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BVetMed3 Alimentary > Small Animal GI Surgery > Flashcards

Small Animal GI Surgery Flashcards

1
Q

What MUST you do before performing GI Surgery on a patient?

A

ASSESS IMMEDIATE NEEDS

Is it fit for surgery, if not how can we correct it?

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2
Q

A patient presents with gastric vomiting. How is that likely to affect its metabolic status?

A 
loss of gastric HCl
—metabolic alkalosis (losing H+)
—hypochloraemia (losing Cl-)
Dehydration
—Poor tissue perfusion 
—Metabolic acidosis as a result of anaerobic metabolism 
Insufficient food intake
—Hypokalaemia
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3
Q

How can a patient with gastric vomiting be stabilised before surgery?

A

Give IV fluids
Can self-correct acid-base imbalance

Need to give K+ in severe cases

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4
Q

A patient presents with a high intestinal obstruction, how would this affect its metabolic status?

A

Mimics gastric vomiting

Metabolic alkalosis and hypochoraemia, loss of HCl

Metabolic acidosis from dehydration

Hypokalaemic from low food intake

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5
Q

A patient presents with a low intestinal obstruction, how will this affect their metabolic status?

A

Loss of pancreatic Na+ and bicarbonate
- metabolic acidosis and hyponatraemia

Dehydration - metabolic acidosis

Low food intake and POOR ABSORPTION - hypokalaemia

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6
Q

How can a patient with acute vomiting due to a high or low intestinal obstruction be stabilised prior to surgery?

A

IV fluids

IV K+

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7
Q

How would chronic vomiting (and diarrhoea) due to a small intestinal partial obstruction affect the metabolic profile of a patient?

A

Vomiting — dehydration and electrolyte loss

Bacterial proliferation

  • bacteria absorb nutrients therefore —maldigestion and malabsorption
  • Intestinal mucosal damage

Diarrhoea, weight loss, hypoalbuminaemia

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8
Q

Why would you only expect bacterial proliferation to occur in partial blockage cases?

A

In complete obstruction, vomiting is acute

Therefore bacteria don’t have enough time to accumulate

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9
Q

How could you correct the metabolic status of an animal presenting with small intestinal partial obstruction?

A

IV fluids

Intravenous K+

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10
Q

What is meant by the terms haematemesis and melena?

A

Haematemesis - vomiting blood

Melena - Passing blood in faeces

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11
Q

How might GI bleeding affect a patient?

A

Anaemia - regenerative/non-regenerative

Hypoalbuminaemia

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12
Q

How can animals with GI bleeding be stabilised prior to surgery?

A

Blood transfusion

Iron supplementation so they can regenerate their RBCs.

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13
Q

What information do you need to check if an animal is fit for anaesthesia and surgery?

A 
Complete history 
Complete physical examination
Check haematocrit and total protein
Check electrolytes: Na+ and K+
Check acid base status 
Complete haematology and biochemistry if clinically indicated
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14
Q

How long does it take to correct metabolic imbalances with IV fluids?

A

Between 1 and 6 hours

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15
Q

What is the relationship between number of bacteria and % anaerobes as you progress through the GIT?

A

Increasing number of bacteria, increasing number of anaerobes.

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16
Q

Where is the most bacteria found in the GIT?

A

Colon

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17
Q

What is the most common bacteria in the large intestine which can result in surgical complications?

A

E. Coli

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18
Q

Why is it important to appreciate the number of anaerobic bacteria present in a given area?

A

Determines the type of antibiotic you would use.

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19
Q

When might prophylactic antibiotics be important?

A 
When immune defences are compromised:
Debilitated animals
GI surgery 
Extensive GI resections
Surgeries more than 90 mins
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20
Q

What could be a potential risk if prophylactic antibiotics are not used prior to GI surgery in immunocompromised animals?

A

SEPTIC PERITONITIS

Fatal in 50%

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21
Q

When might you not use prophylactic antibiotics when doing gastric surgery?

A

In a healthy dog e.g. with a ball in its stomach.

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22
Q

What prophylactic antibiotics might you use when doing gastric surgery?

