Surgery: Upper GI, hepatobiliary and bariatric surgery

• Oesophagus: Dysphagia — The Surgical Approach | Reflux and Hiatus Hernia Surgery | Barrett's Oesophagus and Achalasia | Oesophageal Cancer | Oesophageal Perforation and Foreign Bodies
• Stomach: Peptic Ulcer Complications | Gastric Cancer and Other Gastric Tumours | Life After Gastrectomy
• Bariatric surgery: Obesity Surgery | Complications of Bariatric Surgery
• Gallbladder and bile ducts: Gallstones and Biliary Colic | Acute Cholecystitis | Bile Duct Stones and Cholangitis | Cholecystectomy and Its Complications | Obstructive Jaundice
• Pancreas, liver and spleen: Pancreatic Cancer and Other Pancreatic Tumours | Liver Lumps, Abscesses and Tumours | Liver Transplantation | Splenic Surgery
• Revision: Upper GI and HPB at a Glance | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🍽️ Upper GI, hepatobiliary and bariatric surgery — page 4 of the Surgery chapter. This covers the surgical side of the oesophagus, stomach, gallbladder, bile ducts, pancreas, liver and spleen, plus obesity surgery. The commonest problems are gallstones (colic, cholecystitis, cholangitis, pancreatitis); the most important not to miss are upper GI cancers, which present with dysphagia, weight loss and painless jaundice. Medical management of these organs is in the Gastroenterology chapters; acute pancreatitis is on the Acute Abdomen page.
Your four questions for every patient: Are there red flags for cancer (dysphagia, weight loss, anaemia, jaundice, a mass)? Is this a biliary emergency (cholecystitis, cholangitis) needing antibiotics and drainage? Does the patient need endoscopy, imaging or an MDT decision? Is the patient fit and nourished enough for major surgery?

Dysphagia — The Surgical Approach

• Dysphagia (difficulty swallowing) is a red flag — new dysphagia at any age needs an urgent (two-week wait) upper GI endoscopy (NICE NG12).
• Also refer urgently — people aged 55 and over with weight loss plus upper abdominal pain, reflux or dyspepsia; an upper abdominal mass; consider for persistent vomiting, iron deficiency anaemia and treatment-resistant dyspepsia.
• Patterns (see the Gastroenterology chapters):
  • Progressive dysphagia to solids, then liquids, with weight loss — cancer until proven otherwise.
  • Intermittent food sticking in a young atopic man — eosinophilic oesophagitis.
  • Solids and liquids from the start, regurgitation, chest pain — achalasia.
  • Long-standing reflux with slowly worsening dysphagia — peptic stricture.
  • Pharyngeal pouch (Zenker's diverticulum) — older people; regurgitating undigested food, gurgling, halitosis, aspiration.
• Investigations — OGD with biopsies first; barium swallow (pouch, motility), manometry (achalasia, spasm), CT staging if cancer.

Reflux and Hiatus Hernia Surgery

• Most reflux is treated medically — lifestyle (weight loss, stop smoking, avoid late meals, raise the head of the bed) and PPIs (see the Gastroenterology chapters).
• Anti-reflux surgery (laparoscopic fundoplication — wrapping the top of the stomach around the lower oesophagus: Nissen 360°, Toupet partial) — for selected patients with proven reflux (pH study, manometry) who:
  • Don't respond to or can't tolerate PPIs, or don't want lifelong medication.
  • Have troublesome regurgitation or volume reflux, or a large hiatus hernia.
• Side effects of fundoplication — dysphagia (usually temporary), "gas bloat" (can't belch), inability to vomit, more flatulence, wrap slipping or failing.
• Paraoesophageal (rolling) hiatus hernia — symptomatic ones are repaired (risk of gastric volvulus and strangulation — chest pain, retching without vomiting, inability to pass an NG tube — an emergency).
• Alternative procedures — magnetic sphincter augmentation and endoscopic techniques in specialist centres.

Barrett's Oesophagus and Achalasia

• Barrett's oesophagus — the normal squamous lining of the lower oesophagus is replaced by columnar (intestinal) lining from chronic reflux; risk of adenocarcinoma:
  • Endoscopic surveillance with biopsies — interval depends on the length of Barrett's and whether there is dysplasia (BSG guidance).
  • Dysplasia (especially high-grade) or early cancer — endoscopic treatment (endoscopic mucosal resection of nodules, then radiofrequency ablation) instead of oesophagectomy.
  • PPIs for reflux symptoms.
• Achalasia — loss of nerve cells in the oesophageal wall → the lower sphincter fails to relax and peristalsis is lost:
  • Dysphagia to solids and liquids, regurgitation of undigested food, chest pain, weight loss, aspiration (night cough).
  • Barium swallow — dilated oesophagus with a "bird's beak" narrowing; high-resolution manometry confirms; OGD excludes cancer at the junction ("pseudoachalasia").
  • Treatment — pneumatic balloon dilatation, laparoscopic Heller myotomy (cutting the sphincter muscle, usually with a partial fundoplication), or POEM (per-oral endoscopic myotomy); botulinum toxin injection for frail patients (temporary).
  • Slightly increased long-term risk of oesophageal cancer.

Oesophageal Cancer

• Two main types:
  • Adenocarcinoma — lower oesophagus and gastro-oesophageal junction; the commonest type in the UK; risk factors — reflux, Barrett's, obesity, male sex, smoking.
  • Squamous cell carcinoma — upper and middle oesophagus; risk factors — smoking, alcohol, hot drinks, poor diet, achalasia, caustic injury; common worldwide.
• Features — progressive dysphagia, weight loss, odynophagia (painful swallowing), regurgitation, cough (fistula to the airway), hoarseness (recurrent laryngeal nerve), iron deficiency anaemia; often advanced at diagnosis.
• Diagnosis and staging — OGD and biopsy; CT chest, abdomen and pelvis; PET-CT; endoscopic ultrasound (depth and nodes); staging laparoscopy for junctional tumours (peritoneal spread); fitness assessment (CPET); MDT decision.
• Curative treatment:
  • Early cancers — endoscopic resection.
  • Locally advanced but resectable — neoadjuvant chemoradiotherapy or perioperative chemotherapy, then oesophagectomy (e.g. Ivor Lewis — abdominal and right chest approach); definitive chemoradiotherapy for many squamous cancers.
  • Nutrition — dietitian input, feeding jejunostomy in some.
• Complications of oesophagectomy — anastomotic leak (sepsis, AF, chest pain), pneumonia (the commonest), chylothorax (milky chest drain fluid — thoracic duct injury), recurrent laryngeal nerve palsy, conduit necrosis, later stricture, reflux, dumping, weight loss.
• Palliation (most patients) — oesophageal stent for dysphagia, radiotherapy (external or brachytherapy), chemotherapy and immunotherapy, nutritional support, palliative care.

Oesophageal Perforation and Foreign Bodies

• Oesophageal perforation — causes: endoscopy and dilatation (the commonest), Boerhaave's syndrome (rupture after forceful vomiting, often after a heavy meal and alcohol), foreign bodies, trauma, cancer.
  • Features — severe chest or upper abdominal pain, vomiting, surgical emphysema (crackling under the skin of the neck — Mackler's triad of vomiting, chest pain and surgical emphysema), breathlessness, sepsis, shock.
  • Investigations — CXR (pneumomediastinum, pleural effusion — usually left), CT with oral contrast (leak).
  • Management — nil by mouth, IV fluids, broad-spectrum antibiotics and antifungals, PPI, critical care; drainage of collections; surgical repair, endoscopic stenting or clipping depending on site, timing and size; high mortality if delayed.
  • Mallory–Weiss tear — a mucosal tear after retching causing haematemesis — usually stops spontaneously (not a perforation).
• Food bolus obstruction — sudden inability to swallow after eating (often meat); urgent endoscopy (within hours if unable to swallow saliva — aspiration risk; otherwise within 24 hours); look for an underlying cause (eosinophilic oesophagitis, stricture, cancer).
• Swallowed foreign bodies — most pass; button batteries in the oesophagus (especially in children) cause burns and perforation within hours — emergency removal; multiple magnets can stick together across bowel walls — urgent surgical advice; sharp objects in the oesophagus need removal.

Peptic Ulcer Complications

• Bleeding — the commonest complication (see the Gastroenterology Emergencies chapter): resuscitation, endoscopic therapy first; if it fails or bleeding recurs — interventional radiology embolisation (e.g. gastroduodenal artery) or surgery (under-running the bleeding vessel).
• Perforation — see the Acute Abdomen page (repair with omental patch).
• Gastric outlet obstruction — scarring from chronic duodenal or pyloric ulcers, or cancer (gastric, pancreatic, duodenal):
  • Projectile vomiting of undigested food hours after meals, early fullness, weight loss, a succussion splash.
  • Metabolic — hypochloraemic, hypokalaemic metabolic alkalosis (loss of acid), dehydration, AKI.
  • Treatment — NG decompression, IV 0.9% saline with potassium, PPI, endoscopy (biopsy to exclude cancer), balloon dilatation, stent or surgery (gastrojejunostomy).
• After any complicated ulcer — test and treat H. pylori, stop NSAIDs, PPI, and repeat endoscopy for gastric ulcers to confirm healing and exclude cancer.

Gastric Cancer and Other Gastric Tumours

• Gastric adenocarcinoma:
  • Risk factors — H. pylori, smoking, high-salt and preserved foods, pernicious anaemia and atrophic gastritis, previous partial gastrectomy, family history (CDH1 mutation — hereditary diffuse gastric cancer and lobular breast cancer; prophylactic gastrectomy may be offered), Lynch syndrome.
  • Features — dyspepsia, early satiety, weight loss, anaemia, vomiting (outlet obstruction), dysphagia (cardia), upper GI bleeding, epigastric mass; often advanced at diagnosis.
  • Signs of spread — Virchow's node (left supraclavicular — Troisier's sign), Sister Mary Joseph nodule (umbilicus), Krukenberg tumours (ovaries), ascites, hepatomegaly; acanthosis nigricans (paraneoplastic).
  • Linitis plastica — diffuse infiltration making the stomach rigid ("leather bottle").
  • Staging — OGD and biopsy, CT, staging laparoscopy (peritoneal disease), PET-CT in some; MDT.
  • Curative treatment — perioperative chemotherapy (e.g. FLOT) and gastrectomy (subtotal or total, with lymph node removal); endoscopic resection for very early cancers.
  • Palliation — chemotherapy and immunotherapy (HER2-targeted drugs in HER2-positive cancers), stents for obstruction, radiotherapy for bleeding.
• Gastrointestinal stromal tumour (GIST) — from interstitial cells of Cajal; KIT (CD117) positive; bleeding or a mass; surgery ± imatinib.
• Gastric MALT lymphoma — linked to H. pylori — often regresses after eradication therapy.
• Gastric neuroendocrine tumours — some linked to atrophic gastritis (high gastrin); often small and slow-growing.

Life After Gastrectomy

• Nutritional deficiencies:
  • Vitamin B12 — no intrinsic factor after total gastrectomy — lifelong IM hydroxocobalamin.
  • Iron deficiency (less acid, bypassed duodenum), calcium and vitamin D (bone loss), folate.
  • Weight loss and malnutrition — small frequent meals, dietitian support.
• Dumping syndrome:
  • Early dumping (10–30 minutes after eating) — food rushes into the small bowel, drawing in fluid → abdominal pain, bloating, diarrhoea, palpitations, flushing, faintness.
  • Late dumping (1–3 hours after eating) — a rapid glucose rise triggers excess insulin → hypoglycaemia (sweating, shaking, confusion).
  • Management — small frequent meals, avoid sugary foods and drinks, more protein and fibre, drink fluids between rather than with meals; acarbose or octreotide in severe cases.
• Other problems — bile reflux, small stomach syndrome (early fullness), afferent loop syndrome (after some reconstructions), anastomotic stricture or ulcer, recurrence of cancer.
• The same issues apply to some degree after oesophagectomy and gastric bypass.

Obesity Surgery

• Bariatric (metabolic) surgery — the most effective long-term treatment for severe obesity; often puts type 2 diabetes into remission and improves hypertension, sleep apnoea, fatty liver and survival.
• Who to consider (NICE) — BMI 40 or more, or 35–39.9 with significant obesity-related disease (e.g. type 2 diabetes, hypertension, sleep apnoea); after trying non-surgical measures (including specialist weight management); fit for surgery and committed to long-term follow-up. Expedited assessment for recent-onset type 2 diabetes with BMI 35 or more (and consideration from 30); lower BMI thresholds for people of South Asian, Chinese, other Asian, Middle Eastern, Black African and African-Caribbean family background.
• Operations:
  • Sleeve gastrectomy — removing most of the stomach, leaving a narrow tube; reduces appetite (less ghrelin); can worsen reflux.
  • Roux-en-Y gastric bypass — a small stomach pouch joined to the small bowel, bypassing most of the stomach and duodenum; strong effects on diabetes and reflux.
  • One-anastomosis gastric bypass — a simpler bypass variant.
  • Adjustable gastric band — less used now (slippage, erosion, poor long-term results).
• Before surgery — MDT assessment (surgeon, dietitian, psychologist, physician), optimise diabetes and sleep apnoea, stop smoking, sometimes a low-calorie liver-shrinking diet.
• GLP-1 agonists and tirzepatide are now alternatives or additions for many people (see the Endocrine chapters).

Complications of Bariatric Surgery

• Early — anastomotic or staple-line leak (tachycardia — often the first and only sign; fever, pain, breathlessness — low threshold for CT or return to theatre), bleeding, VTE, pneumonia, wound infection.
• Later surgical problems:
  • Internal hernia after gastric bypass — intermittent colicky pain, bowel obstruction; CT may look normal — low threshold for laparoscopy.
  • Marginal ulcer at the bypass join — pain, bleeding, perforation; risk with NSAIDs and smoking.
  • Strictures (vomiting), gallstones (rapid weight loss), reflux after sleeve, band slippage or erosion.
• Nutritional deficiencies (especially after bypass) — iron, vitamin B12, folate, calcium and vitamin D (bone disease), zinc, copper, vitamin A, protein; thiamine deficiency with prolonged vomiting → Wernicke's encephalopathy (give IV thiamine). Lifelong supplements and at least yearly blood tests (BOMSS guidance).
• Metabolic — dumping syndrome, post-bypass hypoglycaemia (late dumping), kidney stones (oxalate).
• Medicines — absorption may change (avoid modified-release forms where possible, review doses); avoid NSAIDs; oral contraceptives may be less reliable after bypass (use long-acting methods); diabetes and blood pressure drugs often need reducing quickly after surgery.
• Pregnancy — usually advised to wait 12–18 months after surgery; extra nutritional monitoring; avoid glucose tolerance tests after bypass (dumping) — use glucose monitoring.
• Psychological — weight regain, eating disorders, depression, increased risk of alcohol misuse (alcohol is absorbed faster after bypass), self-harm — support and follow-up.

Gallstones and Biliary Colic

• Gallstones are very common (about 1 in 10 adults); most cause no symptoms and need no treatment.
• Types — cholesterol stones (most), pigment stones (haemolysis — sickle cell disease, hereditary spherocytosis; cirrhosis), mixed.
• Risk factors — female, older age, obesity, pregnancy and oestrogen, rapid weight loss (including bariatric surgery), family history, diabetes, Crohn's disease or ileal resection (loss of bile acids), haemolysis, parenteral nutrition, drugs (octreotide, fibrates, ceftriaxone sludge).
• Complications — biliary colic, acute cholecystitis, bile duct stones (obstructive jaundice), cholangitis, acute pancreatitis, Mirizzi syndrome (stone in the gallbladder neck compressing the common hepatic duct — jaundice), gallstone ileus, gallbladder cancer (rare).
• Biliary colic — the gallbladder contracts against a stone blocking its neck:
  • Right upper quadrant or epigastric pain, often after fatty meals or at night, lasting from about 30 minutes to a few hours (usually under 6 hours), may radiate to the right shoulder or back, with nausea; the patient is otherwise well, without fever, and LFTs are usually normal.
  • Ultrasound confirms stones.
  • Treatment — analgesia (NSAIDs are effective), then elective laparoscopic cholecystectomy (NICE CG188); dietary fat reduction may help symptoms while waiting.

Acute Cholecystitis

• Inflammation of the gallbladder, usually from a stone stuck in the gallbladder neck or cystic duct (the obstructed gallbladder becomes inflamed and often infected).
• Features — constant right upper quadrant pain lasting over 6 hours, fever, vomiting, tenderness with Murphy's sign (pain stops inspiration when pressing under the right ribs), raised WCC and CRP; LFTs may be mildly abnormal (marked jaundice suggests a bile duct stone or Mirizzi syndrome).
• Ultrasound — stones, thickened gallbladder wall, fluid around the gallbladder, sonographic Murphy's sign.
• Management:
  • Analgesia, IV fluids, antibiotics (e.g. co-amoxiclav, or per local policy), nil by mouth initially.
  • Early laparoscopic cholecystectomy — ideally within 1 week of diagnosis (NICE) — fewer recurrences and shorter total stay than delayed surgery.
  • Percutaneous cholecystostomy (a drain into the gallbladder under imaging) for patients too unwell for surgery or not responding.
• Complications — empyema (pus-filled gallbladder — high fever, very ill), gangrene and perforation (peritonitis), pericholecystic abscess, cholecystoenteric fistula (gallstone ileus).
• Variants — acalculous cholecystitis (no stones — critically ill ICU patients, burns, trauma, parenteral nutrition — high risk of gangrene); emphysematous cholecystitis (gas-forming organisms — older diabetic men — emergency).

Bile Duct Stones and Cholangitis

• Choledocholithiasis (stones in the common bile duct) — obstructive jaundice (dark urine, pale stools, itch), biliary pain, raised bilirubin and ALP and GGT; may cause pancreatitis or cholangitis.
• Investigations — ultrasound (dilated bile duct — over about 6 mm, more in older people and after cholecystectomy), MRCP (non-invasive picture of the ducts), endoscopic ultrasound.
• Treatment — ERCP with sphincterotomy and stone removal (risks: pancreatitis, bleeding, perforation, cholangitis), or laparoscopic bile duct exploration at the time of cholecystectomy; then cholecystectomy to prevent recurrence (if fit).
• Acute cholangitis — infection of an obstructed bile duct — a life-threatening emergency:
  • Charcot's triad — fever (with rigors), jaundice, right upper quadrant pain.
  • Reynolds' pentad — the triad plus confusion and shock (severe).
  • Causes — stones (most), strictures, tumours, blocked stents, after ERCP.
  • Management — Sepsis Six, IV antibiotics (e.g. co-amoxiclav, or piperacillin–tazobactam if severe), fluids, correct clotting (IV vitamin K), and urgent biliary drainage — ERCP (within 24 hours in severe cholangitis, or within 48–72 hours if responding) or percutaneous transhepatic drainage if ERCP fails or isn't possible.
• Gallstone ileus — a large stone erodes from the gallbladder into the bowel (fistula) and blocks the terminal ileum — older women with small bowel obstruction and gas in the bile ducts (pneumobilia) on imaging; surgery to remove the stone.

Cholecystectomy and Its Complications

• Laparoscopic cholecystectomy — one of the commonest operations; usually a day case or short stay; open conversion in a few percent (severe inflammation, adhesions, bleeding).
• Safety — the surgeon identifies the "critical view of safety" (the cystic duct and artery clearly seen entering the gallbladder, within Calot's triangle) before clipping and cutting, to avoid bile duct injury; subtotal cholecystectomy is used when anatomy is unsafe.
• Complications:
  • Bile leak (from the cystic duct stump or small ducts in the liver bed) — pain, fever, bile in a drain, collections — ERCP and stent, drainage.
  • Bile duct injury (uncommon but serious) — jaundice, bile leak, sepsis, later strictures — needs specialist hepatobiliary repair.
  • Retained bile duct stones — jaundice or cholangitis after surgery — ERCP.
  • Bleeding, infection, port-site hernia, bowel injury.
  • Post-cholecystectomy symptoms — continuing pain or diarrhoea in some (bile acid diarrhoea, retained stones, sphincter problems, or the original symptoms weren't biliary).
• Most people live normally without a gallbladder; a few have looser stools after fatty meals.

Obstructive Jaundice

• Features — jaundice with dark urine, pale stools and itch; raised conjugated bilirubin, ALP and GGT; dilated ducts on ultrasound.
• Causes:
  • Painful — bile duct stones (often with colic, cholangitis or pancreatitis), Mirizzi syndrome.
  • Painless — cancer of the head of the pancreas, cholangiocarcinoma, ampullary cancer, lymph nodes at the porta hepatis, benign strictures (PSC, chronic pancreatitis, previous surgery).
• Courvoisier's law — painless jaundice with a palpable, non-tender gallbladder is unlikely to be from stones (scarred gallbladders don't distend) — think pancreatic or distal bile duct cancer.
• Investigations — LFTs, clotting, ultrasound, then CT (pancreas protocol) for suspected tumours or MRCP; tumour marker CA19-9 (supportive, not diagnostic); EUS-guided biopsy.
• Before procedures in jaundiced patients:
  • Correct clotting — IV vitamin K (vitamin K absorption needs bile).
  • Hydrate well — jaundiced patients are prone to AKI (especially with contrast and surgery).
  • Antibiotic prophylaxis for ERCP or drainage; treat cholangitis.
  • Itch — colestyramine, antihistamines; relieve the obstruction.
• Don't stent before an MDT decision in a potentially resectable pancreatic cancer unless cholangitis or very high bilirubin makes it necessary (stents can complicate surgery).

