I Am Diagnosed as a Medical Titan

Chapter 235: Chapter 157: Surgical Forbidden Zone

Usually, during shift change, the Director’s questions were aimed at the attending physician in charge of the patient or the professor leading the team.

Asking a new hire who had just started today was completely unprecedented.

What was even more shocking was that Yang Xu’s tone was calm. It didn’t sound like he was testing him at all; it was more like... a discussion?

After a moment of thought, Jiang He said:

”The patient is currently presenting with a classic Charcot’s triad, but looking at the white blood cell and bilirubin levels, it could progress to Reynolds’ pentad at any moment. Given the history of biliary surgery, there may be anatomical adhesions and variations. Simple anti-infective treatment can only suppress the surface symptoms. Considering how high the white blood cell count is, toxemia could worsen at any time. ERCP is the first choice, but if ERCP intubation fails or the drainage is ineffective, we need to be prepared for an open common bile duct exploration and T-tube drainage at a moment’s notice. I suggest we prepare a blood supply and have the operating room keep an emergency table free.”

After listening, Yang Xu had only one thought.

’As expected of my student. His thinking is identical to mine!’

He nodded. ”Excellent. We’ll proceed with that plan. Continue the handover.”

Meng Shiyu broke out in a cold sweat listening to this.

When the Director had asked his question, he had also formulated a hypothetical answer in his mind.

But his own answer had been stumbling and not very good at all.

But Jiang He... with barely a moment’s thought, had given a flawless answer.

What kind of on-the-spot reaction time was that?

Meng Shiyu was now genuinely impressed.

’Jiang He really has the goods!’

The handover ended quickly, and it was time for rounds.

The team of doctors filed out of the office.

Director Yang walked at the very front, with the team-leading professors following close behind.

Jiang He had planned to fall back to the end of the line, but Director Yang pulled him to his side.

”You stay with me. We’ll look at a few high-priority patients,” Director Yang said.

Meng Shiyu very consciously walked to the very back of the group, squeezed in with a few interns while pushing the medical records cart used for rounds.

He had now completely accepted his new identity.

’Boss Jiang He’s sidekick!’

Rounds lasted for nearly an hour and a half.

After returning to the doctors’ office, everyone dispersed to write progress notes, issue medical orders, and handle admissions and discharges.

Director Yang had to go to the outpatient clinic. Before leaving, he told Jiang He, ”You just got here today, so don’t rush into managing patients. Log into the system and familiarize yourself with the current distribution of diseases in our department. If there’s anything you don’t understand, ask the others.”

”Okay, Teacher,” Jiang He replied.

After Director Yang left, the atmosphere in the office relaxed considerably.

Jiang He was led to an empty computer and sat down.

This would be his desk from now on.

He entered his employee ID and password and opened the system.

The Hospital Information System’s interface from 2008 was still quite rudimentary, featuring a blocky blue background, simple white text, and clunky navigation.

After changing his password, Jiang He opened the inpatient list for the hepatobiliary surgery department.

Meng Shiyu quickly came over, stood just behind and to the side of Jiang He, and asked, ”Teacher, what do you need me to do?”

Jiang He glanced at him. ”Go to the nurses’ station and get today’s lab reports for beds one through twenty. Sort them by category, then arrange them on my desk in order of bed number.”

”You got it, right away.” Meng Shiyu accepted the task and hurried out.

Jiang He’s gaze returned to the computer screen.

The national-level P3 laboratory had been approved, and the SAP paper had been published.

On the academic and research fronts, his progress was already far ahead of the curve.

But on the clinical side, he was still lacking something.

Affiliated Hospital No. 1 was the top hospital in the city, and its hepatobiliary surgery department was full of hidden talents.

Although he currently had the halos of being Director Yang’s star student and the author of the LNR paper, and had even made a name for himself in the car accident emergency rescue, it wasn’t enough.

The night of the car accident had demonstrated his ability to manage emergency trauma.

Hepatobiliary surgery, on the other hand, was a true test of fine anatomical skill.

If he wanted to establish an irreplaceable clinical position in the department,

then he had to tackle it from two angles.

Routine cholecystectomies—he had to do them, and he had to do them fast and well.

And second, most importantly, he had to find the tough nuts to crack—he needed to conquer more difficult and complex cases.

Jiang He began to go through the electronic medical records of the current inpatients one by one.

Bed five, common bile duct stone with cholangitis. Skipped.

Bed eight, primary liver cancer. Tumor located in the right posterior lobe, 4 cm in diameter, intact capsule, no vascular invasion. Skipped.

