Esophageal Surgery/ Feeding Tubes Flashcards by jared Jensen

What are the three parts of the esophagus

Cervical (left)
Thoracic (Right)
Abdominal (left)

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What supplies blood to the esophagus

thyroid
bronchoesophageal
phrenic
left gastric

blood supply is very segmental and hard for healing (compared to the stomach)

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What muscle controls the upper esophagus

cricopharyngeus muscle

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What muscle control the lower esophagus

lower esophageal sphincter = gastroesphageal junction

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What contributes to the pressure of the lower esophageal sphincter / gastroesophagel junction

1) Muscle layers
2) Esophageal hiatus (diaphragm)
3) Intra-abdominal terminal esophagus
4) Angled gastroesophageal junction

15-20mmHg

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What are the 4 layers of the esophagus

1) Mucosa - longitudinal folds
2) Submucosa
3) Muscularis
4) Adventitia

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T/F: esophagus has serosa

False- it has adventitia

poorer healing

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How does the muscularis layer of the esophagus differ in dogs vs cats

Dogs: striated throughout the esophagus

Cats: smooth muscle at the termination

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Cats have transverse ripples in the __________ of their esophageal mucosa

caudal 1/3

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Why does the esophagus have poor healing potential
6 reasons

1) No serosa
2) Segmental blood supply
3) Constant motion (peristalsis and respiration/ diaphragmatic movement)
4) Tension
5) Poorly mobilized, anchored
6) Lack of omentum (valuable for healing), can potential surgically bring to site

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Should you suture esophagus with single or double layer

Double Layer - two appositionals

1) Mucosa / Submucosa
2) Muscularis / Adventitia

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Should you suture esophagus with continuous or interrupted

Continuous

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Should you suture esophagus with a monofilament or multifilament

Monofilament

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How should you suture the esophagus

1) Double layer- mucosa/submucosa and muscularis/ adventitia
2) Continuous
3) Absorbable or nonabsorbable
4) monofilament

PDS or Maxon recommended

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What suture type should you use for suturing the esophagus

PDS or Maxon

these are absorbable monofiilaments. high initial strength that last 4-5 weeks

want to avoid rapidly absorbing monofilaments like Monocryl and Biosyn

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When doing a double layer of closure of the esophagus you should place the knots of the mucosa/submucosa ____________ and do a ________ pattern in the muscularis / adventitia

knots in lumen for mucosa/submucosa

appositional pattern in the muscularis

can do two appositionals

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when closing the esophagus why might people do interrupted patterns

for anastomosis- permit distension

otherwise you can do continuous

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What are diseases of the esophagus that might warrant surgery

1) Foreign body
2) Stricture
3) Perforation
4) Diverticulum
5) Vascular ring anomalies
6) Tumors
7) Hiatal hernia
8) gastroesophageal intussusception
9) Cricopharyngeal achalasia
10) Esophageal fistula

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What are two differentials for regurgiation in newly weaned puppies and kittens

1) Congenital megaesophagus
2) Vascular Ring Anomalies

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What is the most successful way to get out esophageal foreign bodies

endoscopy

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achalasia

inability of the cricopharyngeal muscle to relax

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asynchrony

incoordination between contraction and relaxation of pharyngeal muscles

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What causes cricopharyngeal dysphagia

1) Congenital: spaniels; goldens
2) Idiopathic neuromuscular dysfunction

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What are the effects of cricopharyngeal dysphagia

regurgitation
aspiration pneumonia

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With cricopharyngeal dysphagia, how does achalasia differ from asynchrony

Achalasia- inability of the cricopharyngeal muscle to relax Asynchrony- incoordination between contraction and relaxation of pharyngeal muscles

What species can get congenital cricopharyngeal dysphagia leading to regurgitation / dysphagia and aspiration pneumonia

Spaniels and Goldens

Hiatal hernia

brachycephalics sharpeis cats

displacement of gastroesophageal junction and reduction of gastroesophageal sphincter pressure due to phrenicoesophageal ligament laxity

Hiatal hernia

What causes hiatal hernia

phrenicoesophageal ligament laxity pressure changes

What are the effects of hiatal hernia

Gastroesophageal reflux and esophagitis +/- megaesophagus displacement of terminal esophagus +/- stomach into the thorx

What are the types of hiatal hernia

Type 1: Gastroesophageal junction (sliding of terminal esophagus more cranial) Type 2: Paraesophageal Type 3: Combination Type 4: Gastroesophageal intussusception

Retrograde invagination of the stomach into the esophagus

Gastroesophageal intussusception rare <3 months of age german shepherd dogs 95% mortality

Gastroesophageal intussusception typically occur in what type of dogs

german sheperds <3 months of age very rare

T/F: Type 1: Gastroesophageal junction (sliding of terminal esophagus more cranial) is often congenital

True

What 3 methods can you do surgically for hiatal hernias

1) Hiatal reduction- pull esophagus back into abdomen and close esophagus 2) Esophagopexy- suture esophageal wall to diaphragm 3) Left-sided gastropexy- pexy fundus on the left side

A left-sided gastropexy is for _________ while a right sided gastropexy is for _______

left sided: hiatal hernia right sided: GDV

T/F: the esophagus has poor healing properties compared to the rest of the GI tract

True

What is the most common feeding tubes

E-tubes

What are methods of nutritional support

-Syringe feeding / force feeding -appetite stimulants -feeding tubes/ enteral -Intravenous feeding / parenteral

What are the resting energy requirements

30 x BW(kg) + 70 used generally thenn multiply by 1.25 to 1.5 if <2kg or >80kg 70(BW^0.75) a 5kg cat = 220 ml per day most diets are 0.6-1.1 kcal/ml 60ml QID = full RER

Why should you avoid overfeeding

GI upset Hepatic dysfunction Increased CO2 production

-otomy

to cut into

-ectomy

cut something out

-ostomy

create an opening (stoma)

-oscopy

viewing

-pexy

surgical fixation

Why might you do a gastrectomy

cut some of the stomach out after devitalized GDV

why might you use a gastrotomy

to cut into the stomach to remove a foreign body

why might you do a gastrostomy

creating an opening in the stomach for a tube

What tube should you use if you anticipate short-term supplemental feeding

Nasal Feeding Tubes

What are examples of Nasal feeding tubes

Nasoesophageal Nasogastric

T/F: placing a nasal feeding tube requires general anesthesia

False- they do not require GA

T/F: you can feed immediately after placing a nasal feeding tube

True

What are the cons of nasal feeding tubes

1) Prone to clogging 2) Liquid diets only 3) easy dislodgement 4) inadvertent airway placement (very tragic)

What is a fatal complication of nasal feeding tubes

misplacement into the airway and cause perforation out into the lung parenchyma air insufflation -> borborygmus saline insufflation -> coughing

What diets must be used with nasal feeding tubes

liquid only

When placing a nasal feeding tube, how can you check for inadvertent airway placement

1) air insufflation -> borborygmus 2) saline insufflation -> coughing 3) Two step placement 4) pH of aspirated fluid 5) Laryngoscopic examination 6) Radiographs 7) Capnograph

If the nasal tube did go into the lung parenchyma, why shouldnt you pull it out

it is plugging hole, can cause pneumothorax if you take it out immediately

T/F: for placement of E-tubes, the patient needs to be under general anesthesia

True

What are the ons of E-tubes

1) Requires general anesthesia 2) Stoma issues 3) Insult to the esophagus

In animals with an E-tube, when is it safe to feed them

When they are recovered from anesthesia

What diet do you feed animals with E-tubes

blenderized normal diets can medicate through the tube

T/F: E-tubes are simple, well tolerated, and have minimal complications from premature removal

True

T/F: esophageal strictures in cats are a concern when placing E-tube

False- only make 2cm incision that will heal with second intention and not form strictures

What is a potential major complication of E-tube placement

Jugular or Carotid perforation be careful going ventral

How long do you need to wait to feed after placing a gastrostomy tube

wait 12-24 hours before feeding

How long do you need to leave a gastrostomy tube in

leave in 7-10 days regardless

What is a major risk of gastrostomy tube

peritonitis with premature removal need to leave in 7-10 days regardless

What are the pros of gastrostomy tube placement

well tolerated large tube feed blenderized normal diets and can medicate through tube decompression multiple ways to place good for esophageal strictures

What should you do for a large dog getting a gastrostomy tube so it doesnt come apart quickly

a gastropexy

What are the methods of placing a gastrostomy tube

-Blind placement -PEG (percutaneous endoscopy guided) -Flank approach -Midline laparotomy -Laparoscopy

For a G-tube what side do you pexy the stomach to the muscle

left side (has the food) the right has a pylous and antrum which you dont want

How do you surgically place G-tube

In body of the stomach Purse-string suture Four-corner pexy Foley or Pezzer

What are the pros of Jejunostomy tubes

feed in the face of vomiting use immediately well tolerated can be sedated/comatose

What are the cons of jejunostomy tubes

1) Invasive 2) Small diameter 3) Hospitalization- continuous feeding 4) Risk of peritonitis with premature removal

What are the gastrointenstinal complcations of feeding tubes

vomiting, diarrhea aspiration peritonitis

What are the metabolic complications of feeding tubes

Refeeding syndrome Hyperglycemia

What are the mechanical complications of feeding tubes

1) Incorrect placement 2) Stoma problems 3) Tube redirection 4) Tube clogging

What should you do nutritionally if the animal does not have a functional GI tract

Parenteral (Partial or Total) central (long-term) or peripheral line (short-term)