Come on, Dr. Wu

Chapter 362 Another rare case
"What else can we do? We need to communicate well with the patient and his family, obtain their consent, and then conduct the examination immediately.

While looking at the nature of what is cut off, check whether it is metastatic cancer or cancer in situ.

Do you think this is carcinoma in situ or metastasis?"

Cheng Shi and the others looked at each other and became much more cautious. To be honest, although Wu Xiaofu was only talking about other people's examples, it was enough to alert them. No one could guarantee that they would not encounter such a thing in the future.

As a doctor, you should not only learn lessons from your own experience, but also from others.

After all, no one wants to suffer the consequences themselves.

They have already learned their lesson. If they are still not cautious, they are really not suitable to be doctors. Therefore, when facing Wu Xiaofu's problem, they must be cautious.

"Metastatic cancer?"

This was their unanimous answer, because the possibility of primary appendiceal adenocarcinoma is really very small, and most of them are metastatic. Just like their usual thinking, they have to pick the one with the highest probability.

Wu Xiaofu nodded, "Yes, it is metastatic cancer, it was transferred from the lungs, distant metastasis, which no one expected. If it was transferred from the gastrointestinal tract, liver, etc., it would be fine. A CT scan may have been done before, and some of it might be seen, but for the lungs, my friend was really not prepared.

The tumor on the lung is not big, it is squamous cell carcinoma, and the only metastasis is to the appendix. It can be treated with surgery, but he has just undergone surgery and is already old, so surgery is definitely not possible in the short term. But if it is delayed for too long, what if the condition becomes more serious?

My friend is very conflicted. Every time he talks about it, he feels regretful. He says that if he had been more rigorous and performed a more thorough preoperative examination, this wouldn't have happened.

In the end, I had surgery. As for what happened afterwards, I won’t go into details.”

Needless to say, everyone knows the outcome of the tumor, not to mention it was in the late stage. Although the patient underwent surgery, he only survived for two years.

The case Wu Xiaofu described really shocked Cheng Shi and the others. It gave them a lot to think about. In fact, there is no harm in having more examinations. Of course, not all families can afford so many examinations.

For these patients, they should think more and not do too many tests, but they should also use their basic knowledge to eliminate all hidden dangers. If they really feel suspicious now, they still have to do what needs to be done.

The outpatient clinic was still going on, and Cheng Shi and the others didn't have time to think for too long.

After the next patient finished his session, Wu Xiaofu would almost always say a few more words to them, either giving examples or some knowledge that they did not learn in textbooks or that they were not exposed to in their daily lives.

This made Jiang Bei sigh even more fortunately that she did not miss classes.

If she missed it today, she would regret it for the rest of her life and lose out on billions.

It was almost the end of the outpatient clinic, at 9:17, Wu Xiaofu and his colleagues were preparing to go off work, but they received an emergency call.

He said he wanted to have a patient come up to see him.

In fact, this happens quite often. When encountering difficult patients in the emergency department, it is common to ask for a consultation or directly send the patient to the outpatient clinic. This is especially true if the patient asks who he wants to see.

Wu Xiaofu saw that the outpatient clinic was over, but he didn't let the patient come up and told him to go down.

This is even better, as it saves the patient from making a trip, and the emergency department will certainly not refuse them.

Cheng Shi and four others also followed. This was a middle-aged male patient. When Wu Xiaofu came, the emergency department had already arranged some tests. The patient was 53 years old and had a history of hypertension for more than ten years.

Whether it is an emergency room or an outpatient clinic, when a patient comes, we have to ask the patient whether he or she has any underlying diseases. Hypertension and diabetes cannot be left out. On the one hand, it affects medication, and follow-up treatment must also consider these issues. Patients with underlying diseases such as long-term hypertension and diabetes often have some complications in their bodies.

It is very likely that the illness you are suffering from this time is a complication caused by these underlying diseases.

The patient came with sudden abdominal pain and bloating. Before coming to the First Affiliated Hospital, he had been to the local health center, traditional Chinese medicine hospital, and county hospital. He had a gastroscopy there, which revealed blood accumulation in the duodenum and intestinal necrosis. With such a serious condition, the patient's family members did not want the local hospital to treat it, so they went straight to the district hospital.

He had blood in his stool on the way. After arriving at the district hospital, his abdominal pain and bloating became more severe. After a careful examination, it was found that diseases such as enteritis and intestinal obstruction must be treated conservatively, and surgery cannot be performed right away.

The district hospital also made the same arrangement, but the anti-inflammatory treatment at the outpatient clinic was not effective after a few days, and the inflammatory indicators in the blood draws were getting higher and higher.

