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Stomach Surgery Flashcards

1
Q

What are the most common gastric foreign body etiologies? Examples in dogs and cats?

A

things ingested by patient or penetrating wounds

  • DOGS = rocks, toys, anything
  • CATS = trichobezoars, needle, string*
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2
Q

What is the most common signalment associated with gastric foreign bodies?

A
  • younger animals (but can be any age)
  • previous history of FB ingestion
  • pica
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3
Q

What are some conditions that predispose to pica?

A
  • behavioral
  • pancreatic exocrine insufficiency
  • hepatic encephalopathy
  • iron deficiency
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4
Q

What are the most common history and physical exam findings associated with gastric foreign bodies?

A

HX: observation or history of consumption, vomiting, anorexia, may be asymptomatic

PE: often unremarkable, distended abdomen, dehydrated, hematemesis, melena

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5
Q

What are 6 common findings associated with chronic gastric foreign bodies?

A
  1. hemoconcentration (dehydration) or anemia
  2. pre-renal azotemia
  3. acidosis: dehydration
  4. alkalosis: vomiting
  5. hypokalemia and/or hypochloremia secondary to vomiting
  6. leukocytosis
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6
Q

How should patients be stabilized before treatment of gastric foreign bodies?

A
  • fluids
  • electrolytes
  • analgesics
  • gastroprotectants
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7
Q

When is emesis contraindicated with gastric foreign bodies? What 2 specific therapies are used?

A

if FB is obstructive

  1. LEAD - chelation
  2. ZINC - transfusion
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8
Q

Where is it preferred to make incisions in the stomach?

A
  • hypovascular area on the ventral aspect
  • avoid esophagus and pylorus

(make incisions big enough so the stomach is not traumatized with foreign body removal)

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9
Q

How does the stomach heal? What is the holding layer?

A

rapidly!

submucosa —> proper apposition results in stronger closure

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10
Q

What enhances formation of the fibrin seal in the stomach?

A

serosa-to-serosa contact

  • water-tight closure is mandatory
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11
Q

What 2 things complicate suturing gastrotomies?

A
  1. reduced gastric volume
  2. reduced tissue pliability
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12
Q

What is the traditional way of closing gastrotomies?

A

2 layer closure

  1. Cushing or simple continuous pattern through serosa, muscularis, and submucosa
  2. oversewn with Lembert or Cushing pattern through serosal and muscularis layers —> further inverts to get a seal
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13
Q

What are some alternate techniques for closing gastrotomies?

A
  • simple continuous in submucosa
  • Cushing pattern in seromuscular layers = tighter closure due to better submucosal apposition
  • simple continuous in serosa, musclaris, and submucosa
  • Cushing pattern in seromuscular layers = more eversion leads to more gastric volume loss
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14
Q

What are the preferred layers of gastrotomy closure?

A
  1. simple continuous in just the submucosa or including the serosa, muscularis, and submucosa
  2. Cushing pattern with a buried suture inverts and provides serosal contact
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15
Q

When is a single layer closure to gastrotomies preferred? Which patterns are used?

A

reduced gastric volume caused by pyloric outflow tracts or thickened gastric wall

  • simple continuous
  • simple interrupted
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16
Q

What is congenital pyloric stenosis (gastric outflow obstruction)? In what breeds is it most common?

A

hypertrophy of circular muscles of the pylorus, causing obstruction of gastric contents

  • brachiocephalic breeds < 1 year of age
  • rare in Siamese cats
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17
Q

What is thought to be the etiology of pyloric stenosis (gastric outflow obstruction)? What are the most common signs?

A

excess gastrin

starts at weaning, when puppies/kittens are switching to solid foods
- intermittent vomiting
- normal to decreased body condition
- abdominal distension without pain

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18
Q

How is pyloric stenosis (gastric outflow obstruction) diagnosed?

A
  • RADIOGRAPHS: gastric distention with delayed gastric emptying and “beak” or apple core near the narrow outflow
  • ENDOSCOPY: cannot observe the muscle, but will likely see retained ingesta
  • ULTRASOUND: layer thickness
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19
Q

What are the 2 treatment options for pyloric stenosis?