Pancreatic Cancer and Other Pancreatic Tumours

• Pancreatic ductal adenocarcinoma:
  • Risk factors — smoking, chronic pancreatitis, obesity, older age, family history and inherited syndromes (BRCA2, Lynch, Peutz–Jeghers), long-standing diabetes; new-onset diabetes over 60 with weight loss can be an early sign.
  • Features — painless obstructive jaundice (head), weight loss, upper abdominal or back pain (body and tail — often presents late), loss of appetite, steatorrhoea, new diabetes, migratory thrombophlebitis (Trousseau's sign), VTE, depression.
  • Diagnosis — CT pancreas protocol, CA19-9, EUS with biopsy; staging (CT chest, sometimes PET or laparoscopy); MDT.
  • Only about 1 in 5 are resectable at diagnosis (no distant spread and limited vessel involvement).
  • Surgery — Whipple's operation (pancreaticoduodenectomy) for head tumours; distal pancreatectomy (with splenectomy) for body and tail; followed by adjuvant chemotherapy (or given before surgery for borderline tumours).
  • Complications of Whipple's — pancreatic fistula (leak), delayed gastric emptying, bile leak, bleeding (a "sentinel bleed" may precede major haemorrhage from a pseudoaneurysm), diabetes, exocrine insufficiency.
  • Palliation (most patients) — biliary stent (ERCP) for jaundice, duodenal stent for outlet obstruction, chemotherapy (e.g. FOLFIRINOX or gemcitabine-based), coeliac plexus block for pain, pancreatic enzyme replacement (often under-used — NICE NG85), VTE treatment, palliative care.
• Pancreatic cystic lesions — often found incidentally; some (mucinous cysts, IPMN) can become cancerous — surveillance or surgery by features.
• Pancreatic neuroendocrine tumours — insulinoma (fasting hypoglycaemia), gastrinoma (Zollinger–Ellison), glucagonoma, VIPoma, non-functioning; MEN 1 association; surgery, somatostatin analogues (see the Endocrine chapters).
• Chronic pancreatitis — surgery or endoscopic treatment for strictures, stones, pseudocysts or intractable pain in selected patients.

Liver Lumps, Abscesses and Tumours

• An incidental liver lesion — characterise with contrast MRI or CT; consider the background (cirrhosis, known cancer, travel); MDT discussion if uncertain.
• Liver resection — up to about two-thirds of a healthy liver can be removed (it regrows); liver failure is a risk if too little is left, especially in cirrhosis.

Liver Transplantation

• Indications:
  • Chronic liver disease with decompensation (ascites, encephalopathy, variceal bleeding, jaundice) or poor prognosis (UKELD score above the threshold), or poor quality of life (intractable itch, recurrent cholangitis).
  • Acute liver failure (e.g. paracetamol overdose, viral, drug-induced) meeting King's College criteria — super-urgent listing.
  • Hepatocellular carcinoma within size and number criteria.
  • Metabolic and inherited diseases (Wilson's, alpha-1 antitrypsin deficiency, some childhood disorders).
• Alcohol-related liver disease — assessment includes abstinence and support to stay abstinent (a period of abstinence and engagement with alcohol services is usually expected).
• After transplant — lifelong immunosuppression (tacrolimus-based — interactions, kidney toxicity, diabetes), infection risk, rejection, biliary complications (strictures, leaks), recurrence of the original disease, skin cancers.
• Refer early — discuss with a transplant centre when a patient with cirrhosis first decompensates, or immediately in acute liver failure.

Splenic Surgery

• Splenic trauma — the most commonly injured organ in blunt abdominal trauma (left lower rib fractures, left shoulder tip pain — Kehr's sign):
  • Haemodynamically stable — non-operative management (observation, serial examination and Hb), angioembolisation for active bleeding on CT.
  • Unstable — splenectomy (or splenic repair) in theatre.
  • Delayed rupture can occur days later — advise patients to return with new pain or dizziness.
• Elective splenectomy — ITP not responding to medical treatment, hereditary spherocytosis and other haemolytic anaemias, hypersplenism, splenic cysts, abscess or tumours, some lymphomas; usually laparoscopic.
• After splenectomy — vaccinations (pneumococcal, Hib/MenC, MenACWY, MenB, yearly flu — ideally 2 weeks before elective surgery or 2 weeks after), antibiotic prophylaxis and stand-by antibiotics, alert card, raised platelets (VTE risk), malaria precautions; risk of overwhelming post-splenectomy infection (see the Haematology Anatomy, Physiology and Pharmacology chapter).
• Complications of splenectomy — bleeding, injury to the pancreatic tail (pancreatic fistula), left lower lobe atelectasis and effusion, subphrenic abscess, gastric injury, thrombocytosis and portal vein thrombosis.

Upper GI and HPB at a Glance

Spot the Diagnosis