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152
R. Caiafa et al.
less nutritional support. Prealbumin is the most commonly
used serum marker to estimate nutritional status.
Timing
The benets of early enteral nutrition have been well established in patients who are critically ill and injured. It should
be started within the rst 24–48h after ICU admission when
appropriate. TPN is usually only initiated if the patient is
expected to be NPO for more than 7days. Enteral and parenteral nutrition is contraindicated in uncontrolled shock, need
for high dose pressors, progressive acidosis, and uncontrolled hypoxemia and acidosis. Enteral nutrition is also contraindicated in patients with uncontrolled upper GI bleeding,
bowel ischemia, bowel obstruction, abdominal compartment
syndrome, GI intolerance, and high-output stulas without
distal feeding access.
Enteral Nutrition
This is the preferred route because it preserves the gut mucosal barrier and decreases infectious complications in surgical
ICU patients through a variety of mechanisms. It also avoids
the complications associated with parenteral nutrition.
Nonsurgical Enteral Access
This approach is preferred in patients who only need shortterm nutritional support. Nasogastric tubes can be placed at
the bedside or under uoroscopic or endoscopic guidance.
Distal feeding tubes can be used in patients with proximal
dysmotility or obstruction or severe esophagitis. They are
placed under uoroscopic or endoscopic guidance. Distal
feeding tubes have been shown in some studies to decrease
the risk of aspiration and pneumonia compared with gastric
tubes.
Surgical Enteral Access
This approach is preferred in patients who will require
long-term nutritional support. The two most common types
of surgical feeding tubes are gastrostomy and jejunostomy.
Gastrostomy tubes can be placed endoscopically, radiographically, or surgically, while jejunostomy tubes are typically placed surgically. Contraindications to all surgical
feeding tube placement include gastric varices, severe coagulopathy, massive ascites, gastroparesis, gastric outlet
obstruction, hemodynamic instability, increasing pressor
requirements, and worsening acidosis. Contraindications to
endoscopic placement include esophageal or oropharyngeal
obstruction and high risk of aspiration.
Gastrostomy tubes are the most common type of surgical
enteral access. Jejunostomy tube placement is indicated in
patients who cannot have a gastrostomy tube placed, such as
those with prior resection of the esophagus, stomach, pancreas, or duodenum. Combination tubes, such as a gastrostomy with a jejunostomy limb, can also be placed.
Prior to the procedure, it is key to obtain a surgical history, specically for abdominal operations. Patients with a
history of gastric resection deserve special consideration
when planning surgical tube placement, although this is not
an absolute contraindication. CT abdomen/pelvis may also
be helpful to delineate anatomy, although it is not required.
For PEG tube placement, 1:1 ballottement of single nger
palpation at the insertion site and transillumination are mandatory to safely proceed with the operation. Gastrostomy and
jejunostomy tubes can also be placed laparoscopically or
during laparotomy. Typically these are elective procedures
performed on relatively stable patients.
Open Stamm Gastrostomy
• Choose site that will come up easily to anterior left
abdominal wall and is not adjacent to pylorus or GE
junction
• Purse-string suture around anticipated location of gastrot-
omy. Can perform two purse-string sutures
• Insert tube through abdominal wall
• Perform two or four sutures through abdominal wall and
gastric serosa to be tied later
• Make gastrotomy within area of purse-string suture, can
use bovie electrocautery
• Insert tube, close pursestrings, tie the abdominal wall
sutures
• Inate balloon
Open Jejunostomy
• Choose site ~30cm distal to ligament of Treitz that will
easily approximate to left anterior abdominal wall
• Conduct a purse-string suture at that site
• Insert jejunostomy tube through abdominal wall
• Create enterotomy
• Insert tube, close pursestring, and ll balloon—ensure
balloon is not occlusive of jejunal lumen
• Place two or four sutures through abdominal wall and
jejunal serosa to be tied later
• Witzel (optional) entails serosal tunnel of jejunum cir-
cumscribing a portion of the jejunostomy tube
• Tie abdominal wall sutures
The most common complication associated with these
tubes is displacement. Tubes with a well-formed tract can be
replaced at the bedside with a Foley or gastrostomy tube with
a balloon. This should be done as soon as possible, and a
study, either abdominal XR or CT abdomen/pelvis, using
water-soluble contrast via the replaced tube should be
obtained to conrm appropriate placement before using the
tube for medications or feeds. Tubes displaced prior to tract
47 Feeding Tubes andNutritional Support
153
formation likely need to proceed to the OR for washout, gastrostomy or jejunostomy closure, and tube replacement,
especially when the patient exhibits peritonitis, hemodynamic instability, or septic shock. Other complications
include tube occlusion and bowel obstruction either due to
torsion around the tube or luminal obstruction by the
balloon.