A
  1. Fredet-Ramstedt pyloromyotomy
  2. Heineke-Mikulicz pyloroplasty
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20
Q

How is a Fredet-Ramstedt pyloromyotomy performed?

A
  • isolate pylorus
  • longitudinal incision through seromuscular layer up to the submucosa to cause a submucosa bulge
  • leave incision open

seromuscular layers

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21
Q

What are 2 advantages and disadvantages to Fredet-Ramstedt pyloromyotomies?

A

ADVANTAGES: quick and easy, less chance for contamination

DISADVANTAGES: no lumen exposure for inspection or biopsy, stenosis may recur (possibly only temporary benefit)

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22
Q

How are Heineke-Mikulicz pyloroplasties performed?

A
  • isolate pylorus
  • full-thickness longitudinal incision
  • place stay sutures at center of incision and orient transversely
  • close incision transversely

full thickness

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23
Q

Pyloromyotomy vs. pyloroplasty:

24
Q

What is acquired pyloric stenosis (chronic hypertrophic pyloric gastropathy)? In what dogs are they most common?

A

muscoal and/or muscular hypertrophy of the pylorus

  • small breeds: Lhasa Apso, Shih Tzu, Maltese
  • excitable or vicious
  • males > females
  • middle-aged to older
25
What are the 3 suggested etiologies of acquired pyloric stenosis? What history is most commonly seen?
1. gastrin secretion 2. increased stress 3. drugs/trauma - intermittent vomiting - vomiting frequency increases over time - dietary modification affects frequency
26
What is seen on radiographs and ultrasounds in patients with acquired pyloric stenosis?
RADIOGRAPHS: gastric distension with delayed gastric emptying ULTRASOUNDS: pyloric wall and muscle thickness (muscularis < 4 mm; pyloric wall < 9 mm)
27
What is and isn't able to be seen on endoscopy in patients with acquired pyloric stenosis?
able to visualize hypertrophy of the mucosa and biopsy it to rule out neoplasia cannot visualize muscular layers
28
What are the 3 grades of acquired pyloric stenosis? What determines them?
1. muscular hypertrophy 2. muscular and mucosal hypertrophy 3. mucosal hyperplasia and muscular/submucosal inflammation ultrasound
29
What are the 4 treatment options for acquired pyloric stenosis?
1. transverse pyloroplasty 2. Y-U pyloroplasty 3. billroth 1 4. biopsy
30
What does the Y-U pyloroplasty achieve? What 3 things does this result in?
transposes antral wall to pyloric region 1. deforms pyloric outflow and creates a wider pylorus 2. shortens gastric emptying time 3. allows mucosal resection
31
How can better exposure be gained when performing a Y-U pyloroplasty? What should be avoided?
transection of the gastrohepatic ligament hepatoduodenal ligament - can damage the common bile duct
32
What is a Billroth 1? When is it performed?
pylorectomy with gastroduedenostomy severe outflow obstruction with grade 3 pathology
33
How is a Billroth 1 performed? What needs to be performed if the common bile duct is damaged?
- excise the pylorus after ligating blood supply - end-to-end anastomosis cholecystoduodenostomy or cholecystojejunostomy
34
What are 2 advantages and 3 disadvantages to performing Billroth 1?
ADVANTAGES - abnormal tissue completely removed, larger increase in gastric outflow DISADVANTAGES = technically difficult, longer procedure, increased risk of leakage
35
What are the most common malignant gastric neoplasias? Specifically in cats?
- adenocarcinoma - leiomyosarcoma - mast cell tumors - fibrosarcomas lymphoma
36
What are the most common benign gastric neoplasia?
- leiomyoma - adenoma - adenomatous polyp (bleeding)
37
What are the most common signs of gastric outflow obstruction?
- vomiting, regurgitation, hematemesis - anorexia - melena: black stool - pain - weight loss - abdominal distension (may be asymptomatic)
38
What are the most common lab findings associated with gastric outflow obstruction?
nonspecific anemia, acidosis, hypochloremia, hypