Bailey 28 Edition Updates

th

Spleen, GB and Pancreas

Dr. R. Rajamahendran MS, MRCS, MCh SGE
Surgical Gastroenterologist
Bailey Update Question
• The grade of the following Splenic injury. Any injury in the
presence of a splenic vascular injury or active bleeding confined
within the splenic capsule
a. Grade 3
b. Grade 4
c. Grade 5
d. Grade 6

Ans. B ( Ref Bailey and Love 28th edition page 1224)

Vaccination protocol in Bailey
• If elective splenectomy is planned, consideration should be given to vaccinating against
pneumococcus, meningococcus C (both repeated every 5 years) and H. infuenzae type b (Hib)
(repeated every 10 years). The last two vaccines are commonly delivered as a combined
preparation.
• Yearly influenza vaccination has been recommended, as there is some evidence that it may
reduce the risk of secondary bacterial infection
• Such vaccinations should be administered at least 2 weeks before elective surgery or as soon
as possible after recovery from surgery but before discharge from hospital.
• Pneumococcal vaccination is recommended in those patients aged over 2 years.
• Hib vaccination is recommended irrespective of age.
• OPSI due to Capnocytophaga canimorsus may result from dog, cat or other animal bites.
Vaccination- SABISTON UPDATE
Pneumococcal Vaccine Meningo coccal vaccine H. Influenza type B
13 Valent- PCV 13 Quadrivalent meningococcal H Influenza Type B conjugate
Followed by conjugate ACWY series vaccine
23 Valent after 8 weeks +
Monovalent Meningococcal
Serogroup B vaccine series

All seasonal vaccines of Influenza, Measles, Mumps, Rubella , Varicells, Tetanus, DPT
Ideal time for vaccination
• IDEAL TIME- 10-12 weeks prior to elective splenectomy or at least 14 days
prior to surgery.
• Emergency settings after 14 days or upon discharge whichever comes first.
Auto transplant
• Into omental pouch ( approximately 50% spleen ) needed to
prevent Pneumococcal sepsis
Booster doses
• PPSV 23 vaccine every 5 years
• Quadrivalent Meningococcal ACWY ( MPSV4)- every 5 years

• Monovalent Serogroup B ( Men B)- no booster

• H. influenza B – No booster
Antibiotic Prophylaxis- 2 approaches
Daily antibiotics Emergency Supply
• Recommended by Australian Spleen
society • Oral Amoxycillin or Penicillin
• Daily antibiotic prophylaxis for • If allergic to above- Macrolide
children upto 16 years or a antibiotics.
minimum of upto 5 or 3 years after
splenectomy. • Emergency supply we recommend-
Amoxycillin+ Clavulanic acid or
• In addition they recommend lifelong Macrolide or Quinolones ( for
prophylaxis for immune penicillin allergic)
compromised patients and
emergency ( Stand by antibiotics )
for adults.
Bailey Update Question
• Regarding the anatomy of Biliary system- False statement is
a. Cystic plate is fibrous sheet continuous with Liver capsule of Segments IV
and V
b. Cystic plate must be exposed to achieve Critical View of Safety.
c. Rouviere’s sulcus marks the right anterior sectoral vein
d. R4U line is very important during laparoscopic cholecystectomy- all
dissection performed ventral to the line

Ans. C ( Ref Bailey 28th edition page 1233)

ROUVIERE SULCUS and R4U line
• The cystic plate is a fat ovoid fibrous sheet continuous with the liver capsule of segments IV
(medially) and V (laterally).
• It is located in the gallbladder bed and needs to be exposed to achieve the critical view of
safety (CVS) during cholecystectomy.
• Rouviè re’s sulcus on the under surface of the right lobe of the liver running to the right of the
hepatic hilum marks the position of the right posterior sectoral pedicle.
• The advantage of identifying Rouviè re’s sulcus and the line joining the roof of the sulcus to
the base of segment IV (R4U line) (Rouviè re’s sulcus→segment IV→umbilical fssure) is that
the cystic duct and the cystic artery lie ventral (anterosuperior) to the line and the CBD lies
below the line.
• CBD injury can be minimised by maintaining the dissection ventral to the line during
cholecystectomy.
• In the case of difficulty, all dissection during laparoscopic cholecystectomy should be
performed ventral to the R4U line
R4U line
Bailey Update Question
The following are the findings of Acute Cholecystitis in USG except
a. USG is the initial imaging modality of choice
b. 90-95% sensitive
c. GB wall thickened >3mm
d. USG showing murphy sign
e. None

Ans E ( Ref Bailey 28th edition page 1235)

• Only 75% of gallstones are identified by CT, it is not used as a screening modality for
uncomplicated gallstones.
• USG is 90-95% sensitive
USG Acute Cholecystitis
• Acute calculous cholecystitis is diagnosed radiologically (sensitivity 90–95%) by
thickening of the gallbladder wall (>3 mm), presence of pericholecystic fluid or direct
tenderness when the probe is pushed against the gallbladder (ultrasonographic Murphy’s
sign).
HIDA
• In 90% of normal individuals the gallbladder is
visualised within 30 minutes following injection,
with 100% being seen within 1 hour
• The bowel is seen usually within an hour in the
majority of patients.
Bailey update Question
• Regarding the anomalies of gall bladder and Cystic duct- False statement
a. Phrygian cap is seen in 5%
b. Absence of Cystic duct is usually pathological, indicating recent passage of the stone.
c. Low insertion of Cystic duct must be fully dissected until the insertion to prevent stone
remaining in CD
d. Ducts of Luschka are those passing from liver to gallbladder

Ans C ( Ref Bailey 28th edition page 1240)

LOW INSERTION OF CD
• Complete dissection of the LOW INSERTION
cystic duct should be avoided because there is a
potential to devascularise the CBD, which could
result in stricture formation.
Bailey Update Question
• Type II a biliary atresia as per Anglo Saxon Classification
a. Atresia restricted to CBD
b. Atresia of CHD with patent GB and CBD
c. Atresia of CHD with obliterated GB,CD and CBD
d. Atresia of right and left Hepatic ducts and entire EH biliary tree

Ans. B ( Ref Bailey 28th edition page 1240)

EHBA- Anglo Saxon Classification
Bailey Update Question
• When EHBA is suspected the GOLD STANDARD investigation is
a. CECT
b. ERCP
c. Fasting USG
d. Endo USG

Ans. C( Ref Bailey 28th Edition page 1241)

EHBA
• Fasting USG is the gold standard when biliary atresia is suspected.
• A shrunken gallbladder, a hyperechogenic liver hilum (‘triangular cord sign‘) or a cyst at the
liver hilum with- out bile duct dilatation with associated anomalies support the diagnosis.
• Hepatobiliary scintigraphy may reveal the diagnosis but MRCP is highly sensitive and specific
in the diagnosis.
• Inflammatory cells, a fibrotic liver parenchyma exhibiting signs of cholestasis and biliary
neoductal structures establishes the definite diagnosis on liver biopsy. Cholangiography is
required to define the surgical anatomy.
DD: EHBA
• The most common differential diagnoses are Alagille syndrome (biliary atresia, congenital
heart disease, skeletal and other abnormalities), progressive familial intra- hepatic
cholestasis and cystic fibrosis.
• Neonatal hepatitis is the most difficult to differentiate.
• Liver biopsy and radionuclide excretion scans are helpful.
Gall stone Statistics
• Longitudinal follow-up study of individuals with silent gallstones has shown that over 20
years only 18% developed biliary pain;
• the mean yearly probability was 2% during the first 5 years, 1% during the second 5 years
and 0.5% during the third 5 years.
Bailey Update Question
• As per Tokyo Guidelines Diagnostic Criteria for Acute
Cholecystitis: Definite diagnosis based on the Table shown below
is
Bailey Update Questions
• The following is not the indication for Prophylactic
Cholecystectomy in asymptomatic cases
a. Multiple GB stones
b. Diabetes mellitus
c. Organ transplant
d. Hemolytic anemias

Ans. A and B ( Ref Bailey 28th page 1244)

