Lecture 2: Gastric Distention & Volulus ( Exam 1) Flashcards
When should surgery be performed
As soon as the px is stable
Why should you still do sx if the stomach is decompressed
Rotation of an undistended stomach still interferes w/ gastric blood flow & may potentiate gastric necrosis
What preop management should be done before a GDV surgery
- IV fluids
- Antibiotics
- Oxygen
- Correct significant electrolyte & acid-base abnorms
- Gastric decompression as needed
- ECG to monitor for cardiac arrhythmias
What are some instruments & equipment need for a GDV surgery
- Foal nasogastric tube & stomach pump
- Suction machine & sterile tubing
- Poole suction tip
- Laparotomy pads
- Balfour retractor
- “Spay pack”
- TA stapler
How should the px be placed in GDV surgery
Dorsal recumbency
Where should the incision be made in GDV
Ventral midline incision is made from the xyphoid to pubis to facilitate a full exploratory celiotomy
What are the goals of GDV surgery
- Assess viability - inspect the stomach & spleen to id/remove damage or necrotic tissue
- Decompression/Derotation
- Gastropexy (DO IT)
What are the steps of a GDV procedure
- Initial assessment of gastric viability
- Gastric decompression
- Gastric derotation
- Abdominal exploratory
- Secondary assessment of gastric viability
- Check for torsion of the gastrosplenic lig
- Palpate intra-abdominal esophagus to ensure the stomach is derotated
- gastropexy
What should be done while doing an abdominal exploratory
- Assess vascular supply to the spleen & do a splenectomy if indicated
- Palpate the stomach wall & pylorus
- “run” the bowel & assess other viscera
How do you check the spleen in GDV surgery
Check the blood flow of the splenic arteries & make sure it is pumping
What could happen if the short gastric arteries are ruptured
- Blood loss
- Gastric infarction/necrosis
Where does the gastric (lesser curvature) & the gastroepiploic (greater curvature) arteries derive from & what do they supply
- Derived from the celiac artery
- Supply the stomach
Where do the short gastric arteries derive from & supply
- Derived from the splenic artery
- Supply the greater curvature of the stomach
What is the % of arterial blood flow that goes to the mucosa, the muscularis, & serosa
- 80% is to the mucosa
- 20% to the muscularis & serosa
If the seromuscular layer is red to purple is it viable or non viable
viable
T/F: observation of the mucosal color is a reliable indicator of gastric wall viability
False it is NOT
If the seromuscular layer is green to black is it viable or non viable
Non viable
Can you palpate the thickness to determine viability
Yes the antrum compared the dorsal fundus will feel thin if necrotic (just cut it to see if it bleeds)
T/F: Fluorescein dye is reliable at low flows
False it is not
Describe a partial gastrectomy
- Mortality & complications increase
- Can resect fairly large areas
- Remove all nonviable tissues
- Tube gastropexy for post op decompression
- Invagination may be used for small areas
What are some methods of securing the ventral antrum to the right body wall
- Tube gastropexy (when the stomach continues to inflate intra-operatively)
- Circumcostal
- Incisional (muscular flap)
- Belt loop
- Recommend incisional gastropexy
Describe the circumcostal gastropexy
- Stronger than most techniques
- Technically more difficult
- Increased surgery time
- Increased complications
What are the incisions made in an incisional gastropexy
- 3 to 5 cm inicision through the seromuscularis
- 8 to 10 cm from the pylorus in an avascular area of the pyloric antrum
- 3 to 5 cm incision in the right ventrolateral abdominal wall caudal to the last rib
What should you always do before making the abdominal wall incision
Always check to see that your gastric incision will reach the selected area of the abdominal wall
Why do you drive the needle from the inside edge of the seromuscular incision out
Will minimize the chance for accidental needle entry into the lumen of the stomach to reduce the chance of developing a fistulous tract
What suture & pattern is preferred
- Continuous closure pattern
- Absorbable monofilament
What are some common post GDV complications
- Cardiac arrhythmias (~45%) (Pre mature ventricular contractions [PVCs])
- Shock
- Hypokalemia
- GI motility abnorms
- Gastric necrosis - peritonitis
- Recurrent dilatation
- Anemia
GDV -> ? -> ?
GDV leads to VPCs which leads to ICU
* So make sure to monitor for VPCS*
What are some other Post GDV complications
- Acid base disturbance
- Sepsis
- Pancreatits
- Hepatic or renal failure
- DIC
- Incisional dehiscence
- Intestinal volvulus
- Esophagitis - megaesophagus
What is some post op care for after a GDV procedure
- Continuous IV fluids for 24 - 48 H
- Monitor K+ & supplement K+ if hypokalemic
- Small amounts of water & soft low-fat food should be offered @ 12 to 24 H
- Patient monitoring of their pulse quality, CRT, MM color, hydration, urine output, & body temp
- Serial bloodwork (CBC, chemistry, & electrolytes esp K+)
- EKG
- Broad spec antibiotics (2 to 5 days)
What % of arrhythmias occur post op
75%
What post op complications that can occur
- Gastritis (secondary to mucosal ischemia)
- GI motility disturbances/ GI ulceration
What should be monitored during post op care
- Gastric necrosis/ peritonitis 2 to 5 days post-op
- Dehiscence 3 to 5 days post-op
- Hypoalbuminemia (early)
- Anemia (early)
- Cardiac arrhythmias
When do most serious complications occur after a GDV procedure
W/in the first 72 H
What are some indications to treat ventricular arrhythmias
- Hypokalemia (correct this first)
- Decreased cardiac output (poor peripheral pulse)
- Multiform premature ventricular complexes
What is the prognosis of GDV
- Fair w/ timely surgery
- Higher mortality than gastric dilatation
- Poor w/ gastric necrosis, perforation, or delayed sx
T/F: Degree of rotation is associated w/ death
No it does not
What increases survival chances
- Early tx
- Aggressive fluid therapy
- Gastric decompression
What is the preferred technique when correcting a GDV
Open incisional gastropexy
