Guidelines 1
Live book 16
Candidate Shift — Bile Leak vs. Major Bile Duct Injury: Two Different Pathways (Addendum Summary, Ch 3)Separate the Strasberg A leak (ERCP stenting and drainage) from Strasberg E1–E5 transection (HPB-center Roux-en-Y hepaticojejunostomy) — and keep the index surgeon away from major duct repair.Candidate Shift — Choledochal Cysts: Excise Completely, Never Drain Internally (Addendum Summary, Ch 3)Excise the whole extrahepatic cyst with cholecystectomy and Roux-en-Y hepaticojejunostomy — internal cyst-enterostomy drainage is abandoned.Candidate Shift — UDCA After Bariatric Surgery: Selective, Not Universal (§3.0 / Trial 3.4)Stop promoting prophylactic UDCA as a universal mandate after bariatric surgery; consider 6 months of UDCA selectively in stone-free patients undergoing RYGB.Practice Shift — Acute Cholecystitis: Early Index-Admission Cholecystectomy, Fitness-Triaged (Table 3.1)Do early laparoscopic cholecystectomy on the index admission for fit Grade I–II acute cholecystitis — and drain, do not resect, the physiologically unfit.Practice Shift — Acute Pancreatitis: Moderate Fluids, Early Feeding, No Prophylactic Antibiotics (Addendum §10.1, Row 1)Resuscitate acute pancreatitis moderately, not aggressively: Lactated Ringer's at 1.5 mL/kg/h with a bolus only if hypovolemic, reassess at 12, 24, 48 and 72 hours, feed early, and give no prophylactic antibiotics for sterile necrosis.Practice Shift — Elective Splenectomy: Vaccinate First, Search for Accessory Spleens, Guard Against PVT (Addendum §10.1, Row 6)Vaccinate ≥14 days before elective splenectomy, operate laparoscopically, search systematically for accessory spleens in ITP, and give extended LMWH prophylaxis with Doppler surveillance where splenomegaly raises portal vein thrombosis risk.Practice Shift — Gallbladder Polyps: ESGAR 2022 Stratification, Cancer on a Separate Pathway (Table 3.1)Manage true polyps by the 2022 ESGAR thresholds — operate at ≥10 mm or 6–9 mm with a risk factor, survey the middle group, discharge the smallest — and never put a suspected cancer on surveillance.Practice Shift — Hepatic Hydatid Disease: Stage-Matched WHO-IWGE Therapy Replaces Uniform Open Surgery (Addendum §10.1, Row 4)Match hydatid treatment to the WHO-IWGE stage: albendazole + PAIR for active unilocular CE1/CE3a cysts, surgery for multivesicular CE2/CE3b or complicated cysts, and watch-and-wait for inactive calcified CE4–CE5 — never instilling a scolicidal agent until biliary communication is excluded.Practice Shift — Hostile Hepatocystic Triangle: The Structured CVS Bailout Pathway (Table 3.1)When obliterative fibrosis blocks the Critical View of Safety, stop dissecting and run the bailout sequence — never divide structures to finish the case.Practice Shift — Infected Necrotizing Pancreatitis: Antibiotics First, Drain Late, Step Up Only on Failure (Addendum §10.1, Row 2)Postpone drainage of infected pancreatic necrosis until it walls off (typically ≥4 weeks) on antibiotics first — immediate drainage and early open necrosectomy are out; escalate step-up only if drainage fails.Practice Shift — Liver Lesions: Leave Hemangioma/FNH Alone, Resect Adenoma by Rule, Spare Parenchyma in HCC/CRLM (Addendum §10.1, Row 5)Leave confirmed hemangioma and FNH alone — no biopsy, no resection, no stopping contraceptives — resect hepatocellular adenoma by sex-and-size rules, and do parenchymal-sparing R0 resection for resectable HCC and colorectal liver metastases with an adequate future liver remnant.Practice Shift — Mild Gallstone Pancreatitis: Same-Admission Cholecystectomy (Table 3.1)Do the cholecystectomy on the same admission once mild gallstone pancreatitis is recovering — do not discharge and rebook it 4–6 weeks later.Practice Shift — Pancreatic Cystic Neoplasms: Kyoto Risk Stratification Replaces Resect-All (Addendum §10.1, Row 3)Stratify pancreatic cysts by the 2024 Kyoto rules: observe serous cystadenoma, resect main-duct IPMN and branch-duct IPMN with high-risk stigmata in fit patients, and put worrisome features through EUS and surveillance — instead of resecting every branch-duct IPMN ≥3 cm.Practice Shift — Suspected CBD Stones: Stratify First, No Routine Diagnostic ERCP (Table 3.1)Stratify suspected CBD stones by ASGE/ESGE risk before touching the duct — ERCP is for therapy, and intermediate-risk patients get non-invasive imaging first.Stepwise Clinical Decision Pathway — Biliary & HPB Surgery (§3.2)Grade acute cholecystitis by TG18 first, then follow the five-step biliary pathway in order.Stepwise Clinical Decision Pathway — HPB & Non-Traumatic Splenic Surgery (§10.2)Work the HPB pathway in four steps: resuscitate acute pancreatitis moderately and feed early, postpone infected-necrosis drainage until walled-off encapsulation, characterise liver lesions before intervening, and run elective splenectomy as a vaccination-and-search bundle.