When the patient's family saw that this was not working, the district hospital recommended surgery. However, the family still felt uneasy, so they went straight to the First Affiliated Hospital.

Wu Xiaofu examined the patient's physical condition and found a bulging abdomen and signs of pan-abdominal peritonitis.

I had a blood test in the emergency room, and the blood routine test showed elevated white blood cells and neutrophils, which are indicators of inflammation, and my hemoglobin was also low.

Coagulation function indicators were also abnormal.

The blood biochemical C-reactive protein is also high. This series of blood indicators indicates that the patient's body inflammation has reached a certain level of severity.

Since the patient has already undergone a series of anti-inflammatory conservative treatments in the district hospital and the results were poor, there is no point in continuing with these treatments in the First Affiliated Hospital and surgical treatment is the only option.

While Wu Xiaofu was preparing for the surgery, he asked the emergency department to take the patient for a superior mesenteric artery CTA to check for blood clots. The patient had had intestinal obstruction for some time, so the problem of blood clots must be considered. You know, surgeries with and without blood clots are different.

After the film was taken and a closer look was taken, it was found that the proximal blood vessels of the jejunum were suddenly cut off, so thrombosis must be considered.

This is a clear surgical acute abdomen with peritonitis, intestinal necrosis, gastrointestinal bleeding, and peritoneal effusion and blood.

The operation was urgent, so Wu Xiaofu did not delay and went straight to the operating room to take the patient. Of course, before that, he still had to communicate with the patient's family.

After all, the surgery requires cutting a section of the intestine, and, considering the patient's condition, it will have to be a fairly large section.

The location of the patient's necrosis is close to the duodenum. If he wants to be safe, he may have to move the duodenum, which will cause even greater damage. Even if Wu Xiaofu is confident that he will not move the duodenum, he still has to explain it to the patient.

When they heard that the patient needed to have his intestines removed, their family members immediately started crying.

The patient needs to have his intestines removed. He is only 53 years old. After the intestines are removed, they won't grow back. Will there be any complications in the future? What if he can't digest food?
Although Wu Xiaofu said that these are not things to worry about after recovery, the patient's family members still have to consider these things in their habitual thinking.

Fortunately, after visiting several hospitals, the patient's family also realized the seriousness of the patient's condition, otherwise, they would not have come to the First Affiliated Hospital.

Surgery is definitely necessary. When they heard that Wu Xiaofu was in the hospital, they took the initiative to ask if Wu Xiaofu could take a look. Now that Wu Xiaofu has given his opinion, they naturally cannot ignore his kindness.

Although it was heartbreaking, I still felt very happy when signing.

After a while, it was already ten o'clock when I entered the operating room.

Although it was so late and they had to work overtime, Cheng Shi and the others were actually very happy. Wu Xiaofu took them to the surgery and only took them with him, not anyone else.

Doesn't this mean that they might be able to get a chance to become assistant surgeons? "Tell me, what is the cause of the patient's intestinal necrosis?"

Cheng Shi and the others were already completely accustomed to the fact that they could take tests at any time and in any place. They could think directly without any panic.

"The proximal part of the necrotic jejunum is the ascending part of the duodenum, with an obvious ischemic line. Could it be an incarcerated paraduodenal hernia?"

"The patient has a 10-year history of hypertension. Long-term hypertension may lead to acute arterial embolism, which may cause intestinal necrosis."

"The patient's preoperative CT scan did not show main trunk embolism. It is also possible that the patient's intestinal inflammation led to the possibility of collateral embolism of the proximal jejunal artery."

……

Several people expressed their opinions, and Wu Xiaofu nodded without denying any of them. After the operation, they would know.

At 10:15, anesthesia was completed and the operation began.

It was a laparoscopic surgery, and Cheng Shi held the mirror. Cheng Shi and Jiang Bei arrived first, so if they were to be given a chance, they would definitely be given first. Jiang Bei was on the night shift yesterday, and even if Wu Xiaofu was bold enough, he would not give the mirror to her after enduring until now, so Cheng Shi had to be his assistant.

Jiang Bei was also a little annoyed. Why did she have to work the night shift yesterday when she had such a good opportunity? It was a good opportunity for Cheng Shi.

She had no complaints. The concept of being responsible to patients had been implemented to the end in her many years of medical career. Even if Wu Xiaofu asked her to do it, she would refuse. After all, she had been up all night and a whole day. Although she could open her eyes, her movement sensitivity was definitely not up to par. She couldn't hold Wu Xiaofu back in such an operation.

