E2- Intestinal sx Flashcards
What is important to rememeber about fluid therapy before intestinal surgery?
correct pre-existing
treat hypovolemia- combo of crystalloids and colloids
monitor electrolytes
Should we use prophylactic antibiotics before intestinal sx?
its still debated
clean contaminated/contaminated
small intestinal flora: gram -/+
(give 20-30min prior to incision, no more than 24hrs after)
Give an example of prophylactic antibiotics before sx
cefazolin 22mg/kg
List the 4 standard criteria of assessing viability
pink, moist glistening color
pulsation of mesenteric vessels
bleeding from cut surface
peristalsis- pinch test
What can we inject to assess viability of intestines?
fluorescein dye injected IV
T/F: you can use a pulse ox on the intestines to determine viability
True
In the intestines, sutures must penetrate ______
submucosa
Appositional pattern is recommended for ____ healing.
Give 2 examples
primary healing
simple continuous or simple interrupted
The modified Gambee suture pattern can be used for what?
to help with everted mucosa
What is important to remember when handling tissue with forceps?
grasp as little tissue as possible to minimize tissue trauma
note: forceps are grasping tissue just at cut edge and not the full thickness of the intestinal wall
When taking an intestinal biopsy, what is important about the size?
full thickness biopsy- wide enough that all layers remain intact (sample 3-4mm wide)
After we finish an intestinal biopsy, what is important to do before we close the animal up?
leak test!
Describe a longitudinal intestinal biopsy
Describe a transverse wedge biopsy
-wedge should not be >____ % of circumference
full thickness wedge 3-4mm wide taken perpendicular to long axis of intestine
-wedge should not be >20-25 % of circumference
Minimally invasive biopsy method?
Laparoscopic- standard technique, use of cutting/coagulation unit (harmonic scalpel)
Small intestinal obstruction clinical signs are determined by?
location of obstruction
degree of obstruction
moving vs. stationary
integrity of intestinal wall
Small intestinal obstruction pathophysiology
distension of bowel proximal (oral)
absorption
Describe the clinical presentation of a proximal intestinal obstruction
duodenum or proximal jejunum
acute/severe signs
persistent vomiting
gastric secretions
electrolyte imbalances
dehydration
Describe the clinical presentation of a distal intestinal obstruction
distal jejunum, illeum, illeocecal junction
vague
intermittent anorexia
lethargy
occasional vomiting
several days or weeks
Diagnosis of intestinal obstruction
CS/Hx
rads: dilated intestinal loops, plicated intestinal loops, radiopaque foreign body
repeat rads
ultrasound
contrast studies (dont use barium if suspected perforation bc will cause peritonitis)
Who usually presents with linear foreign bodies?
young animals, ususally cats
Give examples of linear foriegn bodies
sewing thread, yarn, string, tinsel
When do we see signs of a linear foreign body?
when the foreign body becomes fixed at some point cranially typically around tongue (base of tongue) or at pylorus
Clinical signs seen with a linear foreign body
vomiting
depression
abdominal pain: posture, gait, guarding on palpation
palpable bunching of intestines in central abdomen
Where do we need to check when doing an exam for a suspected linear foreign body?
UNDER THE TONGUE
What are radiographic signs of a linear foriegn body?
plication- bunching up
With a linear FB- how do we “free” the FB?
by cranially removing from base of tongue or performing gastrotomy
With a linear FB- examine _____ border of the intestine for perforations
mesenteric
How can a red rubber catheter help when removing a linear FB from the intestines?
attach the catheter to FB and push it through
Linear FB removal complication from inflammatory changes?
impaired intestinal function secondary to inflam
Linear FB complication from extensive resections?
short bowel syndrome
T/F: With a nonlinear FB, we have to do a complete abdominal exploratory
TRUE
Describe the direction/placement of the removal of a foreign body
remove through enterotomy ABORAL (distal) to foreign body
(resection and anastomosis if non-viable
_____ is telescoping or invagination of the intestines
intussusception
List 2 underlying causes of intussusception
parasitism
parvovirus- (viral)
Intussesception clinical signs are influenced by what?
location and degree of obstruction
- ileocolic
- jejuno-jejunal
- cecum
An intussusception makes a _____ lesion on an ultrasound
target lesion- transverse plane
What is the signalment and history for intussusception?
young puppies
acute or chronic
physical exam palpation- feels like abdominal mass
What surgical options are there for intussusception?
exploratory celiotomy
manual reduction- gentle traction
resection and anastomosis -unsuccessful reduction, non viable
biopsy
Complications of manual reducations
brusing, tearing of mucosa
What is enteroplication used for?