Indications for Prophylactic
Cholecystectomy
• Large > 3cm gallstones
• CBD stone
• Hemolytic conditions ( Sickle cell anemia and hereditary spherocytosis)
• Gallbladder polyps > 1cm diameter
• Suspicious of malignancy
• APBPD
• Porcelain GB
• High prevalence areas like North india, native americans, Mexicans etc
• Transplant cases
• Bariatric cases
Update in Grade III- NA changed as
Epinephrine
Bailey Update Question
• Charlson Co morbidity index- 5 or less with antibiotics controls
the inflammation – what will you do as per Tokyo guidelines
a. Early Cholecystectomy
b. Delayed LC
c. Observation
d. GB drainage

Ans. A ( Ref Flow Chart Bailey 28th page 1246)

Grade 1
c- CCI5 or less/ ASA PS- II or less ( low risk)
d- CCI 6 or greater / ASAPS III or more ( not low risk)
g- Bail out procedures
Grade II
a- Antibiotics and general supportive care successful.
b- Antibiotics and general supportive care fail to control infammation
e- Blood culture should be taken before initiation of administration of antibiotics.
f- Bile culture should be per- formed during GB drainage.
Grade III
h - Negative predictive factors: jaundice (T Bil ≥2 mg/dL), neurological dysfunction, respiratory dysfunction.
i- FOSF: favourable organ system failure = rapidly reversible after admission and before early LC.
j- CCI 4 or greater, ASA-PS 3 or greater are high risk.
k- Advanced centre = intensive care and advanced laparoscopic techniques are available
Bailey Update Question
• Xanthogranulomatous Cholecystitis- False statement
a. More common in female
b. Extravasation of bile into GB wall- from rupture of Rokitansky
Aschoff sinuses is the cause
c. Mimics like cancer GB
d. Laparoscopic cholecystectomy must be done

Ans. D ( ref Bailey 28th edition page 1248)

Xanthogranulomatous GB
• Xanthogranulomatous cholecystitis is an uncommon inflammation of the gallbladder, more
frequently seen in India and Japan. It is more common in females.
• It is caused by extravasation of bile into the gallbladder wall from rupture of the Rokitansky–
Aschoff sinuses or by mucosal ulceration as a result of a focal or diffuse destructive
inflammatory process, with accumulation of lipid-laden macrophages (xanthoma cells),
fibrous tissue and acute and chronic inflammatory cells.
• USG shows GB wall thickening (diffuse or focal, with intact mucosal lining), intramural
hypoechoic nodules or bands and often the presence of gallstones.
• CT shows 5- to 20-mm intramural hypoattenuating nodules and poor/heterogeneous
contrast enhancement. As with acute cholecystitis, early enhancement of the adjacent liver
parenchyma may occur.
R/o Cancer
• Extension into the liver along with enlarged hepatoduodenal lymph nodes closely mimics
gallbladder carcinoma.
• Diagnosis is difficult and depends on pathological examination.
• Intraoperatively, frozen-section examination should be carried out to differentiate
xanthogranulomatous cholecystitis from carcinoma of the gallbladder (coexistence of
gallbladder cancer 2.3–13.3%).
• Because of diagnostic difficulties if there is preoperative suspicion of xanthogranulomatous
cholecystitis open cholecystectomy should be considered.
Bailey Update Question
• Regarding Gall stones in Pregnancy- False statement is
a. Hormonal estrogen changes during pregnancy increases Cholesterol secretion and
progesterone reduces Bile secretion and causes cholesterol stones
b. Women in 1st trimester are managed conservative in mild cases
c. Second trimester cases of moderate or severe disease must undergo cholecystectomy
d. In third trimester – laparoscopic cholecystectomy is not possible and hence open is
advised

Ans. D ( Ref Bailey 28th edition page 1248)

