing the risk of further hematemesis.
Zheng Ren went to ask the patient of his condition and pose a few simple math problems, such as the sum of 74+7+7+7.
For patients with mild hepatic encephalopathy, such questions would be more difficult.
However, there was also a limit to multiple-digit addition.
Even doctors would be confused by too many numbers.
The patient's condition seemed promising. Zheng Ren decided to monitor him for another two days. If blood ammonia levels stopped rising, they could remove the second stent.
When they exited the ward, Zheng Ren spotted a genuine smile on Chief Xia's face.
The patient was her former classmate and they were close enough that she could sign his consent forms. Surviving without serious postoperative complications was truly something worth celebrating.
Zheng Ren planned to check on the female suicide victim in the ICU on his way back. He occasionally remembered having an unfinished mission about her adenomyosis.
It was not obsessive-compulsive disorder; he could perform TIPS surgery in order to level up his skills. The skill points he could earn with a high-level surgery was equivalent to the rewards of three to five missions.
Of course, experience points from missions could be used in emergency situations, but those were another story.
As he was about to leave, Chief Xia's expression turned serious, as if she had just made an important decision.
"Little Zheng, can you help check on one of my patients?"
"Oh? Does the patient require TIPS surgery?" he asked.
"No, it is one of those intractable diseases. The differential diagnoses were unclear and the patient is not in a good state," Chief Xia said, slightly embarrassed.
An experienced department chief admitting ambiguity in her diagnosis required a whole lot of courage.
If Zheng Ren had not done her a huge favor by taking on a gallbladder torsion and TIPS surgery in the last two days, Chief Xia would never have asked a doctor from another department for help. She would rather let her patient transfer to another hospital.
"What's the patient's condition?" Zheng Ren asked curiously.
"The patient is a 62-year-old female. Clinical symptoms presented sepsis with abdominal pain and jaundice," Chief Xia said as she led him to the ward, "An abdominal CT scan detected liver abscess and pneumobilia. The abscess is 5.2 x 4.2 cm wide."
Liver abscesses and jaundice were a fatal combination.
Zheng Ren quickened his footsteps as he listened.
"The results of magnetic resonance cholangiopancreatography (MRCP) showed biliary–enteric communications between the duodenum and bile duct. However, there was a low-grade filling defect in the liver and extrahepatic duct." Chief Xia matched his pace. "We consulted the general surgery department, who suggested a low success rate due to the patient's poor condition and an unknown diagnosis. Proceeding with exploratory laparotomy would have a high chance of failure."
"What about her medical history?" Zheng Ren asked.
"She had a cholecystectomy about twenty-four years ago."
Just a cholecystectomy? He was doubtful. It ought not to have any relation with this disease.
They reached the ward mid-conversation.
Two rows of lower-ranking doctors of the gastroenterology department quietly and obediently stood at attention in the corridor, holding medical file folders.
"Boss, look at those doctors. They're so well ordered," Su Yun said softly beside Zheng Ren.
"If we're doing this, the first person required to stand straight would be you," Zheng Ren snapped back as he was anxious to see the patient.
That would probably be true, Su Yun thought.
They entered the ward and Zheng Ren glanced at the System's monitor on the upper right of his vision.
An unfamiliar diagnosis appeared before Zheng Ren's eyes—sump syndrome.
Sump syndrome, also known as blind loop syndrome and enteric bacterial overgrowth syndrome (EBOS), was an uncommon complication stemming from a side-to-side choledochoduodenostomy.
Its clinical symptoms were caused by the acc.u.mulation of food, debris and calculi in the reservoir formed between the Roux-en-Y choledochojejunostomy and ampulla of Vater.
The patient's entire body had turned yellow, looking like a little yellow person.
Overall, she was in a poor state. Zheng Ren rubbed his hands, warming them to more closely match the patient's body temperature.
When his fingers came into contact with her body, they came away burning.
Her temperature was at least 39 °C, most likely due to severe infection.
There was point tenderness on her upper right abdomen near the duodenum, accompanied by rebound tenderness. Percussion tests returned a dull sound, typical of gastrointestinal symptoms.
Zheng Ren frowned and fell into deep thought. "Chief Xia, we need a bedside ultrasound."
The self-reported medical history of cholecystectomy differed from the side-to-side choledochoduodenostomy as a predisposing factor. He had to verify it with other tests.
Even though the System had been rather reliable, as a doctor… especially one from a Class Three Grade A Hospital, he required solid evidence.
Otherwise, after the surgery, the patient's family members could file a lawsuit for fraudulent medical practices.
These things were not uncommon, but Zheng Ren had no control over them.
Regardless of his misgivings, he still had to perform the surgery and save those that needed saving.
More than ten minutes later, the doctor from the ultrasonography room returned to the ward with an emergency B-scan ultrasound trolley.
They plugged it in and closed the curtains. When the B-scan doctor began to apply the gel on the patient's stomach, Zheng Ren interjected, "Let me take a look first, alright?"
...
