Hepatobiliary, Pancreatic and Splenic Surgery
Core Concepts
Focus on gallstone disease, acute pancreatitis, and hepatobiliary malignancies. Understand the indications for cholecystectomy (symptomatic gallstones, acute cholecystitis, gallstone pancreatitis). Know the revised Atlanta classification of pancreatitis and its management: early fluid resuscitation, enteral nutrition, and antibiotics only for infected necrosis. For pancreatic cancer, recognize the importance of resectability criteria (vascular involvement) and the role of neoadjuvant therapy. Splenic surgery: indications for splenectomy (trauma, ITP, hereditary spherocytosis) and the need for vaccinations.
Traps in Questions
A common trap is the timing of cholecystectomy in gallstone pancreatitis: current evidence supports early cholecystectomy (within 72 hours or same admission) for mild cases. Another trap is the use of ERCP in acute pancreatitis: it is indicated only with concurrent cholangitis or persistent biliary obstruction. For pancreatic pseudocysts, intervene only if symptomatic or enlarging, and wait at least 4–6 weeks for maturation. Also, beware of the “post-splenectomy sepsis” question: encapsulated organisms (Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis) are the culprits.
Worked Example
A 60-year-old woman with gallstone pancreatitis, no organ failure, and no cholangitis. What is the best management? Answer: Early laparoscopic cholecystectomy during the same admission after resolution of pain and normalization of enzymes.
Rule of Thumb
In acute pancreatitis, enteral feeding is preferred over parenteral; nasogastric feeding is safe and does not worsen outcomes.