Spleen And Pancreatic Srugery Flashcards
What is the anatomy of the spleen?
Within leafy of greater omentum
Attached to stomach —> gastrosplenic ligament
Blood in —> celiac artery —> splenic artery
Blood out —> splenic v. —> gastrosplenic v. —> portal v.
Capsule
Fibromuscular trabeculae
Parachyma: white and red pulp
What are non-pathologic anatomic alterations of the spleen?
Siderotic plaques (Ca/iron deposits)
Ectopic splenic tissue
— splenosis - usually from seeding of cells after sx/trauma (usually in omentum)
— accessory spleen - incidental congenital issue
What are the functions of the spleen?
RBC storage and maturation
Senescent/sick RBC removal
Hematopoiesis
Immune fun
What pathology can lead to diffuse splenomegaly?
Drug induced - thiopental or acepromazine
Congestion (torsion)
Infiltrative diseases (LSA/MCT)
Immune-mediated disease (opsonizing bacteria)
What pathology causes a mass in the spleen
Neoplasia Hematoma Nodular hyperplasia/ EMH Trauma —> splenosis Abscess
Splenic torsion most commonly is associated with GDV, but can be an isolated event. What usually is the cause of this torsion when isolated?
Stretch or congenital absence of gastrosplenic ligament
Breeds predisposed to splenic torsion?
Great Dane
Greater Swiss mountain dog
German shepherd
English bulldog
What are acute clinical signs of splenic torsion?
Acute abdomen - similar to GDV or because of GDV —acute abdominal pain/shock —abdominal distention —cardiovascular collapse —dysrythmia —DIC
What are chronic signs of splenic torsion?
Vague/intermittent signs for up to 2weeks —vomiting/diarrhea —weakness/depression —anemia —hematuria/hemoglobinuria —PU/PD
How do you diagnose splenic torsion?
Radiographs
- mid abdominal mass
- abdominal effusion
- gas bubbles in spleen
- C shaped spleen
U/S
- mottled/diffuse hypoechonic areas
- intraluminial echogenic densities in veins
- now flow in splenic vessels (Doppler)
CT scan
What is the treatment for splenic torsion?
Pre op stabilization
- fluids
- transfusions
- antibiotics
Exploratory laparotomy
-splenectomy
Gastropexy
- at risk breed for GDV or to address GDV
T/F: you should derotate the spleen prior to splenectomy
False
What are the risk factors associated with death from splenic torsion?
Septic peritonitis at initial examination
Intraoperative hemorrhage
PO development of respiratory distress
T/F: neoplasia can cause splenic torsion
False
Not a cause
If you have splenic infarction, should immediately do splenectomy surgery?
No
Think of other problems associated with thrombosis or hyperocagulable states
- renal dz
- hyperadrenocorticisom
- neoplasia
- DIC
- heart disease
Prior splenic torsion —> devascularized area may turn into mass-effect (hematoma)
What are caudses of diffused splenic hyperplasia
Immune simulation (eg rickettsial infection)
Splenic hyperactivity (IMHA - removing abnormal cells)
What are causes of nodular splenic hyperplasia?
Sites of extramedullary hematopoiesis — can be single or multiple SIBCAPUSALAR nodules
T/F: FNA is a poor method for diagnosing splenic hyperplasia
False
How would you manage rupture of the spleen from blunt force trauma?
Conservative management is preferred — compression bandage and supportive care
Splenectomy — in ALL at risk breeds for splenic dz (labs/Golden’s/ GSD)
Top DDX for splenic neoplasia in dog?
Hemangiosarcoma
Sarcoma
Top DDX for spenic neoplasia in cats?
Mast cell tumor
What is the rule of 2/3rds for splenic neoplasia?
2/3 of dogs with splenic mass will have a malignancy
2/3 of those dogs with malignancies will be hemangiosarcoma (HSA)
What are risk factors for HSA?
Older
Large dog > 21kg
Breed - GSD, labs, Golden’s, poodles
Presence of hemoperitonum —> chance of malignancy > 80%
How does mass size correlate to malignant vs benign splenic neoplasia??
