Estimated reading time: 7 minutes

Another important lecture has been added to Conceptual Surgery, covering a few questions that are quite familiar to anyone preparing for DNB Surgery. 

The questions are not very complicated. The real challenge is knowing what to write and how to present it in the exam. 

In this discussion, Dr. Amrit Nasta takes up three useful areas: GERD scoring systems, complications of anti-reflux surgery, and bilioma after cholecystectomy. 

Let’s quickly go through the important points. 

GERD Scoring Systems: What Should You Remember? 

If you get a question on scoring systems for GERD, don’t just write down a list of names. Mention what each score is actually used for. 

The main ones worth remembering are: 

1. DeMeester Score 

Think of 24-hour pH monitoring when you hear DeMeester score. 

A nasal catheter records acid exposure in the distal esophagus over 24 hours. The patient’s symptoms can also be matched with reflux episodes. 

The commonly remembered normal value is: 

DeMeester score <14.7 

A higher score suggests abnormal acid reflux. 

For the exam, write the test, what it measures and the significance of the score. That’s usually enough to build a good answer. 

2. LA Classification 

This one is much more straightforward. 

The Los Angeles classification is used during endoscopy to grade the severity of reflux esophagitis. 

It has four grades: 

• Grade A 

• Grade B 

• Grade C 

• Grade D 

The grading is based on the extent of mucosal breaks and their relation to the esophageal mucosal folds and circumference. 

If you’re asked about GERD scoring systems, LA grading is one you should not miss. 

3. Quality-of-Life / Symptom Scores 

GERD isn’t only about what is seen on endoscopy. The patient’s symptoms matter too. 

Questionnaire-based scoring can assess things like: 

• Heartburn 

• Dysphagia 

• Frequency and severity of symptoms 

• Effect on day-to-day life 

These scores can also be compared before and after treatment to see whether the patient has actually improved. 

4. Hill Classification 

The Hill classification is slightly different. 

It is mainly used to assess the gastroesophageal junction and the gastroesophageal flap valve, and is particularly useful when discussing hiatus hernia. 

In simple terms, it gives an idea about how tight or lax the gastroesophageal junction is. 

Quick Way to Remember 

For GERD, keep these four names in mind: 

DeMeester → 24-hour pH study 
LA → Endoscopy 
Quality-of-life score → Symptoms 
Hill → GE junction / hiatus hernia 

That small association can save you time during the exam. 

Complications of Laparoscopic Anti-Reflux Surgery 

This is another question where presentation matters. 

Don’t write every complication in one long paragraph. Divide them into intraoperative, early postoperative and late complications. 

It instantly makes the answer easier to read. 

Intraoperative Complications 

During port insertion, you can have: 

• Epigastric vessel injury 

• Bowel injury 

• Other port-related injuries 

During dissection around the GE junction, possible injuries include: 

• Esophageal perforation 

• Gastric perforation 

• Splenic injury 

• Injury to the pancreatic tail 

• Pneumothorax 

Early Postoperative Complications 

Dysphagia is an important one to remember. 

Some patients have temporary dysphagia because of postoperative edema around the wrap. It may settle with time. 

Other early problems can include: 

• Gas-bloat syndrome 

• Atelectasis 

• Infection 

• Persistent dysphagia 

Late Complications 

Later on, the patient may develop: 

• Persistent dysphagia 

• Recurrent or persistent GERD 

• Inadequate reflux control 

• Wrap migration or herniation 

• Rarely, vagal nerve injury 

One Exam Tip 

Whenever you see a question asking for complications, stop yourself from writing a random list. 

Make categories. 

Intraoperative → Early → Late 

It takes almost no extra time but makes your answer look much more organised. 

Bilioma After Cholecystectomy 

Now comes a very practical question: What causes a bilioma after cholecystectomy, and how do you manage it? 

A bilioma is basically a collection of bile outside the biliary system because of a bile leak. 

After cholecystectomy, the first thing you should think about is a cystic duct stump leak. 

What Can Cause the Leak? 

There are several possibilities: 

Cystic duct stump leak 

• Clip slippage 

• Ligature failure 

Bile duct injury 

• Accessory bile duct injury 

• Right posterior sectoral duct injury 

• Common hepatic duct injury 

• CBD injury 

Thermal injury 

A bile duct can also be injured by heat during dissection. 

Distal obstruction 

An unrecognised CBD stone can increase pressure within the biliary system and contribute to leakage from the cystic duct stump. 

Bile spillage during gallbladder perforation can also contribute to a collection. 

For a four-mark question, don’t overcomplicate it. Give the causes in a clear structure and move on. 

How Do You Manage a Bile Leak? 

This is where the clinical situation becomes important. 

Imagine a patient who has undergone cholecystectomy and comes back after a day or two with: 

• Right upper quadrant pain 

• Fever 

• Abdominal tenderness 

A bile leak should be high on your list. 

1. Admit and Assess 

Don’t simply treat it as routine postoperative pain. 

Admit the patient and assess the severity. 

A significant bile leak can become serious if it is not managed appropriately. 

2. Look for the Collection 

Imaging helps confirm whether a bilioma has developed. 

Ultrasound can be used as an initial investigation, while a CT scan can give a better idea about the collection and its extent. 

3. Drain the Bilioma 

Once the collection is identified, the next step is drainage. 

A suitable collection can often be managed with image-guided percutaneous drainage, such as a pigtail catheter. 

If the patient presents with peritonitis or a large infected collection, surgical drainage and lavage may be necessary. 

4. Find the Source of the Leak 

Once the patient is stabilised, the next question is: 

Where exactly is the bile coming from? 

Depending on the situation, MRCP or ERCP can help identify the source. 

5. Treat the Leak 

If the leak is suitable for endoscopic treatment, ERCP with biliary stenting can be used. 

However, major bile duct injuries are a different situation. 

If there is a significant proximal duct injury or an injury that cannot be managed with endoscopic stenting, the patient may eventually require biliary reconstruction. 

What Should You Take Away From This Lecture? 

For a quick revision, remember these points: 

• DeMeester → 24-hour pH monitoring 

• LA classification → Endoscopic grading of reflux esophagitis 

• Hill classification → GE junction / flap valve assessment 

• For anti-reflux surgery complications, write them as intraoperative, early and late. 

• Dysphagia is an important postoperative complication. 

• After cholecystectomy, always consider cystic duct stump leak when a patient develops a bilioma. 

• Other causes include bile duct injury, accessory duct injury, thermal injury and distal obstruction. 

• Management of bile leak can be remembered as: 
  Stabilise → Image → Drain → Locate the leak → Treat 

• ERCP with stenting can help in suitable leaks. 

• Major bile duct injuries may require delayed reconstruction. 

New Lecture Dropped on Conceptual Surgery! 

Want more such important DNB discussions, repeat questions and exam-focused surgical lectures? 

A new lecture is now available on Conceptual Surgery. 

Download the eConceptual App and subscribe to Conceptual Surgery to access more such high-yield lectures and make your residency preparation more focused. 

Watch Complete Video: DNB Surgery Paper Discussion: GERD, Anti-Reflux Surgery & Bilioma By Dr. Amrit Nasta