... Patients with liver disease typically have a darkened skin tone. This is not about physiognomy.
Chapter 310 - Douchebag
The emergency doctor from the ultrasound room recognized Zheng Ren, since most of his patients were from the emergency department.
He laughed. "Chief Zheng, are you planning to do the B-scan yourself?"
"I know a little," Zheng Ren retrieved the probe from him and moved it around the patient's abdomen to search for the location he wanted, looking closely at the image on the monitor.
There was obstruction at the far end of the bile duct. Zheng Ren switched between two different positions, lateral and anteroposterior, to confirm that the obstructions were not made of dense calculi but rather decomposing, fermented food debris.
The obstruction point matched complications from side-to-side choledochoduodenostomy and disproved the differential diagnoses of Roux-en-Y choledochojejunostomy and choledochoduodenal fistula.
It was apparent that dilation of the bile duct was the leading cause of the patient's obstructive jaundice.
There was also gas in the biliary tract as well as cysts in the liver that he strongly suspected to be liver abscesses.
All symptoms pointed to sump syndrome. From her condition, the patient required emergency surgery.
Zheng Ren put the probe back onto the B-scan ultrasound trolley and threw a piece of tissue on the patient as he thought about the procedure. "Wipe her down," he said casually.
"Chief Zheng, are you sure?" The B-scan doctor was very impressed by Zheng Ren's skill and was aware that he could never reach the man's level.
He might not have been able to do exactly as Zheng Ren had done, but the job was done, and he did not even have to lift a finger.
His question came as he wiped off
the coupling agent on the patient.
"I'm quite certain of it," Zheng Ren said, "Chief Xia, if the family members agree, let's proceed with surgical treatment. Please inform them to seek me out in the emergency ward for preoperative preparations."
"Alright." Chief Xia nodded, her expression heavy and serious.
This patient and the one who underwent TIPS surgery the night before were entirely different.
Chief Xia did not know this one personally and could not guarantee for or sign off for the emergency surgery as she had then.
She had to communicate with the patient's family members and brief them about the condition at hand, but could also hand such duties over to Zheng Ren.
Zheng Ren left the gastroenterology department, still debating between a laparoscopy or laparotomy.
A laparoscopy would leave only a small wound. Patients in the emergency ward who had undergone a laparoscopic cholecystectomy all returned home after the first night of surgery.
However, to treat all the complications in a single surgery, an open cholecystectomy would be the best choice.
Still...
"Boss, the way you threw the tissue on the patient and told the guy to do the wiping made you seem like a f*cking douchebag," Su Yun chuckled.
At a moment like this, only Su Yun was able to joke around.
Zheng Ren was shocked but immediately understood what Su Yun was implying. Being distracted had let him drop his guard.
Douchebag… tsk tsk.
How fitting. Zheng Ren was amused.
Su Yun followed up with a serious question. "What were you thinking about?"
"I'm deciding between a laparoscopy or a laparotomy."
"You have to perform a laparotomy. It's difficult to remove food debris with a laparoscope. You would also need to administer antibiotics after a surgery, which is such a hassle. Most importantly, I don't want to hold the monitor," Su Yun said frankly.
Even though Su Yun looked delicate and frail, he preferred a wide, open surgical field, which was why he had chosen thoracic surgery as a research student.
Following the minimization of general surgeries, there was a steep decrease in open thoracotomy. An incision 40 cm long was rarely seen anymore.
Zheng Ren suspected that this was Su Yun's original intent behind learning heart transplants.
"Let's opt for laparotomy, then," Zheng Ren concluded, not because Su Yun did not want to hold a monitor, but because the patient had a very complicated condition. They could require a B-scan ultrasound probe to locate liver abscesses during surgery before puncturing and draining them of pus. Furthermore, they had to treat the obstructive jaundice with all the accompanying procedures.
They both returned to the emergency ward. Old Chief Physician Pan had assigned Yang Lei to the first shift.
Chang Yue had brought the professor around each ward to speak to the patients and discuss how they had violated orders against returning home last night.
After completing the ward rounds, she noticed that patient compliance rates had at least doubled simply from bringing Professor Rudolf Wagner along.
In Sea City, it was common to bring house officers around during ward rounds. However, no one had ever seen a foreign 'house officer' before.
The ward was in total order. Zheng Ren informed Yang Lei to prepare for surgery.
Since Yang Lei had made the request that day, Zheng Ren also intended to let him take over part of the surgery to let the man improve.
It was only several months ago that Zheng Ren had to deal with Cen Meng and Chief Liu not allowing him to perform surgery.
He had never expected to now be in a position to allow someone else to do it.
Come to think of it, everything seemed too mystical.
Shortly after, Zheng Ren received a call from Chief Xia to inform him that the patient's family members had agreed to the surgery and were on their way to the emergency ward. She would send the patient to the operating room after completing preoperative assessment.
Chief Xia was very efficient at her job, which was a trait that Zheng Ren admired.
Zheng Ren did not rely on Yang Lei or Chang Yue to conduct the preoperative briefing.