Codes 36
BIL-POL-THR-01 — Gallbladder polyp ≥10 mmCholecystectomy (surgery) recommended — Polyp maximal diameter ≥10 mm on imagingBIL-AC-COMP-01 — The burden carried by the drainage pathway itselfReintervention 66% (45/68) · Recurrent biliary disease 53% — Need for reintervention and recurrent biliary disease within 1 year, drainage arm of CHOCOLATEBIL-AC-MORT-01 — 30-day mortality by TG gradeGrade I 1.1% · Grade II 0.8% · Grade III 5.4% · from 3.1% to 25% — All-cause 30-day mortality stratified by TG13/TG18 grade at diagnosisBIL-AC-SUC-01 — Early (≤24 h from admission) vs delayed (day 7–45) laparoscopic cholecystectomyMorbidity 11.8% early vs 34.4% delayed · 5.4 vs 10.0 days · no significant difference — Predefined morbidity within 75 days (primary endpoint)BIL-AC-SUC-02 — Laparoscopic cholecystectomy vs percutaneous catheter drainage in high-risk patientsMajor complications 12% (8/66) LC vs 65% (44/68) drainage · 3% vs 9% · 5 vs 9 days — Major complications = composite of infectious/cardiopulmonary complications ≤1 month, reintervention ≤1 year, recurrent biliary disease ≤1 year; death ≤1 yearBIL-AC-THR-01 — TG18 severity grade definitions— (definitions card; the figures are MORT-01) — Grade III (severe): dysfunction of ≥1 organ system (cardiovascular — hypotension requiring dopamine ≥5 µg/kg/min or any norepinephrine; neurological — decreased consciousness; respiratory — PaO₂/FiO₂ <300; renal — oliguria or creatinine >2.0 mg/dL; hepatic — PT-INR >1.5; haematological — platelets <100,000/mm³). Grade II (moderate): any of — WBC >18,000/mm³, palpable tender RUQ mass, symptoms >72 h, marked local inflammation (gangrenous/emphysematous cholecystitis, pericholecystic or hepatic abscess, biliary peritonitis). Grade I (mild): neitherBIL-ALT-DIS-01 — Oral bile-acid (ursodeoxycholic acid) dissolution — ADJUDICATED / DISPUTED(i) Complete dissolution: pooled 63% after >6 months' therapy · (ii) Long-term cure: only 27% · (iii) Recurrence after dissolution: 25–64% at 5 years; 49–80% at 10 years · Guideline position: litholysis NOT recommended — (i) Complete dissolution of stones on UDCA, confirmed imaging, in strictly selected patients; (ii) long-term cure (stone-free and remaining so); (iii) recurrence after successful dissolutionBIL-ALT-DIS-02 — Extracorporeal shock-wave lithotripsy (ESWL) — ADJUDICATED / DISPUTEDStone-free ("cure"): 55% · Recurrence: >40% within 4 years · Guideline position: not a standard therapy — Stone-free rate ("cure") after ESWL, usually with adjuvant UDCA, in carefully selected patients; and recurrence thereafterBIL-CBD-COMP-01 — Post-ERCP pancreatitis (PEP) — DISPUTEDProspective clinical series: 3.47% · RCT control arms: pooled 9.7% · 10.2% — Pancreatitis after ERCP — definitions differ: clinical (pain + enzymes + admission) vs protocol enzyme surveillance in trial armsBIL-CBD-MORT-01 — 30-day mortality of acute cholangitis by TG gradeGrade I 1.2% · Grade II 2.6% · Grade III 5.1% — TG13/TG18 grade at diagnosis (Grade III = organ dysfunction), all-cause 30-day mortalityBIL-CBD-PREV-01 — CBD stones accompanying gallbladder stones3–16% · 5–12% — Choledocholithiasis found in patients with gallbladder stones (imaging/operative findings; strong age gradient)BIL-CBD-SUC-01 — Successful duct clearance at ERCPBenchmark: >90% clearance · Large stones (>10 mm): complete clearance at first ERCP 85% — Complete stone extraction: the