Laparoscopic puncture and pneumoperitoneum.

After Wu Xiaofu separated the tissues for a while, everyone was finally able to see the condition of the patient's intestinal cavity.

Cheng Shi is a man of big heart and calm personality. Wu Xiaofu tells him where to point the mirror and he can basically do it. It seems that he has experience in holding the mirror before, which makes Wu Xiaofu feel more at ease.

The patient's intestinal necrosis is very severe, especially in the upper part of the jejunum. Fortunately, the boundary with the duodenum is still very clear, so it does not need to be moved. The broken ends can be connected.

Because the inflammation has existed for some time, the patient's intestinal tissue adhesions are also very serious, which looks scary.

The necrotic part is congested and necrotic, and it is bulging and has accumulated a lot of things.

Even with laparoscopic surgery, a strange smell is inevitable.

At this time, it is difficult to carefully peel off the adhesions of intestinal tissue near the necrosis, because if you are not careful, the intestinal cavity will be damaged and the contents will flow out, which will be terrible. If it flows into the abdominal cavity, the chance of subsequent infection and inflammation will increase. The intestinal cavity is already difficult to recover, and adding such infection factors will increase the possibility of subsequent complications.

So, be careful.

It is not without reason that enema is performed first when doing gastroenteroscopy or something like that. Fortunately, this is looking from the outside in, not from the inside of the intestinal cavity outward. Otherwise, given the accumulation in the intestinal cavity, basically nothing can be seen.

After all the separations were completed, the cause of the patient's intestinal necrosis was actually revealed.

Looking at the situation in front of them, Cheng Shi and the others were also surprised. It was the first time they had seen it. Not to mention seeing it with their own eyes, they had never seen it in videos or books.

It turned out to be a hernia sac.

"Paraduodenal hernia!"

Wu Xiaofu was also a little surprised. It was the first time he had seen this type of hernia.

Paraduodenal hernia is congenital and can cause abdominal pain and vomiting. It can also cause incarceration necrosis. It is divided into left-sided and right-sided types.

The reason for this situation is that during embryonic development, part of the intestine and intestinal loops are wrapped in the retroperitoneal recess next to the duodenum, which is also called mesenteric hernia, congenital mesocolon hernia and retroperitoneal hernia.

Because it is caused by abnormal intestinal rotation during the embryonic period, it is a congenital intra-abdominal hernia, which is more common on the left side.

In the right-sided type, the proximal end of the jejunum enters the right side behind the superior mesenteric vascular bundle.

Left-sided type: the proximal end of the jejunum enters the left space behind the inferior mesenteric vein.

The patient in front of us is of the left type.

"You didn't work in vain today. I've been doing surgery for so long, and this is the first time I've seen a situation like this. You may only see this once in your lifetime. If there are related topics in the future, you can talk about it."

Several people nodded after hearing this, and some even looked a little excited.

Not to mention the future, after they go back, they will have something to talk about with the people around them. In medicine, when encountering such a rare situation, no matter who talks about it, it is very face-saving. The most important thing is that if they really encounter it again in the future, they will not be helpless. Moreover, the next time Wu Xiaofu asks about the possible cause of intestinal obstruction based on related cases, they will be able to answer this possibility.

However, this sudden change also added some difficulty to the operation.

Since it is caused by paraduodenal hernia, it is not enough to just remove the necrotic intestine. The paraduodenal hernia must be resolved first.

However, whether it is an external hernia or an internal hernia, it is not difficult to solve.

Open the hernia sac, put the jejunum inside the hernia sac back to its original position, then close the hernia sac, done.

Of course, the suture must be done well to prevent hernia from occurring again later. Otherwise, even if it is solved this time, hernia may occur again in the future.

After resolving the hernia, start resolving the necrotic part of the intestine.

When performing the removal, you need to use a bag to protect it to prevent foreign objects in the intestinal cavity from getting everywhere. Therefore, you cannot rush the removal and must be very careful instead.

After removing the necrotic part and seeing that the edge of the retained intestinal cavity is rosy and the blood circulation is good, you can feel relieved and finally perform anastomosis of the broken ends.

This actually depends a lot on the surgeon’s skills.

After many doctors have completed the suturing, necrosis, intestinal leakage, etc. will occur, and a second laparotomy is not uncommon because of this suturing technique.

Of course, there is definitely no problem with Wu Xiaofu. Now Wu Xiaofu's suture skills are recognized as good.

Take out the necrotic intestinal cavity, flush the abdominal cavity, put in drainage, close the abdomen, done.

(End of this chapter)