194. The constantly reversing surgical plan

[I saw many book friends writing about liver flukesomiasis. Liver flukesomiasis is completely different. For details, you can go to the previous book for a detailed introduction, so I won’t go into details here]

The prevention and control of parasites in China has always been very strong, and it can be considered that Schistosoma schistosomiasis has basically been eliminated. Although there are sporadic infections, more imported cases are returned to China, but Kawei has indeed not encountered schistosomiasis cirrhosis for a long time.

On the one hand, the diagnosis is on the other hand.

There are endless examination methods in modern times. A single liver b-ultrasound can make schistosomiasis cirrhosis without any hiding [1]. Moreover, early bloody stools and anemia will also make clinicians more vigilant, and diagnoses can be clarified by feces by detecting the contact history of insect eggs and epidemic water.

Perhaps it is because the domestic prevention of schistosomiasis is too good. Kawei, who has been working in big cities, seems to have forgotten the various schistosomiasis cirrhosis I have encountered and lacks awareness of this little thing.

Now, I will recall the key points of cirrhosis of Schistosoma cirrhosis. One of the important ones is that there are few nodules and only produce some fiber hyperplasia on the liver envelope, so a simple direct look is prone to deviations.

The mainstream schistosomiae are divided into schistosomiae, schistosomiae Mannello and schistosomiae. Their life history is similar [2], but their requirements for the living environment after entering the body are somewhat deviated.

Most of them gather around the portal vein, adsorbing on the blood vessels and constantly sucking blood and growing until they grow into adults, and then leaving this area to find their own parasitic location. Once the number in the portal vein system reaches a certain level, obstruction will occur, so portal hypertension, giant spleen, upper gastrointestinal bleeding and ascites.

Now talking about tourism history, the history of epidemic and water contact has lost its meaning. It is meaningless to talk about the types of schistosomiae, whether it is schistosomiae, Mann, or Egyptian schistosomiae.

Because the black adults in the mesenteric blood vessels are enough to illustrate the problem.

At this stage, there is no room for surgical treatment. The anatomy of the liver hilaria alone can kill the surgeon. All Kawei can do now is to try to improve Fernan's upper gastrointestinal bleeding, at least to stop the bleeding.

The operation returns to the previously envisioned giant splenectomy + spleen-renal vein shunt.

Although he went back to the original surgical plan after a long journey, clarifying the cause of the disease gave Kawei confidence and was willing to add something else to the original plan.

However, before this, he had to let the audience know about this, and he also needed to make a subjective modification to the previously stated Fernan medical history: "The prisoner's body seems to be parasitized by some kind of insect, and they can be seen in the blood vessels of the mesenterology."

"It looks like a very tiny nematode." Herman leaned forward and observed carefully and said, "I remember a German doctor who went to Egypt a few years ago mentioned a nematode, which is about the same size as this one."

Nematodes found in Egypt?

It was basically that Egyptian schistosomiasis had not escaped.

Kavey asked, "Do you know what the name of that nematode is?"

"It seems to be named after the doctor, called Slits."

This is a very ancient name. Because it is too difficult to obtain Western books, it has been active in the parasite control manuals in the 1960s and 1970s in China. It was not until later that its scientific name was slowly changed to Schistosoma schistosomiasis. [3]

Kavey breathed a sigh of relief. Since someone had confirmed this insect, it would be easy to explain: "The insect exists in his blood vessels, blocking blood flow, which causes hypersplenia and enlargement of the spleen, and makes the surface of the liver as rough as a layer of linen."

The audience, who had not been interested in surgery, began to close their eyes and look at the mesenteric blood vessels in Kawei's hand.

It is so exciting for insects to penetrate the human body that they naturally hope to see clearly. Unfortunately, even if the telescope magnification is adjusted to the highest level, they can only see some intestinal segments and mesenteria, and they are powerless to do anything about the blood vessels inside the mesenteria.

