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6th MELEAH Surgery test 2 (gonna make it my bitch) > 2. Surgery of the stomach > Flashcards

2. Surgery of the stomach Flashcards

1
Q

What are the 5 surgical diseases the of the stomach?

A

1. Gastric foreign body

2. Benign gastric outflow obstruction

3. Gastric neoplasia

4. Phycomycosis

5. Gastric dilatation-volvulus

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2
Q

What are the layers from the outside to the inside of the stomach? (4)

A
  1. Serosa
  2. Muscular
  3. Submucosa
  4. Mucosa
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3
Q

The ______ layer is made up of longitudinal, inner, circular, and oblique.

A

Muscular

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4
Q

The ________ is the ****holding layer****

A

SUBMUCOSA

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5
Q

What is the mucosa made up of?

A
  • Glandular tissue
  • Parietal, chief, mucus, and endocrine cells
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6
Q

What contributes to the short duration of healing in the stomach? (4)

A
  • Extensive and redundant blood supply
  • Reduced bacterial numbers
  • Rapidly regenerating epithelium
  • Omentum
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7
Q

What cells contribute to collagen production?

A

Smooth muscle cells

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8
Q

What do you need to consider todo pre-surgery for stomach sx? (+/-6)

A
  • Correct electrolyte imbalances
  • Hydration status
  • Fasting
  • 8-12 hours
  • H2 antagonists
  • Proton pump inhibitors
  • Prophylactic antibiotic use? Possibly consider but sometimes contraindicated
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9
Q

What is our surgical approach when we want to do somach surgery…how do we start? What do we always take the opportunity todo?

A
  • Patient in dorsal recumbency
  • Ventral midline celiotomy (xuphoid to pubis)
  • Always take the opportunity to perform an abdominal exploratory when performing abdominal sx
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10
Q

When entering the abdomen what is ususally the first structure you see after performing an incision that often gets in your way and Dr. Carnick likes to just cut away?

A

Falciform ligament

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11
Q

What are some instruments you may need to perform an abdominal exploratory for visualization (2)

A
  1. Balfour retractors
  2. Self retaining/nontraumatic retractors
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12
Q

For a routine gastrotomy we always want to perform a ______ layer closure. We can either do a “traditional” closure known as ______ ______ aka (_______pattern) where you include the serosa, muscularis, and the _______ and then oversew it with a _______pattern where we include the _____ and _______ layers.

A

For a routine gastrotomy we always want to perform a DOUBLE layer closure. We can either do a “traditional” closure known as DOUBLE INVERTING aka (CUSHING pattern) where you include the serosa, muscularis, and the SUBMUCOSA and then oversew it with a LEMBERT pattern where we include the SEROSA AND MUSCULARIS layers.

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13
Q

What are some alternate technqies for a gastic closure and include the layers? Can we do a single or double layer for these alternate techiques?

A
  • Simple continuous- mucosa (can help to decease bleeding into lumen)
  • Cushing or Lempert pattern submucosa, muscularis, serosa layers
  • ALWAYS DOUBLE LAYER FOR ROUTINE GASTROTOMY
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14
Q

The gastric closure techniques is influenced by the _______, if any, in the stomach wall and surgeon prefererence

A

pathology

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15
Q

When are the indications for doing a single layer closure for gastric closure? Which patterns do we use?

A
  • Pyloric outflow tract
  • Reduced gastric volume
  • Thickened gastric wall
    • Simple interrupted
    • Simple continuous
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16
Q

When choosing suture material for gastric closure you need to choose material that _____ ______ for ____ days necessary to regain gastric wall ________. Avoid braided suture because the _______ contents ____ up the braided portion

The suture we use normally is some form of ______ and make sure it’s ________

A

When choosing suture material for gastric closure you need to choose material that RESISTS DEGRADATION for 14 days necessary to regain gastric wall STRENGTH. Avoid braided suture because the BACTERIA contents WICKS up the braided portion.

