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Surgery > E2- Spleen and pancreas > Flashcards

E2- Spleen and pancreas Flashcards

1
Q

What attaches the spleen to the stomach?

A

gastrosplenic ligament

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2
Q

Blood flow into the spleen?

A

celiac a. to splenic a.

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3
Q

Blood flow out of spleen?

A

splenic v. to gastrosplenic v. to portal v.

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4
Q

Splenic white pulp Vs red pulp

A

white pulp- nodular lymphoreticular tissue: site of immune response

red pulp- venous sinuses: stores RBCs/traps antigens

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5
Q

Should we worry about siderotic plaques?

A

NO- non pathologic

pale yellow/rust color- Ca/iron deposits

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6
Q

Should we worry about ectopic splenic tissue?

A

NO- non pathogenic

splenosis- usually from seeding of cells after sx/trauma, tiny nodules sitting in omentum near spleen

accessory spleen- incidental congenital issue, bigger than a nodule

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7
Q

T/F: we need our spleen to survive

A

FALSE- we do not need it

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8
Q

What is stored in the spleen?

A

10-20% of RBCs and 30% platelets

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9
Q

What cells mature in the spleen?

A

RBCs

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10
Q

Senescent/sick RBC removal

A

become non pliable and cant squeeze through pores of splenic sinuses = rupture or they are phagocytized

filters

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11
Q

T/F: Hematopoeisis in the spleen is active during fetal development

A

TRUE

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12
Q

How does the spleen help in immune function?

A

removal of poorly opsonized bacteria (better than liver)

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13
Q

Causes of splenomegaly

A

(symmetric enlargement)

drug induced: thiopental and acepromazine- 5-40% of blood can be sequestered in spleen during anesthesia, propofol=minimal effects

congestion (torsion)

infiltrative diseases

immune mediated dz

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14
Q

Causes of splenic mass

A

(asymmetrical enlargement)

neoplasia

hematoma

nodular hyperplasia/EMH

trauma ► splenosis

abscess

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15
Q

Splenic torsion is most common with ____

A

GDV

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16
Q

Splenic torsion from stretching of ____ during previous GDV or trauma

A

gastrosplenic ligament

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17
Q

What dog breeds are predisposed to splenic torsion?

A

large/giant breed dogs

great dane

greater swiss mountain dog

german shepherd

english bulldog

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18
Q

Clinical signs of acute splenic torsion

A

acute abdomen- similar to GDV or BECAUSE OF GDV

acute abdominal pain/shock

abd distension

cardiovascular collapse

dysrhythmias

DIC

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19
Q

Clinical signs of chronic splenic torsion

A

vague/intermittent signs for up to 2 weeks

vomiting/diarrhea

weakness/depression

anemia

hematuria/hemoglobinuria

PU/PD

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20
Q

How do we diagnose splenic torsion? what is the best dx method?

A

rads

  • mid-abdominal mass
  • abdominal effusion
  • gas bubbles in spleem
  • C-shaped spleen

Ultrasound*** best method

  • mottled/diffuse hypoechoic areas
  • intralumunal echogenic densitites in veins
  • no flow in splenic vessels

CT scan

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21
Q

How do we stabilize P pre-op for splenic torsion?

A

fluids- end point resuscitation

transfusion

antibiotics

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22
Q

What is the treatment for splenic torsion?

A

Exploratory Laparotomy***** splenectomy

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23
Q

How can we prevent a splenic torsion?

A

gastropexy- at risk breed for GDV or to address GDV

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24
Q

What is VERY important to remember when you are removing the spleen?

A

DO NOT DEROTATE IT

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25
Q

Why cant we derotate the spleen prior to splenectomy?

A

spleen will release free radicals and could lead to DIC

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26
Q

Ideally we submit the spleen for ____ assessment to ensure no underlying pathology

A

histopathologic

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27
Q

T/F: neoplasia is a cause of splenic torsion

A

FALSE- neoplasia is NOT a cause of splenic torsion = not found in any case

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28
Q

T/F: splenic infarction is common

A

FALSE- RARE- can often see infarcted areas on abdominal US

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29
Q

T/F: splenic infarction requires surgery

A

FALSE: No, dont race to sx bc usually something systemic needs to be sorted out

renal disease, hyperadrenocorticism- cushings, neoplasia, DIC, heart disease

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30
Q

Splenic torsion can look like what on a ultrasound?

A

mass effect- devascularized area may turn into hematoma

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31
Q

Nodular splenic hyperplasia = sites of _____

A

extramedullary hematopoiesis

single or multiple SUBSCAPLULAR nodules

Very common***

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32
Q

Diagnosis of nodular hyperplasia of the spleen?

A

dx dilemma- can look like cancer

***FNA/Cytology = poor sensitivity***

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33
Q

Splenic nodular hyperplasia is typically asymptomatic but what may happen?

A

could rupture causing hemoabdomen

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34
Q

Are splenic nodules usually benign or neoplastic?

A
  1. 5% patients had benign splenic lesions = most commonly benign
  2. 5% had malignant neoplasia
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35
Q

How is splenic nodular hyperplasia usually found?

A

incidentally- non ruptured splenic masses or nodules w/o associated hemoperitoneum = most commonly benign!

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36
Q

What can cause splenic trauma?

A

blunt force (HBC/falls/dog attack)- ruptures capsule and parenchyma

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37
Q

What type of management is preferred and successful for splenic trauma?

A

conservative management

compression bandage= controversial but this is the time to use it (belly band)

supportive care and transfusion PRN

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38
Q

In splenic trauma can we just do a partial splenectomy?

A

can be considered if possible but in at risk breeds (labs/golden/GSD) please remove ALL spleen- dont leave any behind

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39
Q

T/F: autotransplantation doesn’t really work consistently

A

TRUE

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40
Q

Splenic neoplasia Ddx in dogs

A

Hemangiosarcoma (HSA)

Sarcomas

hemangioma

lymphosarcoma

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41
Q

Splenic neoplasia Ddx in cats

A

Mast Cell Tumor = Most Common

hemangiosarcoma

lymphoma

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42
Q

Splenic neoplasia Rule of 2/3rds

A

2/3rds of dogs w/ a splenic mass will have malignancy

2/3rds of those malignancies will be hemangiosarcoma (HSA)

66.6%

43
Q

Risk factors of hemangiosarcoma in spleen

A

age- older

>/= 21kg

breeds: GSD, labs, Goldens, poodles

presence of hemoperitoneum

44
Q

presence of hemoperitoneum with splenic tumor means ___% chance of malignancy

A

>80%

45
Q

Chances of splenic neoplasia in small breed dogs?

A

50:50 split benign vs malignant

wheaten terriers predisposed

hemoperitoneum NOT associated w/ malignancy

46
Q

What is the benign splenic mass to mass size ratio?

A

bigger the mass, (the better) more likely benign

47
Q

Splenic hemangiosarcoma prognosis

A

Poor :(

***in nearly ALL cases microscopic metastasis is present at the time of diagnosis***

48
Q

What does Cav recommend with splenic hemangiosarcoma?

A

careful staging pre-op

client communication- must know survival stats!

sx not recommended when: visible metastasis, very sick dogs, owner not informed

49
Q

Splenic hemangiosarcoma prognosis with alternative therapies

A

C versicolor mushroom (turkey tail)- significantly delayed metastasis

eBAT- bispecific urokinase angiotoxin designed to target EGFR

50
Q

Two techniques to consider for splenectomy

A

ligation of individual hilar vessels- preferred

ligation of the splenic and short gastric a.

51
Q

Splenectomy: Ligation of individual hilar vessels

A

preferred

preserves branches to pancreas and stomach

time consuming to do by hand

less risk of PO hemorrhage

52
Q

Splenectomy: ligation of the splenic and short gastric a.

A

w/out compromising blood flow to greater curvature of stomach

decreased surgical time

more challenging if large mass or omental adhesions distort anatomy

increased risk of major hemorrhage w/ technique failure

53
Q

What does complete splenectomy with hilar dissection preserve?

A

preserves branches to pancreas and stomach

54
Q

What does complete splenectomy with splenic artery ligation preserve?

A

preserves branch to left limb of pancreas (primary blood supply)

55
Q

Advantages using hemostatic clips with splenectomy

A

faster and easier than hand sewn

56
Q

Disadvantages of a splenectomy using hemostatic clips

A

clip instability, use limited to vessels <4mm diameter and implantation of non absorbable material

most medium to large breeds will have hilar vessels >4mm especially in the center of hilus where splenic a./v. are directly feeding- DO NOT USE CLIPS here

57
Q

What is stapler is good for rapidly ligating and cuts for splenectomy?

A

LDS- ligate divide stapler

58
Q

Electrothermal bipolar system- ***Ligasure***

A

handle vessels up to 7mm w/ minimal thermal damage to surrounding tissue

local hemostasis, fast, no foreign material left behind

$$$- good investment

59
Q

Monocaudary Vs bipolar caudary

A

biopolar caudary is good for delicate tissues

mono-caudary has a lot of electro thermal spread- a lot of heat transfer

60
Q

Partial splenectomy

A

PLEASE remove whole spleen in at risk breeds for splenic dz, Cav is not a fan of this procedure

indication: trauma, focal abscess, partial infarction

61
Q

What is the most common complication of splenectomy?

A

hemorrhage- if ligations arent sound

62
Q

What complication causes 2x risk of death?

A

Arrhythmias****

63
Q

Whats the deal with arrhythmias and splenectomy?

A

typically ventricular, similar to GDV

MOA: compromised venous return to the heart caused by intra-abdominal hemorrhage and compression of the caudal vena cava

64
Q

How should we monitor rhythms with splenectomy?

A

holter monitoring (continuous EKG)- 70% would have been missed if not wearing monitor

arrhythmias are especially in Ps w/ splenic rupture- only 6% of dogs w/o rupture had arrhythmias

65
Q

How do we visualize the left limb of pancreas?

A

looking in deep leaf of greater omentum

66
Q

Blood supplyof pancreas for left limb? right limb?

A

left limb- branch of splenic a.

body/right limb- caudal pancreaticoduodenal a. → branch of cranial mesenteric

67
Q

What does the pancreatic duct drain? What does the accessory pancreatic duct drain?

A

pancreatic duct: drains Right lobe

accessory pancreatic duct: drains left lobe

68
Q

The pancreatic duct enters the duodenum at _______ with _____

A

major duodenal papilla with bilde duct

(primary and ONLY duct in cats)

69
Q

The accessory pancreatic duct drains into _____ in DOGs

A

duodenum at minor duodenal papilla in DOGs

70
Q

T/F: cats dont have an accessory pancreatic duct

A

TRUE- CAT=Cant Accessorize That

71
Q

2 Functions of the _exo_crine system via pancreas

A

digestive secretions via duct system

major and minor duodenal papilla

72
Q

4 Cell types of the endocrine system via pancreas

A

4 cell types:

A- make glucaogn

B- insulin (60-70% of islet cells)

D- somatostatin

F (or P)- pancreatic polypeptide

73
Q

T/F: pancreatitis is a very common surgical disease

A

FALSE- NOT a surgical dz

cross over in clinical signs that may prompt exploratory laprotomy but could EXACERBATE the condition due to manipulation and hypoperfusion/tension during anesthesia

74
Q

What is the most common type of endocrine pancreatic neoplasia?

A

insulinoma- insulin based

75
Q

Laparoscopic biopsy of the pancreas

A

obtain from edge of organ (careful of deep vessels)

cats may not have grossly abnormal tissue = procure multiple samples

76
Q

Surgical biopsy of the pancreas

A

Guillotine technique

focal lesions in body = shave biopsy or trucut

do partial panceatectomy if lesion near caudal aspect of limbs

77
Q

Why is it important to handle the pancreas with care?

A

it will secrete digestibe enzymes and cause pancreatitis if overhandled

78
Q

Suture Fracture/ Guillotine Technique for surgical biopsy of pancreas

A
  • if diffuse dz is present
    • sample distal aspect of right limb = easiest access
    • get multiple bx’s
  • individual lobule dissection for small central body lesion
  • Halstead’s principles = handle with care
79
Q

Partial pacreatectomy: indications for procedure? What works best for ligation?

A
  • indications: tumor removal
  • incise omentum and capsule
  • dissect b/t lobules to isolate vessels and ducts in portion of gland to be removed
  • hemoclips or biopolar cautery work BEST for ligations
80
Q

If remaining ducts in the pancreas are patent, we can remove ___% of the pancreas

A

80%

81
Q

What very common issue must we warn owners about because it is very unpredictable who gets it?

A

Pancreatitis

82
Q

What causes Exocrin pancreatic insufficiency (EPI)? Tx?