quality-indicator benchmark for extrahepatic stones <1 cm in normal anatomy (performance target), and SR figure for large stonesBIL-CBD-SUC-02 — Early/urgent drainage in Grade II cholangitisMortality 2.0% early vs 3.7% delayed — 30-day mortality, early/urgent biliary drainage vs drainage after >48 h, within Grade IIBIL-CBD-SUC-03 — One-stage (lap CBD exploration or rendezvous at cholecystectomy) vs two-stage (pre/postoperative ERCP)No significant difference — Primary outcomes: mortality, morbidity, retained stones, conversionBIL-CBD-SUC-04 — Transcystic (via cystic duct) laparoscopic stone extraction success~75% — Successful duct clearance via the transcystic route alone, at lap cholecystectomyBIL-CTX-CAN-01 — Incidental gallbladder cancer in cholecystectomy specimensLow-incidence countries: pooled 0.32% (95% CI 0.25–0.42) · High-incidence countries: 0.83% (0.58–1.18) — GBC first diagnosed on histopathology of a cholecystectomy specimen removed for presumed benign disease ("incidental"; "truly incidental" = no preoperative or intraoperative suspicion)BIL-CTX-GLP-01 — GLP-1 receptor agonists and gallbladder/biliary diseaseComposite gallbladder/biliary disease RR 1.37 (1.23–1.52) · RR 1.27 (1.10–1.47) · RR 1.36 (1.14–1.62) · RR 1.55 (1.08–2.22) · weight-loss trials RR 2.29 (1.64–3.18) — Composite of cholelithiasis, cholecystitis, other biliary disease and biliary interventions across RCTs of GLP-1 RAs (any indication)BIL-CTX-WL-01 — Gallstone formation during rapid weight lossPlacebo 32% — New gallstones on ultrasound at 6 months after gastric bypass without prophylaxis (placebo arm)BIL-CTX-WL-02 — Ursodiol prophylaxis against weight-loss stonesUDCA 600 mg/day: 2% — New-stone formation at 6 months, UDCA dose arms vs placebo (same RCT)BIL-GB-COMP-01 — Major bile duct injuryEASL (guideline synthesis): major BDI 0.2–0.4% · CholeS (any recorded CBD injury): elective 0.2% · delayed 0.4% · emergency 0.3% — Injury to the main biliary tree requiring repair/reconstruction (EASL "major" definition); CholeS recorded any CBD injuryBIL-GB-COMP-02 — Bile leakCholeS: elective 0.9% · delayed 1.6% · emergency 2.2% · EASL quoted range: 0.4–1.5% — Bile leak by ISGLS-type definition as recorded in CholeS; EASL historic-comparison range alongsideBIL-GB-COMP-03 — Conversion to open surgeryCholeS: elective 1.6% · delayed 4.6% · emergency 5.3% · overall 3.3% · EASL all-comers quoted range: 4–8% — Laparoscopic procedure converted to open, by pathwayBIL-GB-COMP-04 — 30-day readmission and overall complicationsReadmission 7.1% · Any complication 10.8% — All-cause 30-day readmission; any recorded complication ≤30 daysBIL-GB-COMP-05 — New-onset postcholecystectomy diarrhoea (PCD) — DISPUTEDFarrugia: pooled 13.3% (462/3,476), study range 2.1–57.2% · Farahmandfar: 9.1% (302/3,306) · ~63.5% of PCD patients — New diarrhoea after cholecystectomy, definitions varying by study (questionnaire/interview/stool chart)BIL-GB-CTX-01 — Porcelain gallbladder and cancerup to 20% · selective/spotty mucosal calcification ~7% · complete homogeneous wall calcification — carcinoma rate very low — Gallbladder carcinoma found in calcified (porcelain) gallbladders, by calcification patternBIL-GB-CTX-02 — Very large stone (≥3 cm) and cancer riskOR 2.4 · ≥3 cm: OR 10.1 · Absolute-risk firewall: — Odds of gallbladder cancer by largest stone diameter, vs stones <1 cmBIL-GB-CTX-03 — Haemolytic