Exam 2 Stomach sx

Question 1

What are predisposing factors for gastric FB

Answer 1

objects ingested by pt

penetrating wounds

Question 2

What are the CS & hematology findings of gastric FB

Answer 2

distended abd, dehydration, hematemesis, asymptomatic

anemia or hemoconcentration, azotemia, alkalosis or acidosis, hypokalemia, hypochloremia, leukocytosis

Question 3

How to dx gastric FB

Answer 3

imaging

radiographs if radioopaque, u/s if radiolucent, endoscopy for direct visual

Question 4

Tx for gastric FB

Criteria for choosing tx

Answer 4

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.

Question 5

Sx approach for gastric FB removal

Answer 5

ventral midline approach from xiphhoid to pubis

Question 6

How to close a gaastrotomy incision

Why choose one option over another

Answer 6

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)

Question 7

CS associated w/ gastric outflow obstruction

Answer 7

intermittent vomiting

dietary change alters CS

normal -> decr BCS

abd distension w/o pain

“poor doers”

Question 8

Causes of gastric outflow obstruction

how to differentiate between them

Answer 8

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

Question 9

blood supply to stomach

Answer 9

main arteries:

Celiac, R gastric, L gastric, R gastroepiploic, L. gastroepiploic

• match numbers-

* don’t neglect the Gastric pacemaker area!

Question 10

differentiate b/t congenital & acquired pyloric stenosis/signalment/hx

Answer 10

brachiocephalic breeds (Boston terr.), siamese cats (rare)

CS begin at weaning

• small breeds (Lhasa Apso, Shih Tzu)*
• temperment (excitable or vicious), middle age males*

Question 11

what pathology is associated w/ congenital & acquired pyloric stenosis

Answer 11

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

Question 12

digestive hormone implicated in pyloric stenosis etiology

what are hormones effects

Answer 12

gastrin

Gastrin is the major regulator of gastric acid secretion and is trophic for gastric smooth muscle and mucosa

Question 13

dx modalities for pyloric stenosis

which is best & why

Answer 13

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

Question 14

specific goals of sx correction of pyloric stenosis

sx technique(s) typically used & why

Answer 14

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

Question 15

tumors most commonly seen in proximal part of stomach

tumors most commonly seen in distal part

Answer 15

Gastric adenocarcinoma - pyloric antrum, lesser curvature

Leiomyomas - cardia

Question 16

signalment, physical findings, tx options & px for gastric adenocarcinoma, Leiomyosarcoma & leiomyoma

Answer 16

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

Question 17

different presenting pathologies of gastric adenocarcinoma

Answer 17

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

Question 18

signalment, physical findings, tx options, and px for pythiosis (oomycosis)

Answer 18

young lg breed, working dogs, fall & winter

can mimic gastro adenocarcinoma, aggressive lesion, wt. loss, v/d, hematochezia

sx excision, antifungals, Px guarded-poor!

Question 19

principles/goals of suturing a gastrotomy incision

Answer 19

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)

Question 20

advantages/disadvantages of suturing stomach w/ inverting suture patterns

what are Cushing, Connell & Lembert patterns

Answer 20

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

Question 21

indications, advantages/disadvantages of following sx procedures:

Fredet-Ramstedt

Heineke-Mikulicz

Y-U pyloroplasty

Bilroth 1

Bilroth 2

Roux-N-Y

Answer 21

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

Question 22

physiological post-op effects of Billroth 1 & Billroth 2

Answer 22

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.