Pregnancy and Cholecystitis
• Acute cholecystitis is the second most common non-obstetric indication for surgery in
pregnant women.
• Hormonal (oestrogen) changes during pregnancy increase cholesterol secretion and
progesterone reduces bile acid secretion, reducing the ability of bile to solubilise cholesterol;
bile becomes supersaturated with cholesterol.
• Progesterone also slows gallbladder emptying, which further promotes the formation of
stones owing to bile stasis.
• Prepregnancy obesity, multiparity, increasing age and genetic predisposition are risk factors.
• USG and non-contrast MRI are acceptable diagnostic modalities.
Trimester and management
• For women in their first trimester, the mainstay of treatment for mild cases is conservative.
• Non-steroidal anti-inflammatory drugs are effective analgesics but are generally avoided in
pregnancy, especially after 32 weeks of gestation, because of potential adverse fetal effects,
e.g. premature closure of the ductus arteriosus
• In the second trimester, with moderate or severe disease, good surgical candidates (American
Society of Anesthesiologists [ASA] I or II) should undergo cholecystectomy during their initial
hospitalisation as there is a high risk of recurrence or serious complications.
• In the third trimester, non-operative medical management with antibiotics and fluid therapy
should be initiated.
• The patient should be re-evaluated after delivery.
• Generally, a waiting period of 6 weeks following delivery is preferred to allow the mother to
recover from the delivery, bond with the infant and regain her strength.
Bailey Update Question
• Bouveret Syndrome is Gallstone obstructing at level
a. Colon
b. Duodenum
c. Ileum
d. Stomach

Ans. B ( Ref Bailey 28th edition page 1248)

Gall stone ileus
• Gallstone ileus is an infrequent complication (0.4%) of cholelithiasis, occurring as a result of
impaction of one or more gallstones within the gastrointestinal tract.
• It is seen more frequently in the elderly and in women. Frequently an episode of acute
cholecystitis leads to erosion of inflamed tissues, resulting in a cholecystointestinal fistula.
• A majority of small gallstones pass through the intestines spontaneously.
• However, gallstones of size 2–5 cm get impacted, usually in the terminal ileum or at the
ileocecal valve owing to the relatively narrow lumen and less active peristalsis here.
• Less common locations include the stomach and the duodenum (Bouveret’s syndrome).
• Impacted stones may lead to necrosis and perforation followed by peritonitis.
Plain X ray
A plain abdominal radiograph shows:
• Partial or complete intestinal obstruction
• Pneumobilia or contrast material in the biliary tree
• An aberrant rim-calcified or total-calcified gallstone
• A change in the position of such a gallstone on serial films (‘tumbling sign’).

• CT is considered superior to plain radiographs or USG, with a sensitivity of up to 93%.

• It additionally shows an abnormal gallbladder with air, an air–fluid level or fluid
accumulation with an irregular wall.
Management
• In addition to the management of intestinal obstruction, enterolithotomy has been the most
common surgical procedure performed.
• A longitudinal incision is made on the antimesenteric border proximal to the site of gallstone
impaction, and the gallstone is brought proximally to a non-oedematous segment of the
bowel by gentle manipulation and extracted.
• A chole- cystoenteric fistula should not be resected unless the patient is stable and there are
residual gallstones that may cause infection or recurrent ileus
Bailey update Question
The following are risk factors of difficult cholecystectomy except
a. Previous multiple attacks
b. High ASA score
c. EHPVO
d. Multiple GB stones
e. Neck impacted stones

Ans. D ( table page 1249, 28th edition Bailey)

Bailey Update Question
• The following are high risk factors of CBD stones
a. Presence of Jaundice
b. 2 X normal times of LFT
c. > 10 Stones
d. CBD diameter > 10 mm

Ans. C ( Ref Table 71.4 , Bailey 28th edition page 1249)

Update point
• The gallbladder is separated from the liver bed for about 2 cm to allow confirmation of the
anatomy.
• Unless there are specific indications, routine cholangiogram is not performed.
• However, if doubt exists regarding the anatomy, cholangiogram is warranted.
• Real-time intraoperative imaging using indocyanine green (ICG) fluorescence
cholangiography (with special scopes and imaging system) improves visualisation of the
biliary tree during laparoscopic cholecystectomy and enables better visualisation and
identification of the biliary tree.
• It can be considered a means of increasing the safety of laparoscopic cholecystectomy.
• This is likely to reduce risk of biliary duct injury
Bailey update question
• The following are red flag signs during laparoscopic cholecystectomy except
a. Failure of timely progression
b. Anatomical disorientation
c. Difficult to visualize operative field
d. Instrument malfunction

Ans d ( Ref Table 71.5, Bailey 28th edition page 1250)

Update points
Update Points
Update points
Bailey update point
• B-SAFE method in laparosopic cholecystectomy uses following
landmarks except
a. Bile duct
b. Rouvier’s sulcus
c. Hepatic artery
d. Duodenum
e. Portal vein

Ans. E ( Ref Bailey 28th edition page 1251)

B SAFE Method
• Dissection on the posterior aspect of the hepatocystic triangle can be safely started
immediately ventral and cephalad to the sulcus.

