5 - Stomach Flashcards
What are indications for sx of the stomach?
- Foreign bodies
- GDV
- Tumors
- Ulcers/erosions
- Pyloric obstruction
- Feeding tubes
What are the 3 approaches to sx of the stomach?
- Ventral midline celiotomy
- Flank
- MIS
What are the 3 basic surgical principles that are used in stomach surgery?
- Stay sutures
- Laparotomy sponges
- Clean/dirty instruments (change gloves)
- Intraperitoneal lavage
What is a gastrotomy?
Incision through the stomach wall into the lumen
What is a gastropexy?
Creation of an adhesion between stomach and body wall
What is a partial gastrectomy?
Partial removal of the stomach
What is a gastrostomy?
Creation of an artificial opening into the lumen
What is a pyloroplasty?
Reconstruction of the pylorus & pyloric antrum
Where should the incision be made in a gastrotomy and how?
Hypovascular area between greater and lesser curvatures;
- Stab incision with scalpel
- Extended with scissors
- Sunction to aspirate gastric contents and reduce spillage
How many layers should be included in closure for a gastrotomy?
2-3 layers
What pattern should be used on the mucosa/submucosa during a gastrotomy?
Simple continuous
What pattern should be used to close the seromuscular layer during a gastrotomy?
Simple continuous
+/- inverting
What type of surgery is a gastrotomy considered (cleanliness)?
contaminated - change gloves and instruments
When is a partial gastrectomy indicated?
Necrosis (GDV), tumor, ulcer/perforation, biopsy
How many layers should be closed in a partial gastrectomy and what instruments can be used?
2 layer closure with invagination;
Doyen forceps, stay sutures, GIA stapler
T/F: A gastrostomy is commonly recommended and performed.
False
What are the 3 techniques by which a gastrostomy tube can be placed?
- Open placement
- Percutaneous endoscopic assisted
- Laparoscopic assisted
What side of the stomach/body wall is used to pexy it during gastrostomy tube placement?
left
What type of pattern is used during gastrostomy tube placement for pexy isolation?
box lock suture pattern
What is the minimum amount of time a gastrostomy tube should be in?
7-10 days
What are the 2 types of pyloric resections and what does each attach to?
- Billroth I = removal of pylorus and attachment to duodenum
- Billroth II = removal of pylorus and attachment to jejunum
What is a pyloromyotomy?
Incision thru pyloric serosa and muscularis
What is a pyloroplasty?
Incision and reorientation of pylorus to increase gastric outflow diameter
What are the 3 types of benign gastric outflow obstruction?
- Pyloric stenosis (muscular hypertrophy)
- Chronic antral muscosal hypertrophy
- Hyperplastic pyloric polyps
What breeds are prone to pyloric stenosis?
Brachycephalic breeds, Siamese cats
How would you correct a pyloric stenosis?
pyloroplasty
How would you correct a chronic antral musosal hypertrophy?
pyloroplasty
How would you correct hyperplastic pyloric polyps?
endoscopic or surgical excision
What procedure is this?
Billroth I
What procedure is this?
Billroth II
What conditions would indicate the need for a gastropexy?
GDV, hiatal hernia, intussusception
What are the only 2 types of gastropexy that you should be doing?
incisional and tube
How long should the incision be for a gastropexy and where?
3-5 cm;
Caudal to the last rib and far enough laterally so that it doesn’t run into the celiotomy
What is a tube gastropexy used for, what pattern is used, and what side is it on?
Placement of a gastrostomy tube, box lock pattern, right side
What gastropexy techniques are not recommended?
Circumcostal, belt loop, closure-pexy, gastrocolopexy
Why would you choose to do a laparascopic or lap assisted gastropexy?
More for prophylactic reasons than for therapeutic reasons
Stomach surgery can have concurrent _____ or _____.
esophagitis, pneumonia
Why are antibiotics generally unnecessary with stomach surgery when there is normal immunity?
The procedure is considered to be clean-contaminated
What layers of the stomach are easily separated from each other?
Mucosa from muscularis and serosa
What area of the stomach should be incised?
Hypovascular area between curvatures
How is hemorrhage controlled during stomach surgery?
Direct pressure
Stomach surgery can be closed with a ___-layer closure with an _____ or _____ pattern.
2, appositional, inverting
What staplers can be used for stomach surgery?
TA or GIA for resection
Healing of the stomach is _____.
rapid
What is GDV?
Clockwise 180 degree rotation of the stomach
What is the biggest risk factor for GDV?
History of a GDV in a 1st degree relative
GDV is _____of the stomach and _____ on its _____ axis.
distension, rotation, mesenteric
How does the stomach become dilated in a GDV?
Rotation causes outflow obstruction at both ends of the stomach preventing mechanisms of removing air (eructation, vomiting, and gastric emptying).
What local effects does venous outflow obstruction in a GDV lead to?