Total Parenteral Nutrition (TPN)
TPN is used when enteral nutrition cannot be initiated or is
inadequate, such as in patients with severe obstruction or
ileus, severe shock, high output stula, severe GI bleeding,
short gut syndrome, or patients who do not have GI
continuity.
Risks include mechanical complications associated with
central line placement, such as pneumothorax, hemothorax,
and arterial puncture; line sepsis; electrolyte disturbances;
and liver dysfunction. Gut disuse is also associated with
mucosal atrophy, bacterial overgrowth, diminished blood
ow, and decreased gut immunity, which all can lead to bacterial translocation across the intestinal wall and increased
infection risk. TPN should not be abruptly stopped, as this
may cause severe hypoglycemia.
Common Curveballs
Clean Kills
• Proceeding with PEG tube placement without 1:1 ballottement of single nger palpitation and
transillumination
• Failure to proceed to OR after tube displacement in a
patient with hemodynamic instability, peritonitis, or septic shock
• Using barium instead of water-soluble contrast to conrm
tube placement after dislodgement
• Using a replaced tube without radiologic conrmation
after dislodgement
• Abrupt discontinuation of TPN resulting in
hypoglycemia
Summary
• Early nutrition is benecial in critically ill patients
• Enteral nutrition is preferred over parenteral nutri-
tion when appropriate
• The most common tube complication is displacement,
and management depends on how long the tube has
been in place
• The most common TPN complications are associated
with central line placement and infection
• Overfeeding related metabolic abnormalities that may
lead to difculty weaning from the ventilator
• Development of refeeding syndrome, which is suggested
by hypophosphatemia, hypokalemia, and hypomagnesemia in patients with prolonged malnutrition, excessive GI
losses, chronic alcohol abuse, metastatic cancer, or recent
abdominal surgery
Bibliography
Courtney T.Sabiston textbook of surgery: the biological basis of mod-
ern surgical practice. 21st ed. St. Louis: Elsevier; 2022.
John C.Current surgical therapy. 14th ed. Philadelphia: Elsevier; 2023.
Justin D.Clinical scenarios in surgery: decision making and operative
technique. 2nd ed. Philadelphia: Wolters Kluwer; 2019.
Gastric andEsophageal Varices
MatthewSturdivant, YasamanKazerooni,
andLuisCardenas
48
Scenario
A 55-year-old male with a history of ETOH abuse and cirrhosis who presents to the ED in extremis with hematemesis.
He is hypotensive, tachycardic, choking on blood, short of
breath with oxygen saturations in the upper 80s. He was lost
to follow-up after being denied a liver transplant as he was
continuing to drink ETOH daily. On examination, he has spider angiomas, caput medusa, and mild jaundice of his skin.
He presents with a sudden change in his mental status, and
continued large volume hematemesis. You go to see him in
the ED, what is your next step?
Dierential Diagnosis
Bleeding gastric ulcer, Dieulafoy lesion, Mallory Weis tear,
Boerhaave syndrome, traumatic esophageal injury.
Etiology
Cirrhosis and other causes of increased portal hypertension
cause esophagogastric varices. Pre-hepatic causes of portal
hypertension are schistosomiasis and portal vein thrombosis.