Dogs with benign -> higher mean mass to splenic volume
Smaller masses —> more likely to be malignant
What is the prognosis for HSA?? KNOW THIS
Poor
Surgery alone: 1-3months survival
Surgery + chem (doxorubicin): 5-6 months (only 10% survive to a year)
Surgery + chemo +immunotherapy:
—> stage I non ruptured spleen - 425days
—> stage II no benefit
Issue is that nearly ALL cases have microscopic mets at time of diagnosis
What are Dr Cavagnah’s recommendation for surgery on HSA?
Careful staging pre op
INFORM client of survival stats
Do not feel good about surgery if…
- obvious grossly visible mets present pre-op
- very sick dog (coagulothatic/ those needing high volume transfusion)
- owner is not informed
What are some alternative therapies to surgery and chemo for HSA?
C. Versicolor mushroom (turkey tail) —> contains polysaccharopepide causing cell cycle arrest and induce apoptosisi
eBAT= bispecific urokinase angiotoxin designed to target EGFR (HSA has mutation in EGFR that triggers continuous growth) - 6month survival
What are the two possible techniques for splenectomy?
Ligation of individual hilar vessels
Ligation of the splenic and short gastric aa. (Decreased surgical time but must not compromise blood flow to greater curvature of the stomach )
What is the preferred technique for splenectomy if there is anatomic distortion of vascular d/t adhesions or size of mass?/
Hilar dissection
What are the advantages and disadvantages of hemostatic clips for splenectomy?
Advantage — faster and easier than hand sewn
Disadvantages — clip instability, use limited to vessels <4mm diameter and implantation of non-absorbable materials
What type of stapler is classically used for splenectomy?
Ligate divide stapler (LDS)
Staples on either side of blood vessel and then clips between
Size limited, not generally able to use in large breed dogs
What is the Ligasure system?
Electrothermal bipolar system
Handles vessels up to 7mm with minimal thermal damage to surrounding tissue
Local hemostasis by vessel compression and obliteration
Safe to use in splenectomy with minimal complications
What are indications for partial splenectomy?
Trauma
Focal abscess
Partial infarction
remove whole spleen in at risk breeds
What techniques can be used for partial splenectomy?
Cross claps — cut inbetween — oversew capsule
Thoracoabdominal stapler (fast but expensive)
Possible complications to splenectomy?
Hemorrhage — most common
Pancreatitis/necrosis
Gastric wall compromise (iatrogenic :()
Subclinical hemoparasite infections — Bartonella
Portal vein thrombosis
Arrhythmias -2x increased risk of death if present
Arrhythmias are common post op from splenectomy. How should this be monitored?
Holter monitor
Why do we see arrhythmias with splenectomy?
Compromised venous return to the heart caused by intra-abdominal hemorrhage and compression of the caudal vena cava
Typically ventricular
What is the anatomy of the pancreas?
Right (along duodenum) and left limbs (in greater omentum) with central body
Left limb - brach of splenic a.
Right limb- cadual pancreaticoduodenal a. —> branch of cranial mesenteric a.
How does the pancreatic duct system differ between cats and dogs?
Dogs and cats: Pancreatic duct (drains R lobe) enters duodenum and major duodenal papilla
Dog only: accessory PD (drains left lobe) —> into duodenum at minor duodenal papilla
What cell types make up the endocrine pancreas?
A - glucagon
B - insulin
D- somatostatin
F (or P) - pancreatic polypeptide
What are the diseases of the pancrease?
Pancreatitis — very common but not a surgical disease
Pancreatic pseudocyst
Pancreatic abscess
Exocrine pancreatic neoplasia
Endocrine pancreatic neoplasia — usually a result of excess or deficiency in production of one of the hormones
Techniques that can be used to obtain a biopsy from the pancreas?
Laparoscopic
Guillotine
Partial pancrease Tony
Total pancreatectomy - rarely performed (high morbidity and mortality)
When is guillotine technique used for pancreatic biopsy/
Diffuse disease
Individual lobule dissection for small central body lesion
Indications for a partial pancreatectomy? How is this done?
Tumor removal
Incise omentum and capsule
Dissect between lobules to isolate vessel and ducts in portion of gland to be removed
Hemoclips or bipolar capture for ligation (BEST)
If remaining ducts are patent - 80% of pancreas can be removed
Complications to partial pancreatectomy?
Pancreatitis (most common)
Exocrine pancreatic insufficiency ((EPI) - if pancreatic drainage is completely obstructed
Endocrine pancreatic insufficiency
Devitalization of duodenum —> caudal pancreaticoduodenal a. Raised from the cranial mesenteric a. —> vessel also supplies branches of duodenum —> both closely associated with right lobe of pancreas —> if damaged, then duodenum can be compromised
What is the preferred method or dissection/resection for pancreas with the lowest incidence of pancreatitis ?
Liagsure — bipolar sealing device
Indications for total pancreatectomy?
Acute trauma
Severe, chronic fibrosis
Extensive neoplasia
Total pancreatectomy is usually done in conjunction with what procedure ?
Resection and anastomosis of proximal duodenum, ligation of common bile duct and cholecystojejunostomy (Bilroth II)
What is a pancreatic pseudocyst?
Collections of pancreatic secretions and cellular debris w/in fibrous sac or wall of granulation tissue
Lacks epithelial wall = not true cyst (fluid not from lining but from damaged pancreatic duct)
Signalment and presentation associated with pancreatic pseudocyst
Middle aged to older dogs mostly
Usually asymptomatic
Vague signs of abdominal discomfort, anorexia and vomiting
What diagnostics can you do for pancreatic pseudocyst?
US - test of choice
Percutaneous FNA
- diagnostic and therapeutic
What is the treatment for pancreatic pseudocyst ?
Percutaneous aspiration
-1st line tx especially if no clinical signs
If clinically ill
- resection
- debridement, drain, ometalize (rx of choice for “cure”)
T/F: most pancreatic abscesses are sterile. - ie no bacteria
True
Caused by enzyme except into surrounding tissue causing inflammation and fibrous tissue formation — secondary to pancreatitis
How will you diagnose pancreatic abscess?
Radiographs - increased soft tissue density in right cranial or central cranial abdomen (ascities/peritonitis)
US - mass lesions (focal hypoechoic areas) —> can do guided FNA
Lab data is variable
- leukocytosis, neutrophilia
- electrolyte abnormalities if vomiting
- amylase and lipase (little value)
- hyperbilirubinemia elevated LEZ to to EHBO
How are pancreatic abscesses managed?
Resect - often very challenging as disease is NOT localized
Debridement, drain, and omentalize (better outcome then open drainage)
PO enteral nutrition plan = NEED post gastric feeding
What is the prognosis of pancreatic abscess?
Guarded in dogs
High perioperative mortality
—> septic
—> generalized peritonitis
Long and intensive ICU
Types of pancreatic neoplasia?
Exocrine pancreatic adenocarcinoma
Insulinoma - adenocarcinoma of Bcells
Gastrinoma -adenocarcinoma of non B-islet cells
T/F: Exocrine adenocarcinoma are malignant and locally invasive
True
Clinical signs associated with pancreatic neoplasia?
Vomiting
Abdominal pain
Weight loss
Signs of extrahepatic biliary tact obstruction (EHBO)
Treatment and prognosis of exocrine pancreatic adenocarcinoma ?
Surgical resection if possible (usually diffuse disease in cats)
Poor prog
- 3month survival in dog
- <7 days in cats
T/F: insulinoma is usually malignant
True 90% of the time
Rare in cats and dogs
Clinical signs of insulinoma?
Weakness, seizure
Polyneuropathy — chronic hypoglycemia
What is whipples triad?
Clinical signs associated with hypoglycemia
Fasting blood glucose concentration of 40mg/dL or lower
Relief of neuro signs with feeding/glucose admin
What is diagnostic for whipples triad??
Fasting insulin -glucose ratio diagnostic for condition
— insulin HIGH despite hypoglycemia
What is the medical management of insulinoma ?
Glucocorticoids therapy
Oral hyperglycemic agents
—diazoxide (inhibit pancreatic insulin secretion and glucose uptake by tissue)
If severe = ICU and dextrose supplementation in fluid
Surgical management for insulinoma?
Partial pancreatectomy — gold standard
Gets complicated when no nodules seen at surgery or with perioperative imaging —> contrast CT scan (best chance to ID tumor)
50% mets — often recurrent hypoglycemic d/t mets