Venous outflow obstruction –> vascular congestion (back up of blood flow in stomach wall) –> gastric necrosis +/- gastric perforation
What local effects does increased transmural pressure in a GDV lead to?
Increased transmural pressure –> vascular congestoin (back up of blood flow in stomach wall) –> gastric necrosis +/- gastric perforation
What local effects does gastric rotation in a GDV lead to?
Gastric rotation –> tearing of short gastric arteries –> hemoabdomen
A
Gastric distension
B
Caudal vena cava compression
C
Decreased vascular return and cardiac output
D
Hypotension, tissue hypoxemia, vascular stasis, myocardial depressant factor
E
GI necrosis
F
DIC
G
Myocardial ischemia & VPCs (40-70% of dogs)
H
Metabolic (lactic) acidosis
What are clinical signs of GDV?
Retching/non-productive vomiting, distended abdomen, drooling, obtunded/hypovolemic shock
What are PE findings consistent with a GDV?
- Distended abdomen (tympanic cranial abdomen)
- Splenomegaly
- Hypovolemic shock (tachycardia, prolonged CRT, pale MM, weak pulses, cold distal extremities, obtundation)
- ECG-arrhythmias (VPCs)
What should you always treat first in a GDV patient?
shock
In a GDV patient, you should always place the _____ possible catheter (___G or ___G).
largest, 18, 16
What length of catheter is preferred?
shorter
Where should an IVC be placed ina GDV patient?
Thoracic limbs or jugular vein
What type of fluids are used in GDV patients for fluid resuscitation?
isotonic crystalloids
What 6 things should be done in a GDV patient while the fluids are going in?
- FAST scan to look for free fluid
- ECG to check for arrhythmias (treat with lidocaine if severe)
- Check blood-gas
- Lactate
- Monitor BP
- Monitor for resolution of shock
What should only be done AFTER the suspected GDV patient is stable?
radiographs
What is the #1 rule of suspected GDV radiographs?
THOU SHALT ALWAYS TAKE A RIGHT LATERAL ABDOMEN
+/- VD view and thoracic rads if dog is stable
What is the #2 rule of suspected GDV radiographs?
Nothing dies in radiology - stabilize the animal BEFORE taking it to radiology
What is a subtle xray sign of a GDV?
Gas or loops of bowel cranial to stomach
+/- splenomegaly
What does gas in the wall of the stomach suggest in a GDV case?
Gastric necrosis with gas producing;
we may need to resect something in surgery
How is gastric dilatation treated?
IV shock fluids, orogastric or NG tube, monitoring, recommend gastropexy
T/F: Gastric dilatation is not a surgical emergency
True
How is food bloat treated?
NPO, IVF if severe dehydration/shock, +/- emesis
What are 3 medical treatments that can be done for a GDV?
- IV shock fluids (due to CVC compression)
- Pain meds - facilitates gastric decompression
- Decompress stomach (orogastric tube or trocar with 18G-14G catheter)
What pain meds can be used in a GDV?
Opioid +/- midazolam, methadone (less likely to indice vomiting)
What are the pros and cons to passing an orogastric tube in a GDV?
Pros = effective, continuous decompression, gets food and gas
Cons = difficulty passing tube, anesthesia and intubation to protect airway
What are the pros and cons to trocarization in a GDV?
Pros = Low risk, no anesthesia
Cons = Gas only, SQ abscess, peritonitis, splenic laceration
What are the 4 steps taken to surgically repair a GDV?
Celiotomy:
- Decompress and derotate the stomach
- Assess gastric wall integrity
- Assess spleen
- Gastropexy!!!
What 3 things should be assessed about the stomach after it is derotated?
Serosal color, thickness of wall (thin is bad), vascular patency
Once the stomach is repositioned thus relieving _____, the appearance of serosa can greatly improve in _____ minutes.
venous outflow obstruction, 5-10
How can vascular patency of the stomach be assessed after derotation?
Small incisions can be made in questionable areas, and appearance of arterial blood indicates probably survival
How can GDV affect the heart?
Endotoxins and vasoactive agents can be released causing a cardiovascular crisis
T/F: GDV patients do not need IVF postop.
False
T/F: Analgesics should be continued postop.
True
What medications should be considered for postop in GDV patients?
H2 antagonists, proton pump inhibitor, sucralfate, metoclopramide
How often should the EKG be measured postop in GDV patients?
continuously for 24-48 hours
How often should BP be monitored in a GDV patient postop?
Every 4-6 hours
When can GDV patients be fed postop?
Can feed day of surgery, 2-3 small meals
What are the 2 types of gastrogastric intusussception?
Pylorogastric or duodenogastric
How common are gastrogastric intussusception? What breed? What is the prognosis?
Rare;
Large breed (GSD);
Prognosis = guarded
What is the most common stomach tumor in dogs?
adenocarcinoma
What is the most common stomach tumor in cats?
Lymphoma
