Chapter 192 - 174: The Rare Mirizzi Syndrome

Chapter 192: Chapter 174: The Rare Mirizzi Syndrome

Jinggang University Affiliated First Hospital.

In the Hepatic Tumor Surgery and Hepatobiliary Surgery departments, a video titled "Emergency Treatment for Traumatic Liver Rupture" had recently gone viral. Because the doctor who posted it on the forum had intentionally obscured the details, no one knew which hospital or department the surgeon was from.

However, many people had analyzed the previous posts by the user "Wielding the Lancet." They concluded the blogger was likely a top expert from Jin Province Tumor Hospital. The quality of his posts was always high, and this one, in particular, had been featured by the forum moderators, garnering astonishing popularity.

Liu Xingye, an attending physician in the Hepatic Tumor Surgery department, had also watched the surgeon’s procedure several times and was completely in awe.

’Amazing. Truly amazing. I wonder who this doctor is. I never expected the Provincial Tumor Hospital to have someone so talented!’

’Performing an abdominal paracentesis right in the ambulance, followed by a bedside ultrasound, and then daring to open the abdomen to repair the liver rupture and resect the necrotic tissue intraoperatively. That’s boldness born of consummate skill!’

Liu Xingye saved the video, planning to send it to the department’s group chat for everyone else to admire.

Just then, his phone rang. Liu Xingye took it out and saw it was a call from Dr. Wang Nanjin of the Hepatobiliary Surgery department.

Liu Xingye answered immediately.

"Dr. Liu, I’ve admitted a patient with gallstones. However, the physical exam results aren’t looking good. We suspect the possibility of liver cancer and would like you to come over for a consultation."

"If it’s early- to mid-stage liver cancer and still controllable, we can do a two-stage procedure. Stage one would be to deal with the gallstones. If the diagnosis is grim and it’s late-stage liver cancer, we’ll have to proceed directly with the resection of the liver tumor."

Hearing Wang Nanjin’s words, Liu Xingye checked the time. He was free today, so he readily agreed.

Although Wang Nanjin was only a regular attending physician in Hepatobiliary Surgery, his potential and talent were undeniable. He was also a junior colleague whom Shen Xiaofei held in high regard, so Liu Xingye was happy to stay in touch.

After all, once Director Fu and Director Shen retired, their generation of young doctors would become the backbone of the department. Building good relationships early on would certainly be beneficial for their future careers.

Liu Xingye arranged his current work and immediately headed for the Hepatobiliary Surgery department.

He hadn’t expected to run into Wu Ting, who was just saying goodbye to Director Shen Siyuan, right as he stepped out.

"Dr. Wu, here to see Director Shen again today?"

Wu Ting was also very familiar with Liu Xingye and nodded. "Dr. Liu, where are you off to in such a hurry?"

Liu Xingye briefly explained the situation. Then he remembered that Wu Ting had a unique diagnostic technique for early-stage liver cancer and was pleasantly surprised.

"Dr. Wu, it’s perfect! You’re very experienced in diagnosing early-stage liver cancer. How about you come with me to this consultation?"

"I’d be honored, Dr. Liu. Thank you so much."

Of course, Wu Ting couldn’t have asked for a better opportunity.

Soon, the two of them arrived at the Hepatobiliary Surgery department.

Wang Nanjin was clearly a little surprised to see Wu Ting.

"Dr. Wu, what are you doing here?"

Before Wu Ting could answer, Liu Xingye explained first:

"Dr. Wang, I invited Dr. Wu. He has a unique technique for the early diagnosis of primary liver cancer. He previously helped us screen a patient with early-stage primary liver cancer secondary to hepatitis B. We’ve since successfully performed a radical resection, and if the follow-up goes well, the patient will be declared completely cured."

Even now, Liu Xingye was still amazed whenever he brought it up.

"Dr. Wu, you’re this skilled in Hepatic Tumor Surgery as well?"

Wang Nanjin had previously thought Wu Ting’s experience was limited to the radiological diagnosis of hepatic mucinous cystic neoplasms. He hadn’t realized Wu Ting also had special skills in diagnosing early-stage primary liver cancer secondary to hepatitis B.

"Then let’s take a look together."

Wang Nanjin introduced the patient’s case:

"The patient is 59 years old, admitted for one month of pain in the upper right abdomen. Physical exam: skin and sclera are not jaundiced, no remarkable abdominal findings..."

"The abdomen is flat and soft, with deep tenderness in the upper right quadrant, but no muscle guarding or rebound tenderness. Urine test is negative for all three bile pigments. Liver function tests show a certain degree of liver damage..."

"The strangest part is that the gallbladder’s outline is indistinct, and the area is obscured by an acoustic shadow..."

After Wang Nanjin finished his introduction, Liu Xingye and Wu Ting were also puzzled. Based on the physical exam and imaging data, the patient almost certainly had gallstones and chronic cholecystitis, but the situation with the bile duct was very strange.

’An indistinct gallbladder outline... I’ve never seen a case like this...’

Liu Xingye frowned.

"Could it be cancer in the common hepatic duct?"

Dr. Wang Nanjin was also finding it hard to understand.

"It’s not impossible. Look, according to this scan, there’s a mass of at least 5x7 cm in the gallbladder area..."

"Dr. Wu, what are your thoughts?"

Liu Xingye held Wu Ting in high regard and asked for his opinion sincerely.

Wu Ting thought for a moment, then took the rest of the physical exam data and test reports, paying special attention to the preoperative coagulation function tests.