The suture we use normally is some form of MONOFILAMENT and make sure it’s ABSORBABLE (PDS, POLYGLYCONATE)

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17
Q

We use the thoracoabdominal staper for the skin and ______ ______

A

Gastrointestinal anastomosis

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18
Q

What should you feel for subjectively when assessing gastric wall thickness that is viable?

A

The mucosal SLIP, soral surface color, serosal capillary perfusion, peristalsis

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19
Q

How can you tell subjectively when gastric tissue is non viable?

A
  • Thinning of the gastric wall
  • Grey to green to BLACK color and this is 85% accurate!
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20
Q

What is the most obectively indicated measure for assessing gastric wall thickness in 85% of cases?

A

Laser Doppler Flowmetry

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21
Q

When considering performing a gastric biopsy we consider location and it is a ____ layer pattern. We often do these if there’s gross disease, CS of ______ GI disease. How can you choose between endoscopic versus surgical.

A

When considering performing a gastric biopsy we consider location and it is a TWO layer pattern. We often do these if there’s gross disease, CS of UPPER GI disease. How can you choose between endoscopic versus surgical.

We do the biopsy approach through endoscopic if the problem is just the stomach and it’s in the mucosal layer only (you clearly aren’t getting full thickness with one layer so this is an example of partial thickness biopsy)

We do the surgcal approach is we need a full thickness biopsy( if you have the opportunity while in sx do full thickness) and sx is considered when it’s in the submucosal

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22
Q

What is the most common reason for indication for gastromy? Who do we likely see this in?

A
  • Gastric Foreign Body (most FB in the stomach)
  • Dogs > Cats
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23
Q

What signalment do we often see with gastric foriegn body?

A
  • More Younger animals
  • Previous history of FB ingestion
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24
Q

What are some foriegn body predispostions for PICA? (3)