• The B-SAFE method uses five anatomical landmarks (B, bile duct; S, sulcus of Rouviè re; A,
hepatic artery; F, umbilical fissure; E, enteric/duodenum) to correctly place a cognitive map
during dissection
Concept TIME OUT
• During difficult gallbladder surgery, the surgeon may become disoriented and enter the zone
of danger.
• To avoid this, the concept of time out has been introduced as it serves as a procedural
cognitive aid to recall and apply essential safety measures.
Judicious use of Energy device
With a monopolar energy device (mostly hook cautery), it is important to:

• keep a low setting (approximately 30 W) to avoid arcing of the current to the bile duct;
• Divide small amounts of the tissue at a time after a gentle pull to avoid injury to the deeper
structures by the heel of the cautery hook;
• Use intermittent short bursts of current at intervals to avoid thermal lateral spread;
• Avoid blind use of cautery in brisk bleeding.
• Lateral thermal spread occurs less with an ultrasonic energy source, but it may be
cumbersome to use the long and straight jaws to dissect in the hepato cystic triangle.
Stopping rules
• With the help of red flag signs (severe adhesions, severe acute inflammation, large impacted stone in
the neck of the gall- bladder, Mirrizzi syndrome, chronic inflammation with fibrosis or scarring), the
operating surgeon should be able to identify or pre-empt difficult situations that increase the risk of
biliary/ vascular injury and to stop in time.
Call for Help/ second opinion
• The operating surgeon should not hesitate to seek a second opinion whenever needed, and
this should be considered a sign of good clinical practice rather than of surgical ineptitude.
Bail out techniques
• The primary aim is the safety of the patient from biliary/vascular injury. It is important to
perform an alternative procedure (bailout technique) that allows the surgeon to complete the
operation in a safe manner.
• There are five bailout strategies:
1. Abort the procedure altogether;
2. Convert to an open procedure;
3. Carry out a tube cholecystostomy using a 14 Fr Foley catheter (a simple procedure to provide
symptomatic relief until a definitive procedure can be performed);
4. Carry out a subtotal cholecystectomy (open/laparoscopic):
5. Leaving behind a part of the gallbladder is safer than a dif- fcult dissection in the hepatocystic
triangle with a potential for bile duct injury in an attempt to remove the entire gallbladder;
6. Fundus-first approach.
Bailey update Question
• Memorial Sloan Kettering Cancer centre ( MSKCC) classification T stage criteria T2 means
a. Biliary confluence with unilateral extension into second order biliary radicles with no PV
involvement
b. Biliary confluence with unilateral extension into second order biliary radicles with
ipsilateral PV involvement
c. Biliary confluence with unilateral extension into second order biliary radicles with
contralateral PV involvement
d. Biliary confluence with Bilateral extension into second order biliary radicles with no PV
involvement
Ans B ( Ref Bailey 28th edition page 1257)
The MSKCC classification T-stage criteria for hilar
cholangiocarcinoma are as follows

● T1 tumour involving the biliary confluence without extension to second-order biliary radicles.
● T2 tumour involving the biliary confluence with unilateral extension to second-order biliary radicles
and ipsilateral portal vein involvement or ipsilateral hepatic atrophy.
● T3 tumour involving the biliary confluence with bilateral extension to second-order biliary radicles;
or unilateral extension to second-order biliary radicles with contra- lateral portal vein involvement; or
unilateral extension to second-order biliary radicles with contralateral hepatic lobar atrophy; or main or
bilateral portal venous involvement.
CT scan
• CT is not necessary for all patients, particularly those deemed to have a mild attack on
prognostic criteria.
• But a contrast-enhanced CT is indicated in the following situations:
If there is diagnostic uncertainty.
In patients with severe acute pancreatitis to distinguish interstitial from necrotising
pancreatitis .
• In the first 72 hours, CT may underestimate the extent of necrosis. The severity of
pancreatitis detected on CT may be staged according to the Balthazar criteria.
• In patients with organ failure, signs of sepsis or progressive clinical deterioration.
• When a localised complication is suspected, such as fuid collection, pseudocyst or a
pseudoaneurysm.
Bailey update question
• False about the cystic neoplasms of Pancreas
a. SCN is common in older women and appears like bubble wrap
b. MCN have ovarian stroma
c. IPMN mc in older women in head of pancreas
d. IPMN shows thick mucus extruding from ampulla on ERCP

