Chapter 297: The Crown Jewel (Part 1 of 4)
“An emergency?” Su Yun frowned at the mention of the transjugular intrahepatic portosystemic shunt (TIPS) surgery.
The TIPS surgery was hands down the most difficult type of interventional surgery.
Of course, there were many new surgical methods that required certain medical facilities to pull off; the prostate interventional embolization, for example. These surgeries were already considered difficult, but the TIPS surgery demanded the most skill.
“There is a patient in the gastroenterology department, a friend of Department Chief Xia’s, with complications. They had arranged for a surgery in Imperial Capital Hospital but the patient started vomiting blood and is now in critical condition,” Zheng Ren explained as he rose from his seat and put on his white coat, shooting Xie Yiren an apologetic look.
Xie Yiren gave him a wave of support. Her brown-eyed gaze softened as she watched Zheng Ren hurriedly dress for duty.
Reassured, Zheng Ren strode confidently out of the on-call room.
“Can you perform the surgery?” Su Yun asked when he caught up.
“I can try.” Zheng Ren had never done it before but had some training time saved up in the System. He was willing to spend all his points to save a life.
Postsurgical care was the most complicated part of a TIPS surgery.
To address decompensated cirrhosis and its resulting symptoms, esophageal varices and splenomegaly, there were two methods: the first was a splenectomy and porto-azygos disconnection. The second method was TIPS.
This surgery had barely 30 years of history in a clinical setting.
A German research team, headed by Richter, was the first to perform a transjugular intrahepatic portosystemic shunt surgery in 1988. In 1991, they published a paper detailing 16 successful procedures.
Later, Zemel (1991) and Ring (1992) also reported success.
In 1993, the procedure was introduced to other countries.
The first TIPS surgery locally was performed at the turn of the 21st century by Professor Xu Ke’s team from China Medical University.
To this day, the procedure was rarely used in hospitals.
Why?
It was difficult.
Extremely difficult.
Moreover, the post-surgery survival rate was not high.
However, if the patient managed to recover, the benefits of having a shunt in place were huge.
Su Yun had recently started reading up on interventional radiology-assisted procedures and knew that TIPS was the crown jewel of interventional surgery.
Was Zheng Ren going to try it now? Did the hospital even have the necessary instruments and materials?
“Do we have the necessary items?”
“I’ll call Manager Feng,” Zheng Ren said as he scrolled through his phone contacts.
“Manager Feng, it’s Zheng Ren.
“We’re starting a TIPS surgery. Please send over the relevant materials immediately.
“Yes. Old Chief Physician Pan will handle the procurement documentation tomorrow.
“We need it in an hour!”
He hung up.
“Are you confident with post-surgery care?” He said, his footsteps quickening.
Su Yun recalled the TIPS procedure and its risks. “If we can’t prevent hepatic encephalopathy, we can only prescribe amino acids to hopefully control its progression.”
The key lay in managing the potential onset of hepatic encephalopathy.
Zheng Ren mulled the risks over as they arrived at the gastroenterology department.
Department Chief Xia felt some embarrassment when she saw him.
Their first meeting had involved the floating gallbladder.
After Zheng Ren was proven correct, Department Chief Xia had been reluctant to cross paths with the emergency department chief resident.
Even for emergency procedures, she called up Old Chief Physician Pan instead… It was the proper channel to go through as favors were traded among department chiefs.
“Good day, Chief Xia. May I know which room the patient is in?” Zheng Ren asked with a neutral expression. There was no pride or sarcasm in his tone. It was as if their previous encounter had never happened.
“Right this way.” Department Chief Xia put aside her misgivings for the chief resident and brought the two doctors to the resuscitation room.
It was a male patient in his fifties with jaundice-yellow skin and a deathly miasma surrounding him. He held a basin in his hands to catch the dark venous blood pouring from his mouth.
It was like a scene from hell.
The strong stench of blood filled the room. Zheng Ren glanced at the System’s display.
It gleamed a dangerous red.
The System diagnosed hemorrhagic shock, decompensated cirrhosis, refractory ascites, hydrothorax and electrolyte imbalance.
This patient had just recently undergone a splenectomy and porto-azygos disconnection…
Zheng Ren had been deciding between two procedures but was now left with one.
“The vomiting started three days ago. He had just come out of a splenectomy and porto-azygos disconnection surgery, hence the conservative treatment. We managed to control the bleeding with a combination of three hemostatic drugs and epinephrine, but when we were calling the ambulance for a transfer to Imperial Capital, the patient started vomiting large amounts of blood.”
A cocktail of three hemostatic drugs alongside epinephrine was an extreme measure.