Intrahepatic causes of portal hypertension are many with cirrhosis due to alcohol abuse being the most common. Posthepatic causes include hepatic vein thrombosis, right heart
failure, and other causes of cardiac obstruction. Varices can
also form from splenic vein thrombosis. Varices most likely
occur in the distal 1/3 of the esophagus and can occur
throughout the stomach. Screening for varices should start
early in patients with the above causes as bleeding is a fatal
M. Sturdivant · Y. Kazerooni · L. Cardenas (*)
Division of Surgical Critical Care and Trauma, Department of
Emergency General Surgery, Christiana Care Hospital,
Newark, DE, USA
e-mail: yasaman.kazerooni@christianacare.org;
lcardenas@christianacare.org
complication of varices. Only 50% of bleeding from varices
does not stop spontaneously, while 80–90% of the upper GI
bleeds of other causes may stop spontaneously (Friedman
etal. 2022). There is a signicantly high risk of rebreeding
within 10days of initial bleed. Mortality rate is 5–50% with
bleeding and 60–70% with continued bleeding (Friedman
etal. 2022). Patients with variceal bleeding can have bacterial infections with vatical bleeding (20%) and can develop
them in hospitalized patients (50%) which compounds mortality risk if not treated (Friedman etal. 2022). The risk of
mortality is higher when the bleeding is combined with
decompensated cirrhosis. Mortality in recent years has
decreased due to prophylactic antibiotics, use of betablockers, and more effective endoscopic techniques.
Exam
• The ABC’s in trauma are very important to evaluate every
patient in extremis regardless of etiology.
– Secure the airway—The possible large volume of
hematemesis puts the patient at high risk of aspiration
and securing the airway will allow expeditious endoscopic procedure to proceed if the bleeding does not
stop spontaneously.
– Breathing to be evaluated quickly oxygenation and
ventilation.
– Circulation involves
Obtaining large bore IV access.
Administration of blood products and activation of
massive transfusion in the hemodynamically unstable patient.
Cardiac monitoring.
– Assessing GCS is another key portion when evaluating
the patient with profound blood loss causing decreased
mental status.
• Evaluating the patient for pallor, amount of blood loss,
jaundice, palmar erythema.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_48
155
156
M. Sturdivant et al.
• Abdominal examination may reveal palpable hard liver,
palpable spleen, caput medusa, spider telangiectasia,
pain, ascites.
• Rectal examination may reveal bright red blood per rectum or melena depending on the acuity of the bleed.
• You may not know the etiology of the upper GI bleed or
have a high suspicion for variceal bleeding, so proceed
with an upper GI bleed algorithm initially until denitive
diagnosis is achieved.
• Reverse coagulopathy with bleeding. However, elevated
INR may be present in a cirrhotic patient due to underlying liver disease. To conrm coagulopathy, a TEG study
would be benecial.
• EGD is the primary imaging and diagnostic technique
used for variceal bleeding especially in the acute setting.
• Unstable bleeding patients do not belong in the CT
scanner.
• Ensure proper documentation of the varies noted on
endoscopy to ensure proper management (see Table48.1).
• Patients in stable condition who are not actively bleeding
Work Up
may have CT scans that demonstrate the varices, recanalization of the umbilical vein.
• If the patient is in extremis, this expedites the need for
care.
• Lab testing can reveal multiple possible processes related
to the varices such as increased LFTs, low sodium, possible low hemoglobin from hemorrhage, prolonged INR
and bleeding times, low albumin, pancytopenia, and ele-
• Measuring the hepatic vein wedge pressure with a catheter is also a possibility for evaluating the degree of portal
hypertension.
• A pressure of >12 mmHg signies portal hypertension
high enough to start variceal bleeding.
• The normal hepatic venous pressure gradient is <5.
vated BUN from bleeding.
Table 48.1 General rules for recording esophageal varies in Japan
Location (L) Form (F) Color (C) Red color signs (RC)
Ls (locus superior) F0 (no varices) Cw (white) RWM (red whale markings)
Lm (local medialis) F1 (straight, small) Cb (blue) CRS (cherry red spots)
Li (locus inferior) F2 (moderately enlarged, beady) Cw-Th (thrombosed, white) HCS (hematocystic spots)
Lg-c (adjacent to cardiac orice) F3 (markedly enlarged, nodular or
tumor-shaped)
Lg-cf (extension from cardiac
orice to fornix)
Lg-f (isolated in fornix)
Lg-b (gastric body)
Lg-a (gastric antrum)
Reproduced from: Endoscopic management of esophagogastric varices in Japan. Ann Transl Med. 2014 (Miyaaki etal. 2014)
Cb-Th (thrombosed, blue) Esophageal varices: RC0, RC1,
RC2, RC3.