A
  1. Iron deficiency
  2. Hepatic Encaphalopathy
  3. Pancreatic exocrine insufficiency
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25
What kind of vomiting do you see often with CS of foriegn body?
Intermittant vomiting
26
With foriegn body, vomiting is not always present but what does it indicate if they are vomiting? (3)
1. Outflow obstruction 2. Gastric distension 3. Mucosal irritation
27
What are the 4 main CS seen with foriegn body?
1. Vomiting 2. Lethargy 3. Abdominal pain 4. Anorexia
28
What diagnostic imaging modality should be performed first?
**_Radiographs_** (U/S not as good because FB or fluid could cause shadowing masking the FB)
29
What should be attempted before surgery but give yourself a cut off time of 30 min because the patient is under anesthesia and if they end up being a surgical we want to decrease anesthesia time?
Endoscopy to retrieve the foreign body (also can be used as a diagnostic tool)
30
What medical management procedures need to take place while waiting to descide if a FB patient is surgical or no?
1. Rehydrate 2. Correct elctrolyte imbalances **3. MULTIPLE RADIOGRAPHS IF GIVEN FLUIDS WAITING OUT TO SEE IF PATIENT IS SURGICAL (ALWAYS CHECK THE RADS FIRST AGAIN IF PATIENT CAME IN OVERNIGHT AND YOU GAVE FLUIDS THROUGH OUT THE NIGHT, EVEN IF YOU THINK YOU'RE COMING IN AT 7 AM TO PEFORM THE PATIENTS SURGERY AGAIN _TAKE ANOTHER SET OF RADIOGRAPHS BEFORE SURGERY_** 4. INDUCTION OF VOMITING
31
What do we use to induce vomiting in dogs versus cats? How long since the FB was ingested are we still in the time frame to induce vomiting? (3)
* Dogs: Apomorphine * Cats: Xylazine * Within the hour of seeing FB ingestion
32
How much time should we wait trying to retrieve a FB before saying...okay this needs to be surgical?
30 minutes
33
What do we always take multiple times if a significant amount of time (even a couple hours) if giving fluids to patients while awaiting surgery
**MULTIPLE RADS BITCH**
34
What is our incision approach if the FB turns into a surgical case?
Ventral midline celiotomy
35
When performing a FB surgery what should you always take the opportunity todo and why? What type of retractors?
Abdominal exploratory, check to see if FB caused any damage or could potentially catch some form of neoplasia (take the oppotunity while you can!) Balfour retractors?
36
When performing a gastrotomy you need to isolate the stmach to prevent ______ and put in ____ \_\_\_\_. Make an incision into a _______ area on the _____ aspect of the stomach, between the _____ and _______ curvature?
When performing a gastrotomy you need to isolate the stomach to prevent **LEAKAGE** and put in **STAY SUTURES.** Make an incision into a **HYPOVASCULAR** area on the **VENTRAL** aspect of the stomach, between the **GREATER AND LESSURE** curvature?
37
What 2 closures can ypu do for closure of the gastrotomy site?
## Footnote **Double layer inverting pattern** **Double layer appositional, then inverting**
38
Before closing your gastromy what should you always do? (2)
* Lavage with Sterile saline @ 98.6-102.2 F (somewhat warmed and close to body temp to further cause hyothermia as anesthesia tends todo) * Change gloves/instruments prior to abdominal closure
39
Postoperatively what should you be doing after stomach surgery? (3)
* Fluid therapy (Correct electrolyte imbalances) * Food and water within 12 hours * If vomiting persistent, ID cause and treat with either prokinetics, antiemetics orH2 blockers
40
What are the 2 types of benign gastric outflow obstruction CAUSES?
* Congenital pyloric stenosis * Acquired
41
ACQUIRED benign gastric outflow obstruction can be caused by a number of reasons such as? * Foreign bodies * _____ \_\_\_\_\_ _____ \_\_\_\_\_ * \_\_\_\_\_\_\_ * Inflammation/infiltrative disease * Motility disorders * ________ with scarring * Extraluminal masses
* Chronic hypertrophic pyloric gastropathy * Neoplasia * Ulcerations
42
What to we see with congenital plyloric stenosis in terms of pathophysiology and what is the unknown etiology that is suspected? (2)
* Hypertrophy of the circular muscles of the pylorus * suspect excess gastrin production (trophic for gastric smooth muscle and mucosa)
43
What breed signalment do we see with congenital pyloric stenosis and at what what stage do we see this at **to differentiate it from Acquired?**
* Brachycephalic breeds (Boxers, bulldogs) * Siamese cats * _CS at **WEANING** (how to ddx from acquired)_
44
With _congenital_ pyloric stenosis you see _____ of the _____ muscles of the \_\_\_\_\_\_