Ans. C ( Ref Bailey 28th edition page 1281)

Cystic Neoplasms
• Serous cystadenomas are typically found in older women and are large aggregations of
multiple small cysts, almost like bubble wrap. They are benign.
• Mucinous tumours, on the other hand, have the potential for malignant transformation
• CNs are seen in perimenopausal women, show up as multilocular thick-walled cysts in the
pancreatic body or tail and, histologically, contain an ovarian-type stroma.
• IPMNs are more common in the pancreatic head and in older men
• IPMNs arising within the main duct are often multifocal and have a greater tendency to prove
malignant.
• Thick mucus seen extruding from the ampulla at ERCP is diagnostic of a main duct IPMN.
Bailey update question
• The following are absolute indications for surgery in IPMN/MCN except
a. CA 19-9>37IU/L
b. Mural nodules enhancing >10 mm
c. Main Pancreatic duct dilated > 10 mm
d. Jaundice+
e. Solid mass

Ans a ( Ref Fig 72.32, Bailey 28th edition page 1282)

Bailey update question
• The ideal treatment for Borderline resectable cancer in pancreas is
a. Neoadjuvant chemotherapy followed by surgery with adjuvant therapy followed
b. Preop chemotherapy followed by surgery
c. Systemic chemotherapy only
d. Surgery followed by Adjuvant chemotherapy
e. Neoadjuvant CRT followed by Surgery

Ans. A ( Ref Bailey 28th edition page 1284)

Patients will broadly fall into four
categories.
1. Resectable: these patients should be offered surgery, to be followed by adjuvant chemotherapy. Some
centres have begun to suggest that neoadjuvant chemotherapy be used prior to resection, but the
evidence is not strong.
2. Borderline resectable (usually because of significant venous occlusion or arterial abutment): these
patients may be offered neoadjuvant chemotherapy with/without chemoradiotherapy, to be followed by
surgical resection if the disease has been downstaged. Adjuvant therapy should follow.
3. Locally advanced and unresectable: ofer systemic chemo- therapy. Surgery may subsequently be
possible in a small cohort who get downstaged.
4. Metastatic: offer systemic chemotherapy
Bailey update Question
• Regarding the adjuvant therapy following pancreatic cancer surgery- False statement is
a. ESPAC 1 (2004) showed 5FU adjuvant CT showed improved median survival but no
advantage of RT
b. mFOLFIRONOX is modified 5FU+ Leucovorin, oxaliplatin and irinotecan
c. mFOLFIRINOX has median overall survival of over 54 months
d. Latest regimen is Gemcitabine+/- Capecitabine
e. R1 resection cases are offered CHEMORT –further trial in progress

Ans d ( Ref Bailey 28th edition page 1285)

Chemotherapy
• Starting with the large multicentre European study (ESPAC-1) in 2004, which showed an improvement
in median survival after adjuvant chemotherapy with 5-fuorouracil (5-FU) but no advantage with
adjuvant radiotherapy, there have been several further studies that have looked at gemcitabine alone,
gemcitabine with capecitabine and most recently modified fluorouracil plus leucovorin, oxaliplatin and
irinotecan (mFOLFIRINOX).
• The latter has been associated with disease-free survival of over 21 months and median overall survival
of over 54 months.
• Most patients with resected ductal adenocarcinoma are now ofered 6 months of adjuvant chemotherapy
with mFOLFIRINOX.
• Those with a poor functional status or a contraindication to mFOLFIRINOX are ofered gemcitabine
with/without capecitabine.
• Some centres continue to offer chemoradiotherapy, particularly in patients with involved (R1) resection
margins, and further trials of adjuvant chemoradiation are in progress.
Thank you…