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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
What prophylactic antibiotics might you give for colon surgery
COMBINMATION Broad spectrum plus anaerobe specific Metronidazole PLUS 2nd gen cyclosporine or amoxycillin-calavulante
26
Other than antibiotics, how can you minimise bacterial contamination when doing GI surgery?
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
27
What additional measures could be taken to minimise bacterial contamination in colon surgery?
A low diet and at least 12-24 hours starvation Results in decreased faecal volume
28
Which layer of the intestinal wall is strongest? Why? How does this affect suturing technique?
Submucosa High collagen content Suture/staple needs to go through submucosa.
29
What are the phases of intestinal wound healing?
Haemostasis Inflammation Proliferation or granulation Remodelling or maturation
30
What happens during the inflammation stage of intestinal wound healing?
Microbial killing and wound debridement (enzymes released which break down tissue)
31
What happens during the proliferation or granulation phase of intestinal wound healing?
Fibroblast proliferation and collagen synthesis Increased wound strength
32
What is the typical timeline for wound healing in the intestine?
Days 1-4 - Haemostasis Days 1-5 - Inflammation Day 3 onwards (few weeks) - Proliferation or granulation Weeks/years - Remodelling or Maturation
33
When might there be increased risk of wound breakdown?
Overlap between inflammation and proliferation or granulation phase. Collagenase produced in inflammation phase may prevent healing
34
What is the relationship between progression along the GIT and rate of wound healing?
Rate decreases as you progress along GIT.
35
Why is healing faster in the stomach?
Abundant blood supply
36
How long does it take for the small intestine to regain 75-80% of its tensile strength post-surgery?
14 days
37
How much of its normal tensile strength would the colon have regained 14 days post surgery?
50% RISK OF WOUND BREAKDOWN GREATEST NEED A GOOD REASON TO PERFORM SURGERY
38
Which factors impact negatively on intestinal wound healing?
``` Compromised blood supply Traumatic surgical technique Hypoproteinaemia Chemo and radiotherapy Steroids ```
39
Can you normally correct for hypoalbuminaemia prior to surgery?
No - takes too long
40
What surgical technique should you NOT use for GIT surgery?
ELECTROCAUTERY Need to use atraumatic techniques/instruments.
41
How could you minimise the amount of bruising you cause to the intestine?
Reduce the amount of times you pick it up Use sutures to hold it
42
What are the goals of gastrointestinal wound suturing?
Restore normal anatomy Promote rapid healing
43
What methods of suturing are appropriate for gastrointestinal wounds?
Full thickness appositional Simple interrupted or simple continuous
44
What suture material would you use? Why?
Monofilament Retains strength for long enough to permit wound healing - >5 days Absorbable - dissappear after wound healing PDS II - lasts longer than monocryl
45
What are the pros and cons of using staples vs sutures,
Titanium is inert and permanent Results in wound edges turning in or out — not exactly where we found it
46
What incision do you make for an exploratory laparotomy? Is the approach the same for males and females?
Ventral midline Males, go to the right of prepuce and cut through preputial muscle. — Ligate blood vessel on caudal edge
47
How can you hold open the abdomen during an ex lap?
Retractors Balfour or Gossett
48
What is the difference between Balfour and Gossett Retractors?
Balfour has a ‘spoon’ which holds open cranial edge.
49
How can you repair an incision made in the stomach to take a biopsy?
Repair in two layers. Mucosa and submucosa - simple continuous Muscularis and serosa - simple continuous (or inverting Lembert)
50
Describe the blood supply of the jejunum. Why is this important during an ex lap
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
Describe the blood supply of the ileum
Blood supply on both sides | - mesenteric and antemesenteric
52
Describe the blood supply of the large intestine. How is this important during an ex lap
Parallel blood vessels along one side. Only ligate vessels which sit DIRECTLY against the intestine
53
What should you consider before you do an ex lap to investigate the liver?
Fine needle aspirates, | Ultrasound guided biopsy
54
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?
Don’t go too deep More bleeding Plug hole with haemostatic agent
55
What in the history of a patient would indicate a gastric foreign body?
``` Any age, but common in young Previous foreign body ingestion Known foreign body ingestion Vomiting Lethargy Abdominal pain Depression Anorexia ```
56
What clinical signs are associated with gastric foreign body’s?
``` Dehydration Abdominal pain Gastric distension Melaena and haematemesis Dyspnoea if aspiration pneumonia ```
57
How can you image the stomach? What technique isn’t useful?