According to his P3 Early Diagnosis Skill for primary liver cancer secondary to chronic hepatitis B, the principles should be universally applicable to this type of primary liver cancer.

Wu Ting carefully examined the indicators, made some comparisons, and combined them with the other liver function test results. He quickly reached a conclusion.

"Dr. Liu, Dr. Wang, based on my comparison of the coagulation function indicators, the patient does indeed have early-stage primary liver cancer. However, according to her markers, the cancer is still within a controllable range."

"As for this mass, it’s definitely not the cancerous area, and it’s certainly not cholangiocarcinoma."

Drawing upon the Diagnosis Skills of the experts he had learned from and combining it with his current knowledge of cholecystitis and gallstones, Wu Ting proposed a breakthrough hypothesis:

"Gentlemen, I was wondering if it could possibly be the rare Mirizzi syndrome."

Hearing Wu Ting’s diagnosis, it was as if a lightbulb went on for Wang Nanjin and Liu Xingye.

"That’s a real possibility. Mirizzi syndrome is an inflammatory disease of the bile duct caused by external compression of the common hepatic duct from an impacted stone in the cystic duct or gallbladder neck. It’s a rare complication of gallstones."

Mirizzi syndrome was first described by the Argentinian surgeon Mirizzi, hence the name.

Its clinical manifestations are nonspecific, mainly including right upper quadrant pain and fever. Patients often have a history of gallstones, with accompanying symptoms of acute cholecystitis, acute cholangitis, and even intestinal obstruction.

"If the patient really only has early-stage liver cancer with minimal impact, we can indeed perform a two-stage surgery. Stage one to resolve the gallstone issue, and stage two to resect the liver tumor."

After Wu Ting’s suggestion, Liu Xingye and Wang Nanjin, with their professional expertise, quickly formulated a plan.

"To ensure the second stage of the surgery goes smoothly, it would be best to use a minimally invasive, or even non-invasive, approach for the stone removal in stage one."

Liu Xingye and Wang Nanjin looked at each other, both having the same solution in mind.

The two young doctors said in unison:

"We can perform an EST (endoscopic sphincterotomy) on the patient!"

Fearing Wu Ting might not be familiar with it, Wang Nanjin explained in detail:

"This is a therapeutic technique developed from diagnostic ERCP technology. EST doesn’t require general anesthesia and has advantages like being minimally invasive, safe, allowing for quick recovery, having lasting and definitive efficacy, and a low probability of complications..."

Having Director Zhang Heng’s EST "entry" and the purple-grade ERCP "entry," Wu Ting’s understanding of this procedure was no less than that of the two attending physicians. However, he didn’t show it and listened humbly.

Under Wu Ting’s key guidance, the two young attending physicians began to conduct further targeted preoperative examinations, while also holding the preoperative discussion with the patient and obtaining signed consent.

Soon, the additional local examinations and specific liver cancer screening tests were completed.

Looking at the test results, Liu Xingye and Wang Nanjin were full of admiration.

"If it weren’t for Dr. Wu’s reminder, we really would have missed or misdiagnosed it."

"Based on the current conventional markers and imaging data, we did indeed find a very subtle cancerous lesion on the patient’s liver. The tumor is very small and won’t affect our first-stage surgery at all."

"And the patient does indeed have Mirizzi syndrome. We just can’t confirm the specific type yet. For now, we can only proceed with the EST for stone removal. If it’s successful, we’re golden. If we run into problems, we’ll convert to an open procedure and perform a traditional cholelithotomy!"

Once the plan was finalized, the three of them began arranging the surgery as quickly as possible.

The division of labor for the surgery was also very clear: Liu Xingye would be the primary surgeon, Wang Nanjin would handle the duodenoscope, and Wu Ting would be the second assistant.

EST was still a relatively advanced technique and hadn’t been formally implemented at City First Hospital, but it was already a mature Surgical Technique in the general surgery (Hepatobiliary, Hepatic Tumor) departments in the Haijin Port region.

Duodenoscopes are categorized into several models based on the inner diameter of their working channel.

This time, Liu Xingye was using a 4.2mm working channel diameter, the largest model, to facilitate the insertion of the mechanical lithotripter.

As for the choice of sphincterotome, Liu Xingye also chose the needle-knife sphincterotome, which he was most skilled with.

The choice of sphincterotome is a real test of skill; different doctors at different stages of their careers will make different choices.

Liu Xingye was undoubtedly in the "boldness born of consummate skill" category, choosing the most difficult to master needle-knife sphincterotome. Besides that, there were also pull-type and push-type models. Some top experts would even use special sphincterotomes, like a modified Bi-style knife...

Wu Ting also observed and learned diligently. Comparatively, there were some differences in the techniques described in Zhang Heng’s "entry," so he could learn from both to improve his own skills.

As for the final method of stone extraction, there were also various options. This time, Liu Xingye chose a stone retrieval basket.

The surgery officially began.

Liu Xingye began the procedure according to standard surgical practice. However, during the stage of making the incision and inserting the sphincterotome into the bile duct, he discovered a critical problem.

This patient’s Mirizzi syndrome was different from any known type. And to make matters worse, Liu Xingye realized he couldn’t find the patient’s common hepatic duct or common bile duct!

The structure of the common bile and hepatic ducts had vanished!

The hairs on Liu Xingye’s arms stood on end. ’This is bad,’ he thought grimly.

Liu Xingye immediately communicated with Wang Nanjin. Wang Nanjin switched places with him and began to try as well.

Following his usual approach, he also couldn’t locate the patient’s common hepatic duct or common bile duct.

’What is going on?’