A

if pancreatic drainage is completely obstructed

tx: pancreatic enzyme supplementation and low-high fat/highly digestible food

83
Q

Give an example of Endocrine pancreatic insufficiency. When does it occur?

A

diabetes mellitus

if > 80-90% of the pancreatic tissue is removed

tx w/ insulin

84
Q

What rare but relevant issue do we worry about with partial pancreatectomy?

A

Devitalization of duodenum

if pancreaticoduodenal a. which arises from cranial mesenteric a. gets damaged, then duodenm can be compromised

85
Q

Ligasure for pancreatic surgery has shown what?

A

faster sx and short hospitalization

***No pancreatitis*****

Cav’s preferred dissection/resection tool***

86
Q

Indications for a total pancreatectomy

A

RARE- be careful

acute trauma, severe, chronic fibrosis, extensive neoplasia

only do this if you MUST- Cav doesn’t like this procedure

87
Q

Pacreatic pseudocysts is not a true cyst because? How are they usually found?

A

lacks epithelial wall (fibrous sac of granulation tissue)

fluid is not secreted from lining rather is thought to leak from damaged pancreatic ducts and vessels

usually an incidental finding*** may be associated w/ recurrent bouts of pancreatitis or trauma

88
Q

Signalment and history of pancreatic pseudocysts

A

middle to older aged -mostly dogs

asymptomatic, vague signs of abdominal discomfort, anroexia, +/- vomit

89
Q

Diagnosis of pancreatic pseudocysts

A

diagnostic imaging: US= test of choice and most senstive

cant differentiate from abscess on US

90
Q

Pancreatic pseudocyst treatment

A

percutaneous aspiration- 1st line treatment esp if aclinical

if clinically ill from dz: resection, debride and drain (cures), >75% successful treated and survive

91
Q

Pancreatic abscess is usually secondary to?

A

acute bouts of pancreatitis

most are sterile, no bacteria on culture

92
Q

Pancreatic abscess diagnosis

A

rads- increased soft tissue density in right cranial or central cranial abdomen= ascites/peritonitis

US- mass lesions, guided FNA

Lab data- hyperbilirubinemia/elevated LES due to EHBO- inflam of pancreas causing duodenal papilla of CBD to swell shut

93
Q

Treatment for pancreatic abscess

A

resect- often challenging bc dz is NOT localized

debride and drain- omentalize****, active drainage

PO enteral nutrition plan- HAVE ONE= need post-gastric feeding!! can give pancreatitis after

94
Q

Prognosis of pancreatic abscess

A

guarded in dogs

high perioperatve mortality

potential recurrence if non-resectable

95
Q

Pancreatic neoplasia exocrine pancreatic adenocarcinoma

A

Malignant and invades locally- mets 50-78%

very aggressive, deadly- poor px

vomit, abd pain, weight loss, signs of EHBO

surgical resection if possible

96
Q

Pancreatic insulinoma

A

B cells of the islets of Langerhans= secreete insulin despite hypoglycemia

uncommon in dogs, rare in cats

90% malignant

weakness, szs

Dx- Whipples triad

97
Q

Whipples Triad

A
98
Q

Medical management of pancreatic insulinoma

A

small frequent meals, high protein, complex carbs

glucocorticoid therapy- increases hepatic glucose and decreases cellular glucose

oral hyperglycemic agents- Diazoxide=inhibits pancreatic insulin secretion and glucose uptake

If severe= ICU and dextrose supplement in fluids BUT dont overdo it→ remember these dogs are used to living hypoglycemic

99
Q

What is the gold standard of surgical management for pancreatic insulinoma?

A

partial pancreatectomy

100
Q

Insulinoma: recurrence of hypoglycemia after sx is common due to what?

A

metastasis

101
Q

Pancreatic insulinoma prognosis

A

**stage of dz important**

I confined to pancreas = MST 785days

II w/ reginal LN involvement= MST 547days

III systemic mets= MST 217days

102
Q

Gastrinoma are ____ tumors in dogs and cats. Are they usually malignant?

A

rare- highly malignant

103
Q

_______ syndrome describes syndrome of gastric acid hypersecretion, gastrointestinal ulceration and non-B cell pancreatic tumors

A

Zollinger-Ellison

Surgery (15 decks)

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