disease (hereditary spherocytosis, sickle cell disease)from ~5% in childhood to 40–50% by age 10–50 years · prophylactic cholecystectomy advisable at the time of splenectomy · advised during abdominal surgery for other reasons — Gallstone prevalence and the prophylactic-surgery position in chronic haemolysisBIL-GB-CTX-04 — Transplant candidates / recipients; diabetesQualitative — no headline figure issued. · not routinely recommended · heart transplantation · reduce mortality and be cost-effective · Diabetics do NOT need prophylactic cholecystectomy — Whether asymptomatic stones justify cholecystectomy around transplantation, or in diabetesBIL-GB-CTX-05 — Persistent abdominal symptoms after cholecystectomySymptoms persist in every 3rd to 4th patient — Persistence of pre-operative abdominal symptoms (predominantly non-biliary: dyspepsia, bloating, reflux-type) after cholecystectomyBIL-GB-MORT-01 — 30-day mortality by pathwayElective 0.05% (2/4,165) · Delayed 0.2% (6/3,293) · Emergency 0.2% (3/1,451) — All-cause 30-day mortalityBIL-GB-NAT-01 — Annual symptom-onset rate, asymptomatic gallstones — ADJUDICATED~1–2% per year in the early years, declining with time; ~20% symptomatic by 20 years — First biliary pain/symptoms in a previously asymptomatic carrierBIL-GB-NAT-02 — Serious complications in asymptomatic carriers0.1–0.3% per year · 3.0% at 10 years · 2.4% total · zero gallstone deaths — Acute cholecystitis, pancreatitis, obstructive jaundice, cholangitis arising in a previously asymptomatic carrierBIL-GB-NAT-03 — Recurrence of biliary pain after a first colic episode~50% have recurrent pain episodes; ≈50% chance of another colic within 1 year of a single episode — Further pain episodes after an index episode of biliary colic, untreatedBIL-GB-NAT-04 — Complications after symptoms have started1–3% per year · 0.5–3% per year — Acute cholecystitis, biliary pancreatitis, obstructive jaundice, cholangitis per year in symptomatic patientsBIL-GB-PREV-01 — Gallbladder stone prevalence; asymptomatic shareStones in 10–20% of adults · ~80% of carriers asymptomatic — Stones present on imaging/population surveys; "asymptomatic" = no biliary symptoms attributable to the stonesBIL-GB-REC-01 — Return to work / normal activitymedian sick leave 10 days after LC · convalescence ~3 weeks shorter — Majeed RCT (LC vs minilaparotomy): (mean 12.7) vs 14 days (mean 16.0) after mini-laparotomy. EASL (MA of RCTs, LC vs open): hospital stay ~3 days shorter, than open surgery
Memory 16
The 5 FsRisk-factor profile for cholelithiasis (folk device)Charcot's triadAcute (ascending) cholangitis (named triad)Reynolds' pentadSevere acute cholangitisSaint's triadCo-occurring gallstones, hiatus hernia, colonic diverticulosisCalot's triangle — 3 CsCalot's (hepatobiliary) triangle — "the 3 Cs" decodeRigler's triadGallstone ileus on imaging (named triad)I GET SMASHEDCauses of acute pancreatitis — the head formPANCREASGlasgow–Imrie criteria for pancreatitis severityGA LAWRanson criteria on admission — with the gallstone splitC HOBBSRanson criteria at 48 hoursBISAPBedside Index of Severity in Acute Pancreatitis (name-device score)HAPSHarmless Acute Pancreatitis ScoreBalthazar CT gradeCT severity grading of pancreatitisBALIPancreatitis severity scoreChild-Pugh — ABCDEChild-Pugh score componentsAsplenic individuals Have No SpleenOPSI pathogens — overwhelming post-splenectomy infection