Bed fifteen, severe pancreatitis, recovery phase. Currently in conservative observation. Skipped.

Jiang He scanned through them at an extremely fast pace.

Unfortunately, after looking through more than a dozen, he still hadn’t found a case that met his requirements.

Most patients had clear diagnoses and well-established surgical plans; there was no need for him to get involved.

Meng Shiyu returned with a stack of lab reports and placed them by Jiang He’s hand. ”Teacher Jiang, I’ve got them all. I’ve circled the abnormal values in red pen.”

Jiang He nodded. ”Just put them there. Now go get the ones for beds thirty through fifty.”

”Okay.” Meng Shiyu turned and left again without a single complaint.

Jiang He continued to scroll with the mouse wheel.

Suddenly, he froze.

His eyes were fixed on the information for the patient in bed forty-two.

[Patient Name: Zhao Youcheng. Male, 58 years old.]

[Chief Complaint: Painless, progressive jaundice with cutaneous pruritus for over a month.]

Jiang He opened the admission record and scanned it quickly.

One month ago, the patient developed scleral and cutaneous icterus with no obvious cause, along with darkened urine, loss of appetite, and weight loss.

He was treated for hepatitis at a local county hospital for half a month, but his jaundice worsened instead of improving, so he was transferred to Affiliated Hospital No. 1.

[Physical Exam: Deep jaundice of the skin and sclera. Abdomen flat and soft, no obvious tenderness in the right upper quadrant, Murphy’s sign negative, no palpable enlarged gallbladder.]

[Laboratory Tests: Total bilirubin 385.4 μmol/L, direct bilirubin 312.6 μmol/L, alkaline phosphatase (ALP) 450 U/L, gamma-glutamyl transferase (GGT) 680 U/L, tumor marker CA 19-9: 450 U/mL.]

Seeing this, Jiang He’s brow furrowed slightly.

A classic presentation of obstructive jaundice, with predominantly elevated direct bilirubin.

The gallbladder wasn’t palpable, which indicated the obstruction was located above the junction of the cystic duct.

CA 19-9 was mildly elevated, but considering that severe jaundice and biliary tract infections can also cause a false elevation of CA 19-9, this value couldn’t directly confirm a malignant tumor.

He immediately opened the imaging report.

The PACS system from ’08 was slow to load images. A loading icon spun in the middle of the screen for more than ten seconds before the abdominal contrast-enhanced CT images finally appeared.

Jiang He skipped the text report issued by the radiology department and examined the raw images himself.

The liver was slightly enlarged, and the intrahepatic bile ducts showed a distinct, branch-like dilation.

Following the dilated ducts downward, he found an irregular, low-density mass at the hepatic hilum, where the right and left hepatic ducts converge.

Hilar cholangiocarcinoma (a Klatskin tumor).

Jiang He continued to look.

This was the most critical part of the entire case.

On the arterial and portal venous phase images of the contrast-enhanced CT, the tumor not only invaded the confluence of the right and left hepatic ducts but also spread inward along the left hepatic duct while also invading the secondary branches of the right anterior and right posterior hepatic ducts.

In the Bismuth-Corlette classification, this was the worst-case scenario: a Type IV.

Not only that, but the posterior aspect of the tumor was adhered tightly to the main portal vein and had encased the right hepatic artery.

Jiang He exited the CT interface and opened the patient’s progress notes.

The latest entry was from yesterday afternoon, written by the attending physician in charge of the case, Lin Haibo.

[Intradepartmental Discussion Today: Patient is diagnosed with hilar cholangiocarcinoma (Bismuth Type IV). The tumor has extensive invasion, encasing the main portal vein and right hepatic artery. It has been determined that the tumor is unresectable for cure (extremely low R0 resection rate). A forced attempt at surgery would require a hemihepatectomy and caudate lobectomy combined with vascular reconstruction, carrying an extremely high risk of postoperative liver failure. Furthermore, the patient has severe jaundice and poor hepatic reserve function. Overall assessment: no indication for surgery. Plan is to perform percutaneous transhepatic cholangial drainage (PTCD). The patient’s family has been informed of the condition and prognosis. They have expressed understanding and requested discharge to return to their local hospital for palliative care.]

Jiang He stared quietly at the text.

Lin Haibo’s assessment was perfectly sound.

A Bismuth Type IV hilar cholangiocarcinoma with major vascular invasion was a textbook contraindication for surgery.

If you resected it by force, how would you reconnect the severed blood vessels?