X ray, endoscopy Ultrasound isn’t good
58
How can you treat gastric foreign bodies?
Endoscopic retrieval of foreign body Gastrotomy
59
What post- op care is required after a gastrotomy?
Feed, Antacids, Gastric protectants
60
What decision making factors should be made prior surgery for gastric neoplasia?
— is there any metastasis (e.g. to lungs) — is resection and reconstruction achievable?
61
When is resection of the stomach achievable?
When the following structures can be preserved: — Cardia — Common bile duct — Common pancreatic duct
62
What factors affect the prognosis of patients with gastric neoplasia?
Benign tumour LEIOMYOMA resection - good prognosis ``` Malignant tumour (ADENOCARCINOMA) - poor prognosis - symptoms often recur within weeks ```
63
In intestinal resection and anastomosis, when is enterotomy not enough?
ISCHAEMIC NECROSIS NEOPLASIA
64
What is ischaemic necrosis and how can it happen?
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
How can GIT viability be assessed?
Look for: Pulsations in the arterial blood vessels Peristaltic muscle contractions Normal colour Normal wall thickness on palpation
66
How would you resect a piece of intestine?
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
How can you tell if some clamps are atraumatic?
Space between ‘fingers’ of clamp
68
How can you deal with luminal disparity once you’ve resected a piece of intestine?
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
How far apart should sutures be?
3 to 5 mm from the edge and 3-5 mm apart
70
How can you further support the wound after you have performed an end to end anastomosis?
Wrap it with omentum - do every time Tack together with other bits of intestine -do when you’re more worried
71
What history would indicate an intestinal foreign body?
Persistent vomiting, frequently projectile Anorexia Depression No defecation
72
What would an intestinal foreign body present as in clinical exam?
``` Dehydration Depression Abdominal pain Intra abdominal mass String around tongue - string foreign body ```
73
When performing an enterotomy, where should you cut?
Antemesenteric side
74
How would a string foreign body appear on a radiograph?
Stacking of intestines String causes concertina of intestines
75
How can string foreign bodies cause problems?
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
What are the possible types of intestinal neoplasia?
Adenoma/adenocarcinoma - local lymph node and liver Lymphoma Leiomyoma/leiomyosarcoma Mast cell Duodenal polyps
77
What can intestinal neoplasia result in?
Partial obstruction: Chronic intermittent vomiting Diarrhoea Weight loss
78
What is intussuception ?
Invagination of one portion of the gastrointestinal tract into the lumen of an adjoining segment
79
How do patients with intussuceptions present?
``` Acute onset problem Dehydration Abdominal pain Palpable tubular mass Potential protrusion of intussuceptum from anus ```
80
How can you investigate intussuceptions?
Ultrasound — Parallel lines or concentric rings Radiography — Gas distension of loops of small intestine
81
What are the likely causes of intussuception in young and old animals?
History of V+D - particularly parvo puppies or young animals with worms Older animals - more likely to be neoplasia
82
What surgical intervention can you perform to treat intussuception?
REDUCTION - push rather than pull Resect if: Irreducible, ischemic, or mass present
83
How else can you treat intussuception?
Treat the underlying disease DEWORM
84
How should animals be fed post op?
Encourage oral nutrition as soon as possible
85
What are complication of enterotomy and entree to my?
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
How would a patient with persistent ileus present?
Vomiting Diarrhoea Pain Abdominal distension
87
What happens when bacteria enters the peritoneal cavity?
SEPTIC PERITONITIS Inflammatory cells enter the peritoneal cavity and release cytokines Bacteria release endotoxin - Diaphragmatic lymphatic blocked with fibrin
88
How do inflammatory cells in the peritoneal cavity cause problems?
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
What do SIRS and DIC stand for?
SIRS - Systemic inflammatory response syndrome DIC - Disseminated intravascular coagulation
90
What clinical signs are associated with septic peritonitis?
``` Vomiting Anorexia and depression Abdominal pain Abdominal enlargement Hypovolaemic shock Pyrexia Discharge from abdominal wound Diarrhoea Haematochezia, melaena, haematemesis ```
91
How can you diagnose septic peritonitis?
Abdominocentesis Diff quik stain under oil, look for: Toxic (hypersegmented neutrophils) Intracellular bacteria (rods) Background red blood cells
92
How can you treat septic peritonitis?
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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