Administering more than three drugs only increased the risk of complications. A cerebral or myocardial infarction could worsen things.
Zheng Ren took a deep breath and calculated his remaining intensive training time.
After all, the TIPS surgery was the toughest procedure in the world of interventional surgery. Zheng Ren was not confident in his current abilities.
Department Chief Xia took note of Zheng Ren’s sigh. An anguished smile crossed her face as she said, “I’m sorry it had to be you, but you’re the only interventional surgeon we have in the hospital.”
Her tone was unexpectedly sympathetic, but her reasoning was sound. Zheng Ren understood her feelings on the matter.
“Even a 10% chance is better than none.” Department Chief Xia explained, “The patient was once my classmate, and his wife is also from the same school. Don’t worry, Dr. Zheng. No one will hold it against you if you do not succeed.”
The last sentence was to reassure Zheng Ren.
Either they performed an emergency TIPS surgery or the patient would vomit blood until he died.
A few more minutes of hematemesis violent enough to paint the floor and ceilings red, and the man would be gone.
If a standard TIPS surgery was a ten out of ten on the scale of difficulty, an emergency TIPS surgery would be an 11.
“Chief Xia, to be honest, I’ve never performed the procedure. The patient is in critical condition without any viable options. I can try my best, but there’s no guarantee,” Zheng Ren said.
“Thank you,” she said sincerely.
Having a department chief say those words in front of the patient’s family was a testament to Zheng Ren’s abilities.
Su Yun smirked triumphantly.
In contrast, Zheng Ren’s eyebrows creased in worry.
“Do you have the materials needed?” Department Chief Xia cut to the chase.
“I’ve spoken to the supplier. It should be here in less than 20 minutes. Let’s prep the patient and the consent form…”
“I’ll sign for it,” Department Chief Xia interjected.
She seemed very close to the patient and his wife.
“Alright. Let’s prepare for surgery,” Zheng Ren said.
A bell then rang in Zheng Ren’s ears.
[Main Mission: The Crown Jewel – First Stage
[Mission Details: Complete the most challenging procedure in the field of interventional surgery: the transjugular intrahepatic portosystemic shunt surgery.
[Mission Reward: The average completion time for the TIPS surgery is 4 hours and 23 minutes. No special reward will be given if the host exceeds it, but if the host completes the procedure in less than that, the reward will be bountiful.
[Rewards include +2 luck points, two gold chests, 200000 experience points.
[Mission Duration: 6 hours.]
Zheng Ren had planned to ignore the mission but a quick scan through the details made his eyes pop.
The luck points on top of the experience points reminded Zheng Ren of his time in Imperial Capital, and the System promised even more rewards if he finished the surgery early.
Was the TIPS surgery a main mission?
In the world of interventional surgery, TIPS was the ultimate challenge. Zheng Ren felt that he would have to unlock the entire skill tree before he could even attempt a TIPS surgery.
Main mission… Sure.
He wondered what the main mission was for general surgery.
This would be his first attempt at the procedure. Whether it was to save a life or to accomplish a mission, he would have to plan his approach carefully.
He still had some experience points that could be exchanged for training time. It would have to do.
Zheng Ren went through each step of the procedure in his head.
On the surface, the surgery was simple.
Under local anesthesia, access would be gained through the right jugular vein. The guide wire, guide catheter and angiographic needle would then be maneuvered to the hepatic vein, where the needle would be used to puncture the portal vein for stent placement, building a lasting connection between the portal and hepatic veins.
The difficulty lay in puncturing the portal vein and establishing said connection.
The puncture would be performed without any visual assistance. It was up to experience and luck.
Luck played a huge factor in TIPS surgeries, regardless of the skill of the surgeon.
That was why it was the crown jewel of interventional surgical achievement.
Zheng Ren was trying to figure out how to minimize reliance on luck.
As someone who had not even bothered trying his luck with the System’s treasure chests, Zheng Ren was not willing to let it determine his success at the operating table.
Su Yun was a step behind him and noted his slower pace. Zheng Ren seemed deep in thought. “Are you sure about this?”
“No one can be 100% sure about anything,” Zheng Ren replied.
“Professor Rudolph Wagner is sleeping in Shangri-La Hotel,” Su Yun reminded him.
“Oh…” Zheng Ren had forgotten about the professor.
The professor was one of the world’s top interventional surgeons. It would be wise to invite him to assist in the surgery.
Zheng Ren nodded and pulled out his phone.
It rang for a good 30 seconds before the professor picked up. “Professor Rudolph, it’s Zheng Ren.”
Zheng Ren ignored the sleepily-mumbled German greeting and got straight to the point.
“We have a TIPS surgery now. Please come and have a look.”
He hung up without any additional explanation.