48 Gastric andEsophageal Varices
157
Medical Management
Management of the esophagogastric varices must undergo
multidisciplinary methods.
• Adequate monitoring in a critical care setting
– The ICU is the best place for acutely bleeding patients
as invasive monitoring, procedures, and escalated care
can be provided to the patient.
• Avoid over resuscitation with crystalloids, use blood and
blood product resuscitation to euvolemia or until the
patient is hemodynamically stable with improved end
organ perfusion.
– Hemoglobin threshold of 7g/dL to avoid elevated por-
tal pressures and exacerbation of bleeding.
– Platelets >50.
– TEG guided resuscitation of a massive bleeding patient
to reverse coagulopathy of hemorrhage.
• Ceftriaxone (1g every 24h for 7days) is the preferred
prophylactic antibiotic used for variceal bleeding.
Fluoroquinolones are also used for patients with allergies
to the cephalosporins or penicillins.
• Vasopressin and Terlipressin should be initiated early to
lower portal pressures. Used for 24 h and 2–5 days,
respectively (Friedman etal. 2022; Go 2019).
• Octreotide is used in variceal bleeding to decrease bleeding via reduction of portal pressure and indirect vasoconstriction of the associated vessels. Rebleeding, mortality,
and reduced need for transfusions are also decreased with
octreotide. Fifty micrograms octreotide bolus is then followed by 50μg/h drip for 5days (Friedman etal. 2022;
Go 2019).
• Beta blockers are used to decrease the portal pressure in
stable patients without bleeding. If a proton pump inhibitor is started while the etiology was unclear in the UGIB,
it can be stopped after bleeding varices are found.
• After bleeding is controlled an EGD is usually repeated
2–4 weeks later to re-evaluate the esophagus and
stomach.
• A temporizing technique for bleeding that is not controlled with banding or other endoscopic techniques is
balloon tamponade. Blakemore-Sengstaken or Minnesota
tubes are used to tamponade the massive variceal bleeding (Friedman etal. 2022; Go 2019; Klingensmith et al.
2016). This is only a temporary x. The balloons have
different ports and ination channels to inate the balloons in the stomach and the esophagus depending on the
location of the bleeding after appropriate seating, usually
50cm from the teeth. There are also ports along the tubes
to test within the esophagus or the stomach for bleeding.
The balloon must be deated at serial intervals during the
day to prevent ischemia and necrosis. This allows the
medical and surgical team time to resuscitate the patient
or get the patient to IR or OR for interventions.
• Transjugular intrahepatic portosystemic shunt (TIPS) is
performed for recurrent bleeding or massive bleeding.
This creates a shunt between the portal and hepatic veins
to decrease the portal pressure to assist in the cessation of
the bleeding (see Image 48.1). This is 90% effective in
stopping the bleeding and should also be considered in
Child-pugh B and C patients early in the course as there is
a mortality benet (Friedman et al. 2022; Go 2019;
Klingensmith et al. 2016). In any of the shunting techniques, there is a risk of encephalopathy.
• Balloon tamponade, sclerosant injection or coils can also
be injected into the veins to control pressure in interventional radiology.
• Surgical techniques involve creating a shunt between the
systemic veins and the portal veins (nonselective shunts).
Surgical/Procedural Management
• EGD is the preferred method for evaluation and treatment
of the varices. This therapy should be initiated within 12h
or as soon as possible for hemorrhage control. Looking
for the bleeding varices are crucial to identify during
upper endoscopy (white nipple and or red wale signs).
Adequate visualization is critical. Suction old blood.
• Typical therapies for treating the varices include clipping,
cryoablation, sclerotherapy, injection, stenting, hemostatic sprays, and banding.
• Banding is the most effective for distal esophageal varices
and is less effective for gastric varices. This controls acute
bleeding in >90% of patients with a risk of recurrent
bleeding in 30% of patients after the banding.
Image 48.1 TIPS procedure. (Modied from: https://www.saintluke-
skc.org/health- library/tips- transjugular- intrahepatic- portosystemicshunt)
158
M. Sturdivant et al.
• Selective shunts create a connection between the splenic
veins and renal veins.
• In these cases, the GE junction can be devascularized as
described in the segura procedure or the esophagus can be
transected after ligation of the varices.
• Transplant is a denitive therapy for the varices as well as
liver dysfunction.
