Exam 2 Stomach sx Flashcards
What are predisposing factors for gastric FB
objects ingested by pt
penetrating wounds
What are the CS & hematology findings of gastric FB
distended abd, dehydration, hematemesis, asymptomatic
anemia or hemoconcentration, azotemia, alkalosis or acidosis, hypokalemia, hypochloremia, leukocytosis
How to dx gastric FB
imaging
radiographs if radioopaque, u/s if radiolucent, endoscopy for direct visual
Tx for gastric FB
Criteria for choosing tx
conservative medical: fluids, gastro-protectants & antiemetics -> FB passes on its own - small size not likely to get stuck or create issue if not removed immed.
medical: induce emesis -> FB is encouraged/helped to come out the way it went in - quicker removal but still not expected to cause issue coming out (size, location)
non-invasive sx: endoscopic removal - potential for addtl damage if removed by other conservative methods (shape, location,)
invasive sx: gastrotomy sx to remove FB - obvious difficulty in removing by any other method due to location, shape, size or pt being compromised.
Sx approach for gastric FB removal
ventral midline approach from xiphhoid to pubis
How to close a gaastrotomy incision
Why choose one option over another
1. Two layer closure - “traditional”
- Cushing pattern oversewn w/ Lembert
2. Simple continuous in submucosa w/ cushing pattern in seromuscular layers
3. Simple continuous through serosa, muscularis & submucosa w/ Cushing pattern in seromuscular layers
depends on remaining volume of stomach, & surgeons choice - inverting patterns decr. stomach volume but create serosa/serosa seal (better for water tightness)
CS associated w/ gastric outflow obstruction
intermittent vomiting
dietary change alters CS
normal -> decr BCS
abd distension w/o pain
“poor doers”
Causes of gastric outflow obstruction
how to differentiate between them
congenital vs acquired
hypertrophy of circular mm. vs mucosal a/o muscular hypertrophy (usually both tissue types)
CS start at weaning (switch from liquid to solid diet) vs middle age
blood supply to stomach
main arteries:
Celiac, R gastric, L gastric, R gastroepiploic, L. gastroepiploic
- match numbers-
* don’t neglect the Gastric pacemaker area!
differentiate b/t congenital & acquired pyloric stenosis/signalment/hx
brachiocephalic breeds (Boston terr.), siamese cats (rare)
CS begin at weaning
- small breeds (Lhasa Apso, Shih Tzu)*
- temperment (excitable or vicious), middle age males*
what pathology is associated w/ congenital & acquired pyloric stenosis
reduced gastric outflow -> vomiting most common CS, intermittent a/o delayed after feeding
hypertrophy of circular mm. vs. mucosal a/o mm. hypertrophy
Grade 1 - muscular hypertrophy - correct w/ tranverse pyloroplasty
Grade 2 - muscular & mucosal hypertrophy - most common presentation (acquired form) - correct w/ Y-U pyloroplasty
Grade 3 - mucosal hyperplasia + muscular and submucosal inflammation - correct w/ pylorectomy
digestive hormone implicated in pyloric stenosis etiology
what are hormones effects
gastrin
Gastrin is the major regulator of gastric acid secretion and is trophic for gastric smooth muscle and mucosa
dx modalities for pyloric stenosis
which is best & why
radiographs, endoscopy, ultrasound
gastric distension, delayed gastric emptying, “beak”/”apple core” sign (w/ contrast)
Cannot see mm., see retained ingesta, bx unremarkable
u/s is diagnostic because layer thickness can be determined & can differentiate neoplasia
specific goals of sx correction of pyloric stenosis
sx technique(s) typically used & why
goal of sx correction is to remove the obstruction and reestablish normal gastric emptying
Fredet-Ramstedt Pyloromyotomy - only used for congenital, seromuscular layers incised exposing mucosal layer allowing bulge through (creating larger outflow tract), *note stenosis may reoccur