"This is the first time I've seen this."

"Can bugs do this? So curious!"

"I can't see, I can't see at all!!!"

"I can only wait until the operation is over and see if I can take two pieces from him to watch."

There will be praise and belittlement, especially when facing Kavey, some people's jealousy and competitive spirit will be fully activated: "This diagnosis is too hasty, and I have never heard of parasites that can enter blood vessels."

“It looks like a bit sensational trick.”

"Anyway, he will be closed immediately after the operation, so he may not have to cut open the blood vessels and remove the insects one by one. Without evidence, there is reason to doubt the authenticity. If everyone learns from him, how can the surgery develop?"

Of course, it is impossible for Kawei to remove the insects from his surgery. Even if he really has a complete set of microsurgery surgical instruments, he would not do this.

Because even if all the bugs visible to the naked eye are subjectively removed, it is still impossible to determine whether there will be bug residues in other places. Bugs are like cancer. As long as one is missing, it will not take long to turn out thousands of descendants.

To deal with schistosomiasis, you have to be honest and practical to deal with schistosomiasis, praziquantel.

Unfortunately, praziquantel is a synthetic drug, which is definitely not available in the 19th century. In addition to the most basic supportive treatment of internal medicine with adrenal glands and pituitary extract, surgery is a good way to effectively extend the patient's life span.

Modern surgery does not have much intersection between portal hypertension and esophageal fundus varicose, and it is more important to give endoscopic hemostasis + sclerosis + ligation treatment to the endoscopic chamber, or enter the interventional chamber for vascular embolization and flow cessation.

Spleen removal is a difficult surgical method for modern medical care, and the surgical indication has been basically eliminated. Spleen-renothermal venous shunt has gradually withdrawn from the stage of history due to difficulty and complications.

But in the 19th century, this complete set of surgical methods to deal with portal hypertension seemed extremely advanced.

It is so advanced that it makes people feel like watching science fiction movies.

At this time, Herman, who had a little understanding of schistosomiasis, reminded Kawi: "I still remember the doctor's description, 'The bladder of a long-term hematuria is actually filled with gray-white bugs', which makes people creepy when thinking about it."

Schistosoma Egypt prefers the bladder after the portal vein matures, and does like to gather in the bladder. Mann, like Schistosoma Japan, prefers intestinal blood vessels.

But no matter which kind of schistosome it is, its larvae and eggs like to drill randomly. Now, combined with Fernan's bizarre medical history, it is not difficult to see the role of larvae and eggs in it.

The first thing is the first bladder stone.

Although the incidence of bladder stones is very high without antibacterial measures, Fernan's bladder stones are still very likely to be caused by accumulation of insect eggs. If you do not have the habit of breaking and checking, the cause of this disease will easily be missed.

The second is breast hyperplasia.

One thing that has always made Kavey feel strange is that Fernan's breast hyperplasia rate. In just a few days in the hospital, breast hyperplasia became so obvious. In addition to hormones, insect eggs are also an important reason.

Kawei has experienced the raging era of schistosomiasis and has seen cases of ectopic parasitic breasts in the breasts through spinal cord veins and intercostal veins. This external stimulation will cause inflammation of the breasts, and then pathological hyperplasia of the breasts, and eventually even cause breast cancer.

Looking back now, it was a pity that it was not a careful cutting of Fernan's bilateral breast and a large number of specimens.

Finally, it’s the gao pill.

Fernan's gao pill cancer has pathological examinations as the basis, but the cause of it is unknown. Just like the breast, the ectopic parasitic repetitive stimulation of parasites is a breeding ground for chronic inflammation and an important factor in cancer.

On this basis, Kawei could not let go of any organ in the abdominal cavity.

The surgery has also changed from simply treating portal hypertension to portal hypertension treatment + multiple nodules in the abdominal cavity.