Follow-Up
• Patients should be maintained on beta blockers to decrease
splanchnic ow (nadolol, carvedilol, propranolol).
• Serial ligations every 2–4 weeks should be also performed in stable, recovered patients until all varices are
gone.
Clean Kills
• Not performing adequate resuscitation
• Not escalating to the ICU
• Not obtaining denitive airway
• Bringing an unstable patient to radiology for imaging
• Going to the OR without EGD rst
Words ofWisdom
• Don’t forget to take these high stakes cases one step at a
time in an algorithmic fashion.
• Remember to work up the liver disease and if the patient
survives the initial bleed to get source control or denitive
therapy.
Bibliography
Friedman S, etal. Greenberger’s current diagnosis and treatment: gas-
troenterology, hepatology, and endoscopy. 4th ed. McGraw-Hill
Education; 2022.
Go RC. Critical care examination and board review. McGraw-Hill
Education; 2019.
Klingensmith ME, et al. The Washington manual of surgery. 7th ed.
Wolters Kluwer Health; 2016.
Miyaaki H, etal. Endoscopic management of esophagogastric varices
in Japan. Ann Transl Med. 2014;2(5):42. https://doi.org/10.3978/j.
issn.2305- 5839.2014.05.02.
Dieulafoy Lesions
YasamanKazerooni, MatthewSturdivant,
andLuisCardenas
49
Overview
A Dieulafoy lesion is an aberrant vessel that does not reduce
in caliber when it extends from the submucosa to the mucosa.
This large submucosal arterial malformation that usually
occurs within 6cm of the GE junction in the stomach and
can cause massive GI hemorrhage if it ruptures or intermittent bleeding that is unable to be identied. When bleeding
episodes result in hemodynamic instability, there is an absolute need for transfusion of multiple blood products. As the
patients presenting with Dieulafoy lesions often have concomitant cardiac and renal disease, familiarity with this condition is relevant as these patients are at risk of
transfusion-related injuries and signicant morbidity and
mortality.
History and physical for any scenario involving GI bleed
should include malignancy risk factors (smoked meats, family history, weight loss etc.), alcohol use, smoking, NSAID
use, history of H. pylori, history of cirrhosis or portal hypertension, history of pancreatitis, prior endoscopies, prior foregut surgery, and use of anticoagulants or sources of
coagulopathy.
When managing a patient with GI bleeds, always mention
admitting them to a monitored settings, maintain at least two
large bore peripheral IVs, type and crossmatch, secure the
airway in case of massive hematemesis or patients with somnolence and altered mental status, perform NG lavage to
evaluate for upper GI bleed, and start PPI.In patients with
cirrhosis and portal hypertension, start octreotide and antibiotics for spontaneous bacterial peritonitis (SBP) prophylaxis.
Perform endoscopic evaluation within the rst 24 h. CT
angiography can be helpful inlocalization of the GI bleed;
Y. Kazerooni · M. Sturdivant · L. Cardenas (*)
Division of Surgical Critical Care and Trauma, Department of
Emergency General Surgery, Christiana Care Hospital,
Newark, DE, USA
e-mail: matthew.sturdivant@christianacare.org;
lcardenas@christianacare.org
however, endoscopic measures and interventional angiography can be both diagnostic and therapeutic.
Case Part 1
A 67-year-old male with a history of COPD, hypertension,
CAD, and CKD presents to the emergency department for
evaluation of dizziness and multiple melanotic stools over
the past 24 h. He is noted to be tachycardic to 120s and
hypotensive to 83/65. He is mildly tachypneic to 22 breaths
per minute and is maintaining SPO2 >92% on 2 L nasal
cannula. How would you manage this patient?
• Start with a focused history and physical exam.
• Establish two large bore IVs, check coagulation prole,
type and cross, baseline CBC and chemistry prole.
• Admit the patient to the ICU.
• Insert a NG tube. The examiner may say “NGT is inserted
with the return of a large amount of dark blood. What is
your next step?”
• Maintain the NG tube to intermittent suction.
• Start IV proton pump inhibitor at least twice daily or continuous infusion.
• If a patient has evidence of cirrhosis with portal hypertension, start octreotide as well as antibiotics for SBP
prophylaxis.