After removing more than half the liver, the remaining liver volume would be insufficient, and the patient would die of acute liver failure right on the operating table...

But in Jiang He’s eyes, this might not be a dead end.

He reopened the imaging interface and began to use the on-screen ruler to meticulously calculate the liver volume.

The total liver volume was approximately 1200 ml.

Jiang He calculated silently in his head.

’The tumor is mainly invading the left hepatic duct and the right-sided secondary branches. The portal vein isn’t actually completely invaded.’

He zoomed in on the image.

’It doesn’t look like tumor infiltration, but rather dense adhesions caused by long-term biliary obstruction and inflammation.’

’There’s a gap here, at the right branch of the portal vein.’

’As for the right hepatic artery... it’s definitely encased. It’ll have to be resected.’

’But I can free up the gastroduodenal artery (GDA), flip it up, and perform an end-to-end anastomosis.’

He quickly formulated a surgical plan in his mind:

An extended left hemihepatectomy combined with a total caudate lobectomy, along with resection of the involved lateral wall of the portal vein with suture repair, followed by reconstruction of the right hepatic artery using the gastroduodenal artery.

After resection, the remaining right posterior lobe and part of the right anterior lobe would have a volume of about 550 ml.

The future liver remnant (FLR) would be 45% of the standard liver volume. The patient has no underlying cirrhosis, so a 45% volume is sufficient for compensation, and postoperative liver failure wouldn’t occur.

But there was still one minefield: the patient’s current total bilirubin was 385.4 μmol/L.

Therefore, before the surgery, it would be best to first perform a targeted PTCD (percutaneous transhepatic cholangial drainage) of the right intrahepatic bile duct to reduce the jaundice. Get the total bilirubin below 80 μmol/L, or even around 50 μmol/L, to give the liver a two-to-three-week-long breathing period. Wait for the liver function to recover compensatorily into a safe window, and then deliver the final blow.

In summary: first, targeted jaundice reduction, then, an ultimate curative resection.

Jiang He narrowed his eyes.

This case was terrifyingly difficult.

It not only involved complex liver anatomy but also included highly difficult vascular anastomosis.

If he could pull off this surgery and achieve an R0 (no microscopic residual tumor) resection,

he would not only firmly establish his authority at Affiliated Hospital No. 1 but could even shake the entire field of hepatobiliary surgery in the country.

Of course, the most important thing was...

he could save this patient.

Just then, footsteps approached.

The attending physician, Lin Haibo, walked over. ”Jiang He, Director Yang asked me to show you the ropes. Feel free to ask if there’s anything you don’t understand.”

He glanced at the images on Jiang He’s screen.

”Looking at bed forty-two?”

”Yeah, just browsing. Teacher Lin, is this your patient?”

”Yeah. Only fifty-eight years old. His wife came with him. This disease is too vicious. It was already late-stage when they found it. Type IV, vessels all encased. There’s no way to operate.”

”What’s the family’s attitude?”

”What attitude could they have? We talked yesterday afternoon. The old woman cried so hard in the office she could barely stand. They’re from the countryside, family’s not well-off. They’ve already borrowed a lot of money just to come here for treatment. I told them surgery isn’t an option, that we could only place a stent to relieve the jaundice, and they’d live a few more months, however many that might be. The old woman couldn’t bear to spend the money. She said since it’s incurable, they won’t do the stent. They’re processing the discharge first thing tomorrow morning to go home and wait it out.”

In clinical practice, this kind of helpless situation played out every day.

As a doctor, Lin Haibo had long since grown used to it.

But every time he encountered it, his heart still felt heavy.

”These scans, has the Director seen them?”

”Not yet. The Director has been busy lately. I don’t think there’s any need to show him these scans. The risk is too high. Not to mention we couldn’t get a clean resection, if we actually got him on the table, it’s highly likely he wouldn’t make it off. And with their financial situation, the family can’t afford a long stay in the ICU. Don’t bother with this one. In a situation like this, nobody can do anything. If you want to learn something, go look at the scans for the liver cancer patient in bed eight. I’m the lead surgeon for that one tomorrow. If you’re free, you can come to the OR and hold a retractor for me.”

Lin Haibo’s words were well-intentioned; seeing that Jiang He was new, he was willing to mentor him.

But Jiang He didn’t respond to Lin Haibo’s invitation. His gaze never left the complex anatomy of the hepatic hilum on the screen.

After a moment, he said softly:

”Teacher Lin, I think this tumor... is resectable.”