What must we keep in mind while doing the procedure?
to prevent reocurrence of intussusception
must plicate entire small intestine, avoid tight turns
Complications of enteroplication
obstruction, strangulation, perforation
Is enteroplication necessary…. recurrence rate? …complication rate?
low recurrence rates 5%
complication rate 19%
What is cecal inversion? Signs?
cecal intussesception
chronic diarrhea with hematochezia (lower GI signs)
Diagnosis of cecal inversion
radiographs: surgery, contrast studies
endoscopy
ultrasound
Treatments for cecal inversion
attempt manual reduction
expose through colotomy if irreducible
typhlectomy- removal of the cecum
What is mesenteric volvulus?
rare, often fatal
intestines twist on mesenteric axis
- strangulating mechanical obstruction
- ischemia of SI
- can be focal
Mesenteric volvulus mostly occurs in what breed?
German shepards
T/F: mesenteric volvulus is responsive to orogastric intubation
FALSE- nonresponsive
Clinical signs of mesenteric volvulus?
acute abdominal distension and pain
vomiting
shock
How are radiographs a prognastic factor for mesenteric volvulus?
rads are initially unremarkable
once clear on rads its bad news
When we suspect mesenteric volvulus, what do we need to do immediately?
rapid fluid resuscitation
abdominal exploratory
Describe what we do in surgery for mesenteric volvulus
derotation +/- resection and anastomosis- if possible
we worry about reperfusion injury
segmental w/o derotation has a better prognosis
(you cant remove everything, short bowel syndrome if we take too much)
How can we minimize contamination in intestinal surgery?
- pack off affected area
- separate intruments to be used for intestinal procedures from rest of the pack
- occlude intestine proximal and distal with intestinal forceps or fingers
- decompress dilated bowel loops
T/F if intestines are empty, occlusion is not mandatory and decreases manipulation/trauma
True
Begin anastomosis at the _____ border
mesenteric
After anastomosis, what do we do before closure?
wrap with omentum
T/F mucosal eversion in intestinal resection and anastomosis is not a worry
False- minimize mucosal eversion
Cut mesentery close to _____ of segment being removed
vessels
What is going on in this image?
occlude proximal and distal segments as atraumatically as possible
Scissors vs scalpel
the intestine can be divided with scissors or scalpel
scissors- more control; more traumatic
scalpel- less control; less traumatic
During a resection and anastomosis, how can we account for the narrowing that occurs during healing?
angling cut enlarges lumen size intitially to account for the 10-20% narrowing which typically occurs during healing
What suture pattern helps to minimize mucosal eversion in the intestines?
use of modified gambee suture pattern
Why is mucosal eversion a bad thing?
increases risk of infection and adhesion formation
Leakage is most common at what site of the intestinal anastomosis?
leakage most common at mesenteric border- no serosa and fat in mesentery impairs visualization
Explain leak testing anastomosis
occlude intestine proximally and distally
inject saline until intestine is evenly distended- not overly full
gently compress and look for leaks
Can staples be used to close and anastomosis?
yes, use staples that close tightly at tips
Explain the “fishmouth” or Cheattle incision
cut smaller segment at an angle
space sutures closer on smaller segment
placing mesenteric and antimesenteric sutures stretches the smaller segment
____ the anastomosis site bc of intestinal content spillage
Lavage
T/F we cannot use instuments used during surgery on intestinal procedures for the closing part of the procedure
TRUE - contamination
The ____ is very important in reducing the risk of wound healing promblems after intestinal surgery
omentum
**wrap anastomosis with omentum**
When do we use a serosal patch?
when omentum isnt available
Why do we use a serosal patch?
to reinforce suture lines in questionable tissue: enterotomy, colotomy, urinary bladder
induces permanent adhesion much stronger than omentum
T/F surgical principles of the large intestine are the same as the small intestine
true
List the differences of large intestinal surgery compared to small intestinal sx
Large intestinal sx
- high bacterial population
- healing
- intitially, strength of wound weak: 3-4 day lag period
- collagenolysis
- wound stregth 75% of normal at 4 months- slower than SI
- blood supply
- segmental- vasa recta
- maintain tissue perfusion
Indications for a colotomy
foreign body removal
impacted feces
biopsy
Closure of the colotomy
longitudinal
single layer, simple interrupted, appositional
(not worried about having a small lumen size)
A colopexy creates a permanent adhesion between?
colon and abdominal wall
What is the reason we do a colopexy?
recurrent rectal prolapse
T/F: a colopexy can be done both incisional and nonincisional
true
Complications from a colopexy
infection
dehiscence
recurrence
Indications for a colonic resection and anastomosis
megacolon
perforation
neoplasia
irreducible/necrotic intussusception
T/F you can do a subtotal colectomy with or without preservation of the ileocecal valve
true
Megacolon usually occurs in _____
cats > dogs
Causes of megacolon
congenital vs aquired
mechanical or functional colonic obstruction
neurologic
idiopathic
How can feces cause a megacolon?
the longer feces sits, water is absorbed and gets more difficult to pass
concretions form
painful
too large to pass
Prolonged distension from megacolon causes what 2 things?
smooth muscle damage
nerve damage
Congenital megacolon
Aganglionic distal conolic segment- absence of inhibitory neurons = functional obstruction
rare in cats
(hirschsprungs dz in humans)
Neurological conditions
lumbosacral dz
Key-Gaskell- feline progressive dysautonomia
sacral spinal cord deformity- manx cats
Pelvic trauma causes a ____ formation from healing pelvic fracture and SI luxation
how can we tx pelvic trauma
callus
pelvic osteotomy- good prognosis if early (<6m), dependent on degree of distension
What is a complication of the colon sometimes seen from an OVH?
adhesion formation- scar tissue that obstructs the colon
delayed complication
clinical signs may occur weeks to years post op
incidental finding on exploratory
Treatment of a OVH adhesion
surgical dissection and removal
potential for resection and anastomosis
Primary/Idiopathic colon obstruction/megacolon
cats
rule out secondary causes- pelvic trauma, neurologic dz, perineal hernia
dysfunction of colonic smooth muscle- decrease in contractility vs colonic dilation, effects of cisapride
medical vs surgical management
Medical management for megacolon
Diet: low residue diets
Hydration
Enemas- deobstipation under general anesthesia
Prokinetic drugs- cisapride
Stool softeners- lactulose
If medical management is unsuccessful we turn to _____ management
surgical
Ileocecal valve preservation
bacterial overgrowth prevented
increases tension at anastomosis- tension can cause leakage
no real clinical benefit
Preoperative management?
no enemas or stool softeners
bc we dont want the potential for spillage… better to have hard feces
contaminate surgery
Postop bowel movements after intestinal sx
+/- tenesmus: 7 days
diarrhea- loose stool: weeks
increase frequency of defecation
Complications of intestinal surgery
dehiscence and recurrence
ileus
adhesions
obstructions- intussusception, entrapement, stenosis
peritonitis
short bowel syndrome
Post op care of intestinal sx patients
taper fluid and electrolyte therapy as oral intake returns to normal
offer food and water the day after sx unless contraindicated- feed enterocytes orally helps health of intestine :)
pain management
Most complication from surgery occur when?
first 3-5 days
Risk factors for dehiscence after intestinal surgery
foreign bodies and trauma
preop albumin <2.5g.dl (recheck after fluids)
postop rise in band neutrophils
preop peritonitis
Mortality/prognosis with intestinal surgery
leakage/dehiscence increases mortality rates
overall dehiscence rate 7-15% -mortality 74-85%
no dehiscence and discharge from hospital = overall good prognosis