Generally, abdominal cavity exploration has a clear order, starting from the liver, entering the spleen area through the esophageal fissure hole, then the stomach, duodenum, bile tract, pancreas, small intestine, appendix and ascending colon, transverse colon and large omentum, descending colon, sigmoid colon and rectum, and finally bladder.

If you are a woman, you also need to add uterus and attachment examinations.

"Don't rush to give me a scalpel first, I have to do a check."

Kavey rejected the knife Damilgaon brought and put his hands into Fernan's stomach. Because a series of mistakes caused a major reversal of diagnosis in front of him, and with the lack of examination tools, Kavey became more and more cautious.

At the same time, I hope that the three assistants around me will be very cautious when doing surgery in the future like he is now: "The patient has upper gastrointestinal bleeding. Although it seems that it is basically varicose veins caused by portal hypertension, we still need to check the possibility of rupture and bleeding of gastrointestinal ulcers."

Kawei's hand bent from the stomach pylorus to investigate the cardia from the stomach. If there are ulcers that cause severe bleeding, it should be possible to feel strange on the surface: "Generally, the ulcers will penetrate deep into the muscle layer and even penetrate the entire gastrointestinal wall. At that time, it is a special feeling of softness and hardness."

After checking the surface of the stomach, his hand entered the posterior wall of the stomach from the omentum sac and was not retracted until all of them were checked: "The next one is the duodenum, and ulcers may also occur here."

The half hour of the operation started from 1:11 pm to 1:40 pm, and wasted by Kawei on the so-called differential diagnosis and abdominal screening.

After the gastroduodenal ulcer inspection is completed, there is also the screening of nodules deposited by insect eggs. If you find such strange nodules in the abdominal cavity, considering the impact of the size and inflammation on the organs, you need to choose to ignore palliative care or actively remove them.

The detection method of abdominal lumps and nodules is more complicated than ulcers.

Ulcers exist in the gastrointestinal tract, so the investigation can be completed by going down the anatomy of the digestive tract. However, nodules and lumps caused by ovum deposition or ectopic parasites in insects do not have such rules to follow, and it is a carpet-style search without clear objects.

Remove the stomach and duodenum that have been checked just now, and the most troublesome and most likely problematic one is the long intestine.

Schistosoma schistosomiae parasitizes in the mesenteric blood vessels, and the intestines are the first to occupy the territory they occupy when they expand outward. The second is the deep kidneys, whether it is the adrenal glands or the kidney itself, once such nodules appear, there will be no good results.

So after avoiding the unexplored liver duct and the gallbladder, spleen and pancreas that had just been in contact, Kawei placed all the center of gravity on the lower abdomen.

For the intestine, Kawei tried his best to do his best. Every section was pinched by his hands, and finally a huge nodule was found in the left descending colon.

"The position is a bit ambiguous and the volume is quite large." Kawei made a simple measurement with his fingers. "5*4*1cm is covered on the intestinal wall like a lid. If it weren't for his severe liver ascites, he might have touched it during physical examination."

Herman asked, "How to deal with this?"

"It's not small in size, but the degree of invasion is quite good. It's more protruding out of the outside, which does not cause much damage to the inside of the intestinal mucosa."

Kawei carefully touched the degree of infiltration and explained: "If it continues to increase or deepens further, and the infiltration may lead to perforation of the intestinal wall, it must be removed surgically. Now we still have major surgery to do, so let's take it a momentary delay."

Herman nodded and prepared the surgical instruments according to previous training: "Then it's better to do the spleen removal as planned."

Kavey said: "Wait, there is still the last segment of the rectum that has not been checked."

"I'm already checking the rectum."

Damirgang, who was standing aside, had continued to explore downwards according to Kavi's technique. As he spoke, his fingers suddenly touched a big thing. Damirgang's expanded exploration range around him couldn't help but look dark: "What's wrong with his rectum, and there seems to be a larger nodule around him."

[I'm too tired, I'll modify this chapter and typo tomorrow]
Chapter completed!