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Surgery > E2- Surgery of the stomach > Flashcards

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
Q

Clinical signs of FB

A

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

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26
Q

Lab findings for GI FB

A
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27
Q

FB Diagnostics

A

radiographs -not 100% bc of shadows

US- good for sm intestine

Contrast studies- positive contrast gastrography

Endoscopy- dx/theraputic

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28
Q

FB medical management

A
  • Apomorphine induce vomiting in dogs
  • Xylazine in cats
  • fluid therapy- stimulates motility, rehydrate, correct electrolytes
  • monitor w/ serial rads
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29
Q

FB and endoscopy

A

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
Q

T/F: Surgical management for gastrotomy for FB entails an abdominal exploratory (complete exploratory!)

A

TRUEE

31
Q

How do we handle the stomach for a gastrotomy?

A

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
Q

Where do we make our incision for a gastrotomy?

A

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
Q

How do we make our incision into the gastric lumen for gastrotomy?

A

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
Q

Closure of gastrotomy site?

A

double layer inverting pattern (lembert, cushing) …loss of lumen

double layer appositional, then inverting

35
Q

What is important to remember when closing the abdomen after a gastrotomy?

A

change gloves/instruments prior to abdominal closure- contamination from stomch contents!

lavage before closing- warmed sterile saline (~300ml/kg)

36
Q

Postop care for gastrotomy

A

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
Q

Reasons for benign gastric outflow obstruction

A
38
Q

Congenital pyloric stenosis is hypertrophy of what?

A

circular muscles of the pylorus

39
Q

Congenital pyloric stenosis breed predispositions?

A

brachiocephalic dogs (boxers, bulldogs)

siamese cats

40
Q

Congenital pyloric stenosis hx/CS?

A

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
Q

Congenital pyloric stenosis diagnostics

A

Rads- gastric distension, delayed emptying (>8hrs)

contrast rads- “beak” or “apple core” appearance

US- measure thickness of wall

endoscopy- cant see muscle

42
Q

What does the rad show?

A

congenital pyloric stenosis

43
Q

Pyloromyotomy: _____ procedure used ONLY for congenital stenosis

A

Fredet-Ramstedt

may be temporary

1-2cm incision throught the serosa and muscularis layers of long axis of pylorus

44
Q

Transverse Pylorosplasty: ______ procedure

A

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
Q

Prognosis after surgical correction of benign conitions of pylorus is ____

A

very good

(cats- minimal info, may have megaesophagus/esophagitis)

46
Q

Chronic Hypertrophic Pyloric Gastropathy (CHPG)

what is it and signalment?

A

acquired mucosal &/or muscular hypertrophy (both)

small breed dogs, shih tzu, lhasa apso, maltese

males>females

middle aged to older

47
Q

Chronic Hypertrophy Pyloric Gastropathy (CHPG) -Etiology

A

uknown

increased gastrin secretion

acute stress

inflam dz

trauma

48
Q

Chronic Hypertrophy Pyloric Gastropathy (CHPG)- History/CS

A

similar to congenital pyloric stenosis

intermittent vomiting

signalment will differentiate

49
Q

Chronic Hypertrophy Pyloric Gastropathy (CHPG) contrast radiograph

A

gastric distention

delayed gastric emptying

50
Q

Chronic Hypertrophy Pyloric Gastropathy (CHPG)- Ultrasound

A

good dx tool

evaluates muscle and pyloric wall thickness

muscularis <4mm

pyloric wall <9mm

51
Q

Chronic Hypertrophy Pyloric Gastropathy (CHPG)- Endoscopy

A

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
Q

Chronic Hypertrophy Pyloric Gastropathy (CHPG)

-Pathologic Classification: Grade 1

A

muscular hypertrophy ONLY

53
Q

Chronic Hypertrophy Pyloric Gastropathy (CHPG)

-Pathologic Classification: Grade 2

A

mucosal hyperplasia w/ glandular cystic dilation ONLY

-not muscular

54
Q

Chronic Hypertrophy Pyloric Gastropathy (CHPG)

-Pathologic Classification: Grade 3

A

muscularis hypertrophy AND mucosal hyperplasia- both cause enlargement

55
Q

In Chronic Hypertrophy Pyloric Gastropathy (CHPG), a _____ component may be present with any grade

A

inflam

56
Q

Chronic Hypertrophy Pyloric Gastropathy (CHPG)- surgical management

A

Heineke-Mikulicz Pyloroplasty -long incision, transverse closure

Y-U Pyloroplasty

Pylorectomy w/ Gastroduodenostomy (Bilroth I)

57
Q

Y-U Advancement Pyloroplasty

what is it? advantages/disadvantages?

A

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
Q

What is important to remember when making your incision for a Y-U Advancement Pyloroplasty?

A

dont make it a “V” bc it will dehisce and cause a leakage

we want a U shape

59
Q

Bilroth I- Gastroduodenostomy

what is it? advantages/disadvantages?

A

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
Q

Prognosis for CHPG

A

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
Q

Gastrectomy indications

A

(removing part of the stomach)

indications

  • neoplasia
    • location determines type of resection
  • ulceration → perforation
  • significant pyloric outflow obstruction
62
Q

Submucosal resection is for ______ so marginal excision is usually sufficient

example?

A

slow growing tumors

ex. Leiomyoma located w/in cardia

potential to grow back, not often done unless we know the type of tumor

63
Q

Partial gastrectomy is indicated when?

A

lesion is extensive or w/ concurrent ulceration

sx excision & suture closure, TA stapler to ligate & excision of affected tissue

Bilroth I

64
Q

Bilroth II Gastroenterostomy

what is it?

indications?

A

partial gastrectomy followed by gastroenterostomy

indications: extensive gastric resection making gastroduodenostomy impossible

65
Q

Bilroth II Gastroenterostomy remember to consider what?

A

common bile duct

66
Q

Bilroth II Gastroenterostomy Complications

A
  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
Q

Phycomycosis: ____ species is most common in US

A

Pythium

aquatic oomycete, poorly deptated, filamentous

highest incidence in gulf coast states (ask about travel hx)

exact mode of entry unclear- ingestion presumed

68
Q

Phycomycosis pathophysiology

A

severe inflam and infiltrative lesion

induce intense fibrotic reaction

transmural thickening- gastric outflow area most commonly affected

69
Q

Phycomycosis CS

A

vomiting

inappetence

weight loss

diarrhea

palpable mass bc its so thickened/fibrotic

70
Q

Phycomycosis Dx

A
  • 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
Q

Phycomycosis treatment

A

wide surgical excisoin- affects most of the stomach

medical therapy ineffective- antifungals- NOT effective

72
Q

Phycomycosis prognosis

A

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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