• Consult GI for an EGD.Prior to endoscopy, you may perform gastric lavage with normal saline to help with better
visualization.
• You may perform the EGD yourself or request a GI consult given the likely need for advanced endoscopic measures to control the bleeding.
First EGD fails to identify the source of bleeding, given a
large clot burden in the stomach. Patient is now hemodynamically stable, however, continues to have numerous melanotic stools and need for transfusion of packed RBC for
acute blood loss anemia. What is your next step?
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_49
159
160
Fig. 49.1 Algorithm for GI bleed management
Y. Kazerooni et al.
• Consider prokinetic agents (i.e., metoclopramide) and
further NG lavage.
• Request for repeated endoscopic evaluation. If endoscopic visualization remains limited, you should discuss
Interventional Radiology with angiography.
Algorithm for management of most GI bleeds can be
found in Fig.49.1.
Endoscopic Characteristic ofDieulafoy
Lesions
• Active arterial spurting, micro pulsatile streaming or pulsatile vessel in small but healthy mucosal defect.
• Freshly adherent clot to a small mucosal defect with
healthy surrounding.
– Mechanical (i.e., Endo clips), thermal (i.e., Bipolar,
argon beam, monopolar though less ideal), chemical
(i.e., epinephrine injection) techniques can be utilized.
Dual modalities have the highest efcacy.
– When identied endoscopically, biopsy of the lesion in
the acute setting is not recommended given increased
bleeding risk.
On angiography, Dieulafoy lesions are identied as tortu-
ous arterial formations with lack of early venous return.
• If the lesion is not amenable to coil embolization or endoscopic measures and the patient continues to have hemodynamic instability or need for ongoing transfusion, you
will need to proceed with surgical measures.
• This can include gastrotomy and oversewing the lesion or
wide wedge resection.
• If a patient presents with melanotic stools and no evidence of upper GI bleed (per NG lavage or EGD) you
should proceed with repeated colonoscopies, angiography and consider capsule endoscopy. Tagged RBC scans
have high sensitivity but they are not ideal for localizing
the location of the bleed.
Operative Management ofDieulafoy Lesions
• Position the patient supine with arms out under general
anesthesia.
• Perform upper midline laparotomy.
• Endoscopically identify the location of the lesion and perform an anterior gastrotomy accordingly (Fig.49.2).
• Place stay sutures on each side of the gastrotomy for better exposure.
• Once the lesion is identied suture ligate the lesion with
permanent suture such at 2-0 silk.
• Close the gastrotomy in a single layer primarily or with a
laparoscopic stapler.
49 Dieulafoy Lesions
161
involve antrectomy with gastro-enteric reconstruction,
proximal gastrectomy with gastroesophageal anastomosis
or stapled wedge resection of the gastric body.
Clean Kills
• Failing to perform the basic monitoring and resuscitative
needs of your patient.
• Failing to evaluate for upper GI bleed in a patient with
melanotic stools and no overt hematemesis.
• Failure to repeat EGD, or providing other options for
localization and control of the Dieulafoy lesion.
• Failing to take the patient to the operating room when
endoscopic measures and IR measures have failed.
Bibliography
Fig. 49.2 Operative management of Dieulafoy lesion. Perform ante-
rior gastrostomy if the lesion is in the gastric body. Place stay sutures on
each side for better exposure. Once identied, suture ligate the lesion
with permanent suture. Close the gastrotomy in a single layer primarily
or with a laparoscopic stapler
• If unable to obtain hemostasis with suture ligation, you
will have to perform a partial gastrectomy. This may
Baxter M, Aly EH.Dieulafoy’s lesion: current trends in diagnosis and
management. Ann R Coll Surg Engl. 2010;92(7):548–54. https://
doi.org/10.1308/003588410X12699663905311.
Kusnik A, Mostafa MR, Sharma RP, Chodos A. Dieulafoy lesion:
scope it until you nd it. Cureus. 2023;15(3):e36097. https://doi.
org/10.7759/cureus.36097.
Nguyen DC, Jackson CS. The Dieulafoy’s lesion: an update
on evaluation, diagnosis, and management. J Clin
Gastroenterol. 2015;49(7):541–9. https://doi.org/10.1097/
MCG.0000000000000321.
Part VI
Hepatobiliary