With _congenital_ pyloric stenosis you see **HYPERTROPHY** of the **CIRCULAR** muscles of the **PYLORUS**
45
What brachycephalic breed is congenital pyloric stenosis more common in?
Boxers!!! (had to input correction)
46
With congenital pyloric stenosis the vomitting is ______ and \_\_\_\_\_\_\_. Within hours of feeding and the food is _____ \_\_\_\_\_\_. With signs of weaning ______ are okay. NORMAL TO DECREASED BODY CONDITION
With congenital pyloric stenosis the vomitting is **INTERMITTENT** and **CHRONIC**. Within hours of feeding and the food is **PARTIALLY DIGESTED**. With signs of weaning **LIQUIDS** are okay. NORMAL TO DECREASED BODY CONDITION
47
With congenital pyloric stenosis what will you see on radiophraphs that is pretty indicative? (2)
* Gastric distension * **Delayed gastric emptying, gastric contents after fast over 8 hours**
48
What might you see on contrast radiography with songential pyloric stenosis?
“Beak” or “apple core” appearance
49
When do we institute pyloromyotomy surgery?
It's for surgical management of _congential pyloric stenosis ONLY_
50
What procedure used for congential pyloric stenosis can NEVER be usec for ACQUIRED?
Pyloromyotomy
51
What is this? Describe the incision and What layers do you incise through?
Surgical Management- called _Pyloromyotomy_**Used only for congenital stenosis.** 1-2cm incision through the **serosa** and **muscularis** layers of **l****ong axis of pylorus**
52
What is the alternative name for Pyloromyotomy and used for ______ pyloric stenosis?
**Fredet-Ramstedt procedure; CONGENITAL**
53
What is another procedure not usually effective with acquired pyloric stenosis but used for congenital where you change orientation, and what is its alternative name?
**Transverse Pyloroplasty** *"Heineke-Mikulicz procedure"*
54
Describe the incision for Transverse Pyloroplasty and what it's added benefit is over Pyloromyotomy for congential plyoric stenosis?
* 3-5cm full thickness incision over pylorus * Orient incision transversely and close with appositional suture pattern * Recurrence less likely
55
What is this?
**Transverse Pyloroplasty aka Heineke-Mikulicz procedure**, Recurrence less likely than with pyloromyotomy for _congenital pyloric stenosis_
56
Describe the prognosis/outcome after surgical correction of benign conditional of pylorus?
VERY GOOD
57
Acquired mucosal and/or muscular hypertrophy (both) usually results in this condition?
Chronic Hypertrophic Pyloric Gastropathy (CHPG)
58
Describe the size, breed, age, and sex predeilection for Chronic Hypertrophic Pyloric Gastropathy (CHPG)?
* **Small** breed dogs **(\<10kg)** * Shih-tzu, Lhasa apso, Maltese * **_Males_** \> Females * Middle aged to **older**
59
What are 5 of the proposed etiologies of Chronic Hypertrophic Pyloric Gastropathy (CHPG)?
1. Unknown 2. Increased gastrin secretion 3. Acute stress 4. Inflammatory disease 5. Trauma
60
Chronic Hypertrophic Pyloric Gastropathy (CHPG) is similar to what stomach surgical condition? How do we differentiate?
* Similar to congenital pyloric stenosis * both have Intermittent vomiting * **Signalment will differentiate**
61
If it's a chronic stomach conditon it's seen with ____ age dogs, if its acquired only **\_\_\_\_** and **\_\_\_\_** layers. if congential only _____ layer
If it's a chronic stomach conditon it's seen with **OLD** age dogs, if its acquired only **MUCOSAL** and **MUSCULAR** layers. if congential only mucosa
62
What can contrast radiography confirm for Chronic Hypertrophic Pyloric Gastropathy (CHPG)? (2)
* Gastric distension * Delayed gastrin emptying * Narrowing at the pylorus
63
Is ultrasound a good dx tool for Chronic Hypertrophic Pyloric Gastropathy (CHPG) state why or why not? State normals
* Good diagnostic tool * Evaluates muscle and pyloric wall thickness (normals stated below) * Muscularis \< 4mm * Pyloric wall \<9 mm
64
With Chronic Hypertrophic Pyloric Gastropathy (CHPG) what does endoscopy accomplish (2)?
* ABle to visualize MUCOSAL hypertrophy * Can obtain biopsies to rule out neoplasia
65
What are the pathological grades for Chronic Hypertrophic Pyloric Gastropathy (CHPG)? Whar can be present with any grade/type?
* Grade I _**Muscular hypertrophy** ONLY_ * Grade II _*Mucosal* hyperplasia with glandular cystic dilation ONLY_ * Grade III _**Muscular** **hypertrophy** AND Mucosal hyperplasia_ * **Inflammatory component may be present with any type**
66
True or False: For Chronic Hypertrophic Pyloric Gastropathy (CHPG), Grade II is for Muscular hyperplasia with glandular cystic dilation ONLY
FALSE (TRICKED YA) FOR **MUCOSAL** hyperplasia with glandular cystic dilatation only (not muscular)
67
What surgical management can you use for Chronic Hypertrophic Pyloric Gastropathy (CHPG)? (3) Which one is for lower grade?
* Heineke-Mikulicz Pyloroplasty (for lower grade) * Y-U Pyloroplasty * Pylorectomy with Gastroduodenostomy (Bilroth I)
68
What are the advantages and disadvantages of Y-U advancement pyloroplasty for Chronic Hypertrophic Pyloric Gastropathy (CHPG)
* **Advantages** * Increase diameter of pylorus * Access to excise hypertrophied mucosa * **Disadvantages** * **​**Potential necrosis of flap tip * Rapid emptying
69
What takes place with Y-U advancement pyloroplasty for Chronic Hypertrophic Pyloric Gastropathy (CHPG)?
Single pedicle advancement from antrum across pylorus
70
What takes place during Bilroth-Gastroduodenostomy, for Chronic Hypertrophic Pyloric Gastropathy (CHPG)? What are the advantages and disadvantages?
Pylorectomy-gastroduodenostomy * **Advantages** * ​All disease tissue can be removed * **Disadvantages** * **​**Technically more demanding * Increased risk for "dumping" syndrome and reflux gastritis * No pyloric sphinctor
71
Describe the positive and poor prognostic indications with CHPG?
* Good to excellent (85%) * Poor outcome associated with technical failures
72
What can affect prognosis with CHPG?
* Selection of most appropriate technique important * Ability to recognize and treat underlying cause
73
What is the most common reason to perform Gastrectomy?
* Neoplasia (location determines type of resection) * Ulceration * Significant pyloric outflow obstruction
74
With gastrectomy comes implied that it is ______ removal
partial
75
When performing a Gastrectomy, what lyer is resected and what type of excision?
* Submucosal resection * Slow growing tumors so marginal excision usually sufficient * Example: Leiomyoma located within cardia
76
What is indicated when lesion is extensive or with concurrent ulceration? How cna you close?
Partial gastrectomy (suture or stapler)
77
What type of bilroth is indicated for partial gastrectomy
Bilroth 1
78
Which bilroth is partial gastrectomy followed by gastroenterostomy?
Bilroth II Gastroenterostomy
79
What indications are there for Bilroth II Gastroenterostomy? Consider this?
Extensive gastric resection making gastroduodenostomy impossible, consider common bile duct
80
What are the 3 main Bilroth II complications?
1. Alkaline gastritis (Bile and pancreatic secretions flow into stomach) 2. “Blind loop” syndrome (Gastric contents move orally and putrefy) 3. Marginal ulceration (Ulceration of jejunal mucosa – not used to seeing acid contents)
81
What is the most common phycomycosis caused by and describe some details?
* **Pythium** sp. most common in US * Aquatic oomycete, poorly deptated, filamentous * Highest incidence in gulf coast states * Exact mode of entry unclear but Ingestion presumed for enteric form
82
What pathophysiology is often seen with phycomycosis?
* Severe inflammatory and infiltrative lesion * Induce intense fibrotic reaction * Transmural thickening: Gastric outflow area most commonly affect
83
With phycomycosis what area is most commonly affected and what does it cause?
* Gastric outflow area is most commonly affected * Causes transmural thickening
84
What are the 5 most common clinical signs of Phycomycosis?
1. Vomiting 2. Inappetence 3. Weight loss 4. Diarrhea 5. Palpable mass
85
What layers of the stomach are commonly affected by phycomycosis and this indicates why it's hard to visualize with this imaging modality?
* Submucosal and muscularis layers affected * which is why Endoscopy – difficult to find organism
86
What am I seeing on histpath for phycomycosis with pythium insideosum? How can we definitively test for this and confirm?
* _Eosinophilic pyogranulomatous inflammation_ * **Deep tissue samples of fibrotic material can reveal organism** * Elisa tests for P. insidiosum antibodies
87
How do we treat for pithium insidiosum describing what WORKS and DOESN'T WORK?
* Treat with Wide **surgical excision** * Medical therapy is _ineffective_ using Antifungals
88
What is the prognosis with phycomycosis such as pithium insidiosum?
Guarded to poor prognosis One study had median survival time of 26.5 days **:-(** **Maggie and MIKEY**

6th MELEAH Surgery test 2 (gonna make it my bitch) (8 decks)

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