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E2- Surgery of the stomach Flashcards

1
Q

What are the layers of the stomach from outside in?

A

Serosa, muscular, submucosa, mucosa

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2
Q

What is the holding layer of the stomach?

A

Submucosa*****

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3
Q

What are the healing characterisitcs of the stomach?

A

short duration of healing bc of

  • extensive & redundant blood supply
  • reduced bacterial numbers
  • rapidly regenerating epithelium
  • omentum
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4
Q

Smooth muscle cell contribute to ______ production

A

collagen

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5
Q

Presurgical preparation for the stomach

A

correct electrolyte imabalances

hydrate

fast for 8-12 hrs to keep stomach empty

H2 anatagonists

proton pump inhibitors

prophylactic antiobiotic use? controversial

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6
Q

What external incisional approach do we take on stomach surgery?

A

dorsal recumbancy

ventral midline celiotomy- xiphoid to pubis

abdominal exploratory

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7
Q

When entering the abdomen for an exploratory, the ___ may need ligation and resection

A

falciform ligament

-if its big/fatty- has blood supply, make sure to ligate! gets in the way of exploration

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8
Q

What retractors do we use for an exploratory & why?

A

Balfour retractors- hold everything open

self retaining/nontraumatic retractors

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9
Q

For gastric closure we use a ____ layer closure

A

two

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10
Q

Traditional gastric closure is

A

Double inverting- 2 invertings overlap of one another (one including the submucosa holding layer

  • Cushing pattern (serosa, muscularis, submucosa)
  • oversewn with Lembert (serosa, muscularis)
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11
Q

Connell Vs Cushing inverting suture patterns

A

Connell goes into the lumen which exposes it to acid and can break down suture. We should avoid this in organs with lumens, like the stomach and bladder.

Cushing does NOT go through the lumen.

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12
Q

Alternate gastric closure

A
  • simple continuous (appositional pattern)- mucosa (can help decrease bleeding into lumen)
  • Cushing or Lempert pattern (inverting pattern)- submucosa, muscularis, serosa layers
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13
Q

What influences stomach wall closure?

A

pathology and surgeon preference

(ex. wall thickened)

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14
Q

Reasons for a single layer gastric closure

A

pyloric outflow tract

reduced gastric volume

thickened gastric wall (simple interrupted, simple continuous)

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15
Q

What type of suture material do we need to use for gastric closure?

A

resists degradation for 14 days necessary to regain gastric wall strength

monofilament, absorbable

(polydioxanone, polyglyconate, poliglecaprone 25)

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16
Q

Why do we avoid braided suture in gastric closure?

A

bacteria and contentes can wick through the suture

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17
Q

Can we use staples for gastric closure?

A

yep

thoracoabdominal (TA)

gastrointestinal anastomosis (GIA)

skin stapler (stomach is thick, works for intestines)

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18
Q

Ways to tell gastric viability?

A

gastric wall thickness- slip = viability = normal!

serosal surface color, serosal capillary perfusion, peristalsis

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19
Q

Signs of nonviable stomach?

A

thinning of gastric wall, grey-green to black color

85% accurate

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20
Q

Indications for gastric biopsy

A

gross dz

clinical signs of upper GI dz

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21
Q

Endoscopic Vs Surgical gastric biopsy methods

A

endoscopic is only good for mucosal

while surgical is good for getting the other layers that endoscopy cant get

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22
Q

What is the most common indication for a gastrotomy?

A

Gastric foreign bodies!!***

dogs more than cats

16-50% of GI foreign bodies

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23
Q

GI foreign body signalment/hx?

A

younger animals

previous hx of FB

conditions that predispose PICA- eating random things

visualized FB ingestion- DUH!

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24
Q

What are 3 conditions that predispose PICA?

A

iron def

hepatic encephalopathy

pancreatic exocrine insuffiency

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25
Clinical signs of FB
vomiting * not always- stomach is big, things can sit in there a while, intermitent vomiting bc things move around in stomach * outflow obstruction * gastric distension * mucosal irritation lethargy abdominal pain anorexia
26
Lab findings for GI FB
27
FB Diagnostics
radiographs -not 100% bc of shadows US- good for sm intestine Contrast studies- positive contrast gastrography Endoscopy- dx/theraputic
28
FB medical management
* **_Apomorphine_** induce vomiting in dogs * Xylazine in cats * fluid therapy- stimulates motility, rehydrate, correct electrolytes * monitor w/ serial rads
29
FB and endoscopy
ease of removal- no incision, shorter anesthesia need appropriate equipment- shapes of object time limitation- limits anesthesia, dont want them trying all day, take into sx when time is up
30
T/F: Surgical management for gastrotomy for FB entails an abdominal exploratory (**complete** exploratory!)
TRUEE
31
How do we handle the stomach for a gastrotomy?
isolate stomach- food, fluids, prevent leaking on other structures. -protect other organs with moistened lap sponges stay sutures- lift stomach out of the abdomen
32
Where do we make our incision for a gastrotomy?
incision in the hypovascular area on ventral aspect of the stomach, b/t lesser and greater curvature the stomach is highly vascularized so we try to go for the least amount of blood supply
33
How do we make our incision _into_ the gastric lumen for gastrotomy?
stab incision into gastric lumen through mucosa enlarge incision w/ metzenbaum scissors -dependent on size of FB (dont make it bigger than it needs to be)
34
Closure of gastrotomy site?
double layer inverting pattern (lembert, cushing) ...loss of lumen double layer appositional, then inverting
35
What is important to remember when closing the abdomen after a gastrotomy?
change gloves/instruments prior to abdominal closure- contamination from stomch contents! lavage before closing- warmed sterile saline (~300ml/kg)
36
Postop care for gastrotomy
fluid therapy- electrolytes feed food and water w/in 12hrs- protein needed for wound healing if vomiting, ID cause & treat- prokinetics, antiemetics H2 blockers
37
Reasons for benign gastric outflow obstruction
38
Congenital pyloric stenosis is hypertrophy of what?
circular muscles of the pylorus
39
Congenital pyloric stenosis breed predispositions?
brachiocephalic dogs (boxers, bulldogs) siamese cats
40
Congenital pyloric stenosis hx/CS?
CS at weaning- when they start to eat solid food intermittent vomiting- chronic, hours after feeding, partially digested, frequency varies, liquids OK normal to increased body condition
41
Congenital pyloric stenosis diagnostics
Rads- gastric distension, delayed emptying (\>8hrs) contrast rads- "beak" or **"apple core"** appearance US- measure thickness of wall endoscopy- cant see muscle
42
What does the rad show?
congenital pyloric stenosis
43
Pyloromyotomy: _____ procedure used **ONLY for congenital stenosis**
**Fredet-Ramstedt** may be temporary 1-2cm incision throught the serosa and muscularis layers of long axis of pylorus
44
Transverse Pylorosplasty: ______ procedure
_Heineke-Mikulicz procedure_ 3-5cm full thickness incision over pylorus biopsy muscle to get definitive dx orietn incision transversely and close w/ appositional suture pattern recurrence less likely not usually effective with acquired stenosis
45
Prognosis after surgical correction of benign conitions of pylorus is \_\_\_\_
very good (cats- minimal info, may have megaesophagus/esophagitis)
46
Chronic Hypertrophic Pyloric Gastropathy (CHPG) what is it and signalment?
acquired mucosal &/or muscular hypertrophy (both) small breed dogs, shih tzu, lhasa apso, maltese males\>females middle aged to older
47
Chronic Hypertrophy Pyloric Gastropathy (CHPG) -Etiology
uknown increased gastrin secretion acute stress inflam dz trauma
48
Chronic Hypertrophy Pyloric Gastropathy (CHPG)- History/CS
similar to congenital pyloric stenosis intermittent vomiting signalment will differentiate
49
Chronic Hypertrophy Pyloric Gastropathy (CHPG) contrast radiograph
gastric distention delayed gastric emptying
50
Chronic Hypertrophy Pyloric Gastropathy (CHPG)- Ultrasound
good dx tool evaluates muscle and pyloric wall thickness muscularis \<4mm pyloric wall \<9mm
51
Chronic Hypertrophy Pyloric Gastropathy (CHPG)- Endoscopy
able to visualize mucosal hypertrophy can obtain biopsies to rule out neoplasia cant biopsy muscle layer with endoscopy bc you cant get full thickness
52
Chronic Hypertrophy Pyloric Gastropathy (CHPG) -Pathologic Classification: **Grade 1**
muscular hypertrophy ONLY
53
Chronic Hypertrophy Pyloric Gastropathy (CHPG) -Pathologic Classification: **Grade 2**
mucosal hyperplasia w/ glandular cystic dilation ONLY -not muscular
54
Chronic Hypertrophy Pyloric Gastropathy (CHPG) -Pathologic Classification: **Grade 3**
muscularis hypertrophy AND mucosal hyperplasia- both cause enlargement
55
In Chronic Hypertrophy Pyloric Gastropathy (CHPG), a _____ component may be present with any grade
inflam
56
Chronic Hypertrophy Pyloric Gastropathy (CHPG)- surgical management
Heineke-Mikulicz Pyloroplasty -long incision, transverse closure Y-U Pyloroplasty Pylorectomy w/ Gastroduodenostomy (Bilroth I)
57
Y-U Advancement Pyloroplasty what is it? advantages/disadvantages?
single pedicle advancement from antrum across pylorus advantages: * increase diameter of pylorus * access to excise hypertrophied mucosa disadvantages * potential necrosis of flap tip * rapid emptying?
58
What is important to remember when making your incision for a Y-U Advancement Pyloroplasty?
dont make it a "V" bc it will dehisce and cause a leakage we want a U shape
59
Bilroth I- Gastroduodenostomy what is it? advantages/disadvantages?
Pylorectomy- gastroduodenostomy (remove pylorus and put the stomach and duodenum together) advantages * all dz tissue can be removed disadvantages * technically more demanding * increased risk for "dumping" syndrome and reflux gastritis removing the sphincter ► rapid emptying good for tumors/neoplasia in this area
60
Prognosis for CHPG
good to excellent (85%) poor outcome associated with technical failures or picked wrong procedure for dz technique is important (U) ability to recognize and treat underlying cause
61
Gastrectomy indications
(removing part of the stomach) indications * neoplasia * location determines type of resection * ulceration → perforation * significant pyloric outflow obstruction
62
Submucosal resection is for ______ so marginal excision is usually sufficient example?
slow growing tumors ex. Leiomyoma located w/in cardia potential to grow back, not often done unless we know the type of tumor
63
Partial gastrectomy is indicated when?
lesion is extensive or w/ concurrent ulceration sx excision & suture closure, TA stapler to ligate & excision of affected tissue Bilroth I
64
Bilroth II Gastroenterostomy what is it? indications?
partial gastrectomy followed by gastroenterostomy indications: extensive gastric resection making gastroduodenostomy impossible
65
Bilroth II Gastroenterostomy remember to consider what?
common bile duct
66
Bilroth II Gastroenterostomy 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
67
Phycomycosis: ____ species is most common in US
Pythium aquatic oomycete, poorly deptated, filamentous highest incidence in gulf coast states (ask about travel hx) exact mode of entry unclear- ingestion presumed
68
Phycomycosis pathophysiology
severe inflam and infiltrative lesion induce intense fibrotic reaction transmural thickening- gastric outflow area most commonly affected
69
Phycomycosis CS
vomiting inappetence weight loss diarrhea palpable mass bc its so thickened/fibrotic
70
Phycomycosis Dx
* Endoscopy- difficult to find organism bc can only sample mucosal layer * submucosal and muscularis layers affected * histopathology * eosinophilic pyogranulomatous inflam * deep tissue samples of fibrotic material can reveal organism * Elisa tests for P. insidiosum antibodies
71
Phycomycosis treatment
wide surgical excisoin- affects most of the stomach medical therapy ineffective- antifungals- NOT effective
72
Phycomycosis prognosis
gaurded to poor one study had median survival time of 26.5 days since its diff to dx, often too late

Surgery (15 decks)

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