A

Single broad spectrum antibiotic with anaerobic coverage

E.g. second generation cephalosporin OR Amoxycillin- clavulante

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23
Q

When are prophylactic antibiotics always indicated?

A

Small intestine and colon surgery

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24
Q

What prophylactic antibiotics might you use for Small intestine surgery?

A

Single broad spectrum antibiotic with anaerobic coverage

E.g. 2nd generation cephalosporins or amoxycillin -clavulante

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25
Q

What prophylactic antibiotics might you give for colon surgery

A

COMBINMATION
Broad spectrum plus anaerobe specific

Metronidazole

PLUS 2nd gen cyclosporine or amoxycillin-calavulante

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26
Q

Other than antibiotics, how can you minimise bacterial contamination when doing GI surgery?

A

Isolate site of GI entry
Use separate set of instruments and gloves for contaminated part of surgery
Lavage abdomen with sterile saline
Lavage GI wound after closure

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27
Q

What additional measures could be taken to minimise bacterial contamination in colon surgery?

A

A low diet and at least 12-24 hours starvation

Results in decreased faecal volume

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28
Q

Which layer of the intestinal wall is strongest?

Why?

How does this affect suturing technique?

A

Submucosa

High collagen content

Suture/staple needs to go through submucosa.

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29
Q

What are the phases of intestinal wound healing?

A

Haemostasis

Inflammation

Proliferation or granulation

Remodelling or maturation

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30
Q

What happens during the inflammation stage of intestinal wound healing?

A

Microbial killing and wound debridement (enzymes released which break down tissue)

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31
Q

What happens during the proliferation or granulation phase of intestinal wound healing?

A

Fibroblast proliferation and collagen synthesis

Increased wound strength

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32
Q

What is the typical timeline for wound healing in the intestine?

A

Days 1-4 - Haemostasis
Days 1-5 - Inflammation
Day 3 onwards (few weeks) - Proliferation or granulation

Weeks/years - Remodelling or Maturation

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33
Q

When might there be increased risk of wound breakdown?

A

Overlap between inflammation and proliferation or granulation phase.

Collagenase produced in inflammation phase may prevent healing

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34
Q

What is the relationship between progression along the GIT and rate of wound healing?

A

Rate decreases as you progress along GIT.

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35
Q

Why is healing faster in the stomach?

A

Abundant blood supply

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36
Q

How long does it take for the small intestine to regain 75-80% of its tensile strength post-surgery?

A

14 days

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37
Q

How much of its normal tensile strength would the colon have regained 14 days post surgery?

A

50%

RISK OF WOUND BREAKDOWN GREATEST

NEED A GOOD REASON TO PERFORM SURGERY

38
Q

Which factors impact negatively on intestinal wound healing?

A 
Compromised blood supply
Traumatic surgical technique
Hypoproteinaemia 
Chemo and radiotherapy
Steroids
39
Q

Can you normally correct for hypoalbuminaemia prior to surgery?

A

No - takes too long

40
Q

What surgical technique should you NOT use for GIT surgery?

A

ELECTROCAUTERY

Need to use atraumatic techniques/instruments.

41
Q

How could you minimise the amount of bruising you cause to the intestine?

A

Reduce the amount of times you pick it up

Use sutures to hold it

42
Q

What are the goals of gastrointestinal wound suturing?

A

Restore normal anatomy

Promote rapid healing

43
Q

What methods of suturing are appropriate for gastrointestinal wounds?

A

Full thickness appositional

Simple interrupted or simple continuous

44
Q

What suture material would you use?

Why?

A

Monofilament

Retains strength for long enough to permit wound healing - >5 days

Absorbable - dissappear after wound healing

PDS II - lasts longer than monocryl

45
Q

What are the pros and cons of using staples vs sutures,

A

Titanium is inert and permanent

Results in wound edges turning in or out
— not exactly where we found it

46
Q

What incision do you make for an exploratory laparotomy?

Is the approach the same for males and females?

