The Surgeon's Studio

“We’re here to check on the patient after TIPS surgery.” Zheng Ren smiled warmly. “Which ward is he in?”

Chief Xia did not continue her ward rounds, personally bringing Zheng Ren to the resuscitation room.

The patient had managed to sit upright. Despite looking languish with a pallid complexion, the darkened skin on his face had returned to normal.[1]

“The patient vomited blood three times since last night. It was not much; approximately 150 mL. We think it was the stale blood accumulated in his stomach,” Chief Xia reported, “Tests this morning showed that hemoglobin levels have returned to 79 g, coagulation remains slightly weak and blood ammonia is 63. After an examination, there were no typical symptoms of hepatic encephalopathy.”

Since the patient had been implanted with two stents, pressure on the gastric varices was reduced but not completely relieved.

As long as bleeding stopped, other symptoms could be controlled with hemostatic drugs and orally administered cold saline-epinephrine solution.

Zheng Ren was more concerned about hepatic encephalopathy, though.

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 accumulation 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?”

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[1] Patients with liver disease typically have a darkened skin tone. This is not about physiognomy.