Heineky-Mikulicz Pyloroplasty (trans) - full thickness incision (can bx mucosa) w/ transverse closure creating larger outflow tract, reoccurrence unlikely, used for acquired Grade 1
Y-U pyloroplasty - transposes antral wall to pyloric region creating wider pylorus for acquired Grade 2
Billroth 1 - Pylorectomy gastroduedenostomy acquired Grade 3 removes entire affected pyloric region
tumors most commonly seen in proximal part of stomach
tumors most commonly seen in distal part
Gastric adenocarcinoma - pyloric antrum, lesser curvature
Leiomyomas - cardia
signalment, physical findings, tx options & px for gastric adenocarcinoma, Leiomyosarcoma & leiomyoma
gastric adenocarcinoma - dog aggressive sx excision! Gastrectomy, Billroth 1 or 2 (gastrojejunostomy)
gastric leiomyosarcoma - dog, 7 yo, sm. mm. origin, ulcerates in gastric lumen, MST 21 mos
gastric leiomyoma - dog, >15 yo, incidental finding, submucosal resection (scoop out), benign
different presenting pathologies of gastric adenocarcinoma
infiltrative & ulcerated mucosal plaque forms & (rare) discrete polypoid form
diffuse, thickened hard area of tissue w/ fine demarcated line to normal tissue. “linitis plastica” (leather bottle stomach)
diffuse plaques throughout mucosa of stomach
discrete nodular form
signalment, physical findings, tx options, and px for pythiosis (oomycosis)
young lg breed, working dogs, fall & winter
can mimic gastro adenocarcinoma, aggressive lesion, wt. loss, v/d, hematochezia
sx excision, antifungals, Px guarded-poor!
principles/goals of suturing a gastrotomy incision
stomach heals rapidly
submucosa is layer of strength (throughout all GIT)
apposition of submucosa results in stronger closure
serosa-to-serosa contact enhances fromation of fibrin seal
water-tight closure is mandatory
leave as much gastric volume as possible!
(reduced gastric volume or tissue pliability complicate closure)
advantages/disadvantages of suturing stomach w/ inverting suture patterns
what are Cushing, Connell & Lembert patterns
inverting suture patterns give serosa-serosa contact
decr. stomach volume
Cushing pattern - non penetrating pattern, continuous, extends only to the submucosal layer, suture needle bites run parallell to incision
Connell - penetrating pattern, continuous, extends into lumen, suture needle bites run parallell to incision
Lembert - non penetrating pattern, continuous, suture needle bites cross incision
indications, advantages/disadvantages of following sx procedures:
Fredet-Ramstedt
Heineke-Mikulicz
Y-U pyloroplasty
Bilroth 1
Bilroth 2
Roux-N-Y
Fredet-Remastedt - quick & easy, no lumen exposure (seromuscular layer only incision), stenosis may reoccur, only for congenital pyloric stenosis
Heineke-Mikulicz - mucosa exposed facilitating bx, reoccurrence unlikely, exposes lumen
Y-U pyloroplasty - creates wider pylorus, allows mucosal resection, shortens gastric emptying time, must be careful to avoid hepatoduodenal ligament as can damage common bile duct
Billroth 1 - abn tissue compltely removed, larger incr. in gastric outflow, technically difficult, longer procedure, incr. risk of leakage
Billroth 2 - allows extensive gastrectomy w/o tension on suture, alkaline gastritis, “Blind loop” syndrome, marginal ulceration
Roux-N-Y - avoids alkaline reflux gastritis, decr. likelihood of blind loop syndrome, marginal ulceration still an issue, requires one more anastomosis
physiological post-op effects of Billroth 1 & Billroth 2
due to extensive resection of gastric/intestines (Billroth 2) - bile & pancreatic secretions flow into stomach, gastric contents move orally & putrefy, ulceration of jejunal mucosa - not used to seeing acid contents
post-op very“poor doers”, chronic wt. loss, diarrhea, intermittent chronic vomiting, owners must be made aware of long term high maintenance.