A

Ventral midline

Males, go to the right of prepuce and cut through preputial muscle.
— Ligate blood vessel on caudal edge

47
Q

How can you hold open the abdomen during an ex lap?

A

Retractors

Balfour or Gossett

48
Q

What is the difference between Balfour and Gossett Retractors?

A

Balfour has a ‘spoon’ which holds open cranial edge.

49
Q

How can you repair an incision made in the stomach to take a biopsy?

A

Repair in two layers.

Mucosa and submucosa - simple continuous

Muscularis and serosa - simple continuous (or inverting Lembert)

50
Q

Describe the blood supply of the jejunum.

Why is this important during an ex lap

A

Radiating blood supply from one side that sits within the mesentry.

Don’t ligate at origin as you cut off blood to whole jejunum (can ligate branches though)

51
Q

Describe the blood supply of the ileum

A

Blood supply on both sides

- mesenteric and antemesenteric

52
Q

Describe the blood supply of the large intestine.

How is this important during an ex lap

A

Parallel blood vessels along one side.

Only ligate vessels which sit DIRECTLY against the intestine

53
Q

What should you consider before you do an ex lap to investigate the liver?

A

Fine needle aspirates,

Ultrasound guided biopsy

54
Q

What do you need to be careful of when doing a punch biopsy of the liver?

What do you have to do after you’ve taken the biopsy?

A

Don’t go too deep

More bleeding

Plug hole with haemostatic agent

55
Q

What in the history of a patient would indicate a gastric foreign body?

A 
Any age, but common in young
Previous foreign body ingestion
Known foreign body ingestion
Vomiting 
Lethargy
Abdominal pain
Depression
Anorexia
56
Q

What clinical signs are associated with gastric foreign body’s?

A 
Dehydration 
Abdominal pain
Gastric distension 
Melaena and haematemesis
Dyspnoea if aspiration pneumonia
57
Q

How can you image the stomach?

What technique isn’t useful?

A

X ray, endoscopy

Ultrasound isn’t good

58
Q

How can you treat gastric foreign bodies?

A

Endoscopic retrieval of foreign body

Gastrotomy

59
Q

What post- op care is required after a gastrotomy?

A

Feed,

Antacids,

Gastric protectants

60
Q

What decision making factors should be made prior surgery for gastric neoplasia?

A

— is there any metastasis (e.g. to lungs)

— is resection and reconstruction achievable?

61
Q

When is resection of the stomach achievable?

A

When the following structures can be preserved:

— Cardia

— Common bile duct

— Common pancreatic duct

62
Q

What factors affect the prognosis of patients with gastric neoplasia?

A

Benign tumour LEIOMYOMA resection - good prognosis

Malignant tumour (ADENOCARCINOMA) 
- poor prognosis - symptoms often recur within weeks
63
Q

In intestinal resection and anastomosis, when is enterotomy not enough?

A

ISCHAEMIC NECROSIS

NEOPLASIA

64
Q

What is ischaemic necrosis and how can it happen?

A

Death due to loss of blood supply

Excessive pressure within the lumen of the intestine (e.g. due to wedged foreign body).
Disruption of blood supply
Breakdown of gut wall, leakage of gut contents into the peritoneal cavity and SEPTIC PERITONITIS

65
Q

How can GIT viability be assessed?

A

Look for:

Pulsations in the arterial blood vessels
Peristaltic muscle contractions
Normal colour
Normal wall thickness on palpation

66
Q

How would you resect a piece of intestine?

A

Milk out intestinal contents from intestine to be resected

Isolate intestine with atrumatic clamps

Ligate mesenteric vessels

Incise mesentry

Incise intestine close to clams on the intestine to be resected

67
Q

How can you tell if some clamps are atraumatic?

A

Space between ‘fingers’ of clamp

68
Q

How can you deal with luminal disparity once you’ve resected a piece of intestine?

A

Space sutures further apart on the large side

Transects the small side at an angle to match the diameter of the large side

Spatulate small side (cut slit in small)

69
Q

How far apart should sutures be?

A

3 to 5 mm from the edge and 3-5 mm apart

70
Q

How can you further support the wound after you have performed an end to end anastomosis?