The family could be unclear about the patient's medical history. Zheng Ren wanted to clarify if they had withheld it on purpose or out of ignorance.
There was a vast difference between the two.
The family did not take long to reach the emergency room. They were two middle-aged men; the patient's sons, presumably.
Zheng Ren had seen them before in the ward.
They both looked friendly and positive.
Zheng Ren questioned them about the patient's past conditions. Their body language conveyed that they lacked the pertinent medical knowledge. In addition, the patient had received her surgery many years ago, when they were still children.
After confirming his speculations, everything went according to plan.
He briefed them on all possible outcomes of the surgery and also updated them about the patient's current condition. They had no other choice but to proceed with surgery, and even that had a 30% chance of ending in failure.
When he finished, they turned white and broke into a cold sweat.
Su Yun joined Yang Lei for the operating theater after completing preoperative preparations.
The family members signed the surgery consent form, which Zheng Ren passed to Chang Yue before leaving for the operating room.
Professor Rudolf Wagner and Zheng Ren entered the operating room and changed. The professor did not once again try to persuade Zheng Ren to form a research team in Heidelberg University in Germany.
Zheng Ren did not care about the professor's true intentions, being entirely focused on the upcoming surgery.
Sump syndrome. Hopefully, it was not too serious.
As he changed, he entered the System's operating room to practice ten related general surgeries.
All the surgeries were successful, as Zheng Ren had a Master rank in general surgery with experience in hepatobiliary anatomy on top of that. Local anatomy was extremely useful.
As long as one had a strong foundation, it would be easy to learn any surgery.
After ten rounds, he was very well-versed.
He had just finished changing and entered the operating room when the sound of the stretcher trolley reached him.
"Chief Zheng, I'm going to start anesthesia. Do you need anything?" Chu Yanzhi asked.
"General anesthesia. Nothing else for now."
Chapter 311 - Sump Cleaner (Part 3 of 4)
Out of various surgical methods, an endoscopic sphincterotomy to clean the biliary tract left the fewest injuries to the patient.
Although the procedure was minimally invasive, international journal articles had reported a very high rate of recrudescence—approximately 30%.
The patient was already old; if recrudescence occurred within five to ten years, he would be in his seventies. General surgery came with great risk.
Hence, Zheng Ren ruled out an endoscopic sphincterotomy.
He not only had current symptoms to consider but also the long-term effects of treatment.
He entered the operating room just as Xie Yiren finished scrubbing in. She opened a sterile surgical bag with assistance from the circulating nurse and began preparing the machine.
"Zheng Ren, what surgical method are you using?" she asked.
In the operating room and the entire emergency ward, only two people could call Zheng Ren by his first name—Old Chief Physician Pan and Xie Yiren.
"Sphincteroplasty of the sphincter of Oddi, biliary tract cleaning and liver abscess drainage."
Xie Yiren nodded. Having multiple surgical methods was no issue to her.
She asked the circulating nurse to retrieve several instruments that could be required. If they did not have any ready to use, they could simply sterilize others with a high-pressure cooker.
Zheng Ren felt a sense of comfort as he watched Little Yiren busy
organizing and saving him plenty of trouble.
He transferred the patient onto the operating table with Su Yun and Yang Lei before Chu Yanzhi1 commenced anesthesia. The professor did not offer any help; perhaps he thought it outside his scope of duties and stayed aside out of habit.
After anesthesia was administered and the sterile sheets applied, the surgery began.
Ding dong~ The System chimed in a new mission as Zheng Ren stood before the operating table.
[Emergency Mission: Sump Cleaner
[Mission Task: Complete the surgical treatment of a patient with sump syndrome.
[Mission reward: 2,000 skill points, 25,000 experience points.
[Mission Time: 4 hours]
The mission was rather ordinary and not too difficult for Zheng Ren. He had just completed the first stage of The Crown Jewel and was thus swimming in resources.
He checked the mission and its allocated time, then reached out with one hand. A hemostatic clamp with iodine bandages was placed in it.
The surgery was broadcast as scheduled in Xinglin Garden.
[What is today's surgery about?]
[I just found out. Sump syndrome… The surgeries are getting stranger every time. I'm still familiar with most general surgical methods despite not being from the specialty, but this is my first time hearing of this.]
[It's not that rare. It's rather common in general surgery and gastroenterology departments. They will encounter this disease several times a year, mostly in patients who underwent a side-to-side choledochoduodenostomy.]
[It sounds so high-end. I'm new to this surgical method, too.]
[There are many more strange things that you've never heard of. Montreal General Hospital is one of the five largest medical institutions in the world. I've seen almost all rare cases and my guess is that were this more common, they would not have this surgery broadcast. It's a shame that, as a neurosurgeon, I only get to watch general and interventional radiology surgeries on my phone. When will I get the opportunity to watch a brain surgery broadcast?]
The broadcasting room bullet screen began crawling with comments once viewers were aware of the condition being operated on. The initial steps were nothing special: the surgeon made a 15 cm subcostal incision on the right side of the torso.
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