A

Wrap it with omentum
- do every time

Tack together with other bits of intestine
-do when you’re more worried

71
Q

What history would indicate an intestinal foreign body?

A

Persistent vomiting, frequently projectile

Anorexia

Depression

No defecation

72
Q

What would an intestinal foreign body present as in clinical exam?

A 
Dehydration
Depression
Abdominal pain
Intra abdominal mass
String around tongue - string foreign body
73
Q

When performing an enterotomy, where should you cut?

A

Antemesenteric side

74
Q

How would a string foreign body appear on a radiograph?

A

Stacking of intestines

String causes concertina of intestines

75
Q

How can string foreign bodies cause problems?

A

String can cut through the mesenteric side of the small intestine leading to SEPTIC PERITONITIS

Cut string where its tethered then take it out in pieces and check for holes in the gut - REFER

76
Q

What are the possible types of intestinal neoplasia?

A

Adenoma/adenocarcinoma
- local lymph node and liver

Lymphoma

Leiomyoma/leiomyosarcoma

Mast cell
Duodenal polyps

77
Q

What can intestinal neoplasia result in?

A

Partial obstruction:
Chronic intermittent vomiting
Diarrhoea
Weight loss

78
Q

What is intussuception ?

A

Invagination of one portion of the gastrointestinal tract into the lumen of an adjoining segment

79
Q

How do patients with intussuceptions present?

A 
Acute onset problem
Dehydration
Abdominal pain
Palpable tubular mass
Potential protrusion of intussuceptum from anus
80
Q

How can you investigate intussuceptions?

A

Ultrasound
— Parallel lines or concentric rings

Radiography
— Gas distension of loops of small intestine

81
Q

What are the likely causes of intussuception in young and old animals?

A

History of V+D - particularly parvo puppies or young animals with worms

Older animals - more likely to be neoplasia

82
Q

What surgical intervention can you perform to treat intussuception?

A

REDUCTION - push rather than pull

Resect if:
Irreducible, ischemic, or mass present

83
Q

How else can you treat intussuception?

A

Treat the underlying disease

DEWORM

84
Q

How should animals be fed post op?

A

Encourage oral nutrition as soon as possible

85
Q

What are complication of enterotomy and entree to my?

A

Persistent ileus

Stricture at anastomosis site - partial obstruction

Short bowel syndrome (if more than 70% has been resected) - malabsorption and malnutrition

Intestinal incision dehiscence

86
Q

How would a patient with persistent ileus present?

A

Vomiting
Diarrhoea
Pain
Abdominal distension

87
Q

What happens when bacteria enters the peritoneal cavity?

A

SEPTIC PERITONITIS
Inflammatory cells enter the peritoneal cavity and release cytokines

Bacteria release endotoxin
- Diaphragmatic lymphatic blocked with fibrin

88
Q

How do inflammatory cells in the peritoneal cavity cause problems?

A

Release cytokines
Vasodilation and increased capillary permeability
Increased fluid and protein in peritoneal cavity

Hypovolaemia and decreased vascular oncotic pressure — HYPOVOLAEMIC shock

SIRS and DIC
DEATH

89
Q

What do SIRS and DIC stand for?

A

SIRS - Systemic inflammatory response syndrome

DIC - Disseminated intravascular coagulation

90
Q

What clinical signs are associated with septic peritonitis?

A 
Vomiting
Anorexia and depression 
Abdominal pain 
Abdominal enlargement 
Hypovolaemic shock 
Pyrexia
Discharge from abdominal wound
Diarrhoea 
Haematochezia, melaena, haematemesis
91
Q

How can you diagnose septic peritonitis?

A

Abdominocentesis

Diff quik stain under oil, look for:

Toxic (hypersegmented neutrophils)
Intracellular bacteria (rods)
Background red blood cells

92
Q

How can you treat septic peritonitis?

A

Pre-op stabilisation inc. antibiotics

Ex lap - find and correct leak

Peritoneal lavage and drainage

Intensive post-op care, IV fluids and nutrition

BVetMed3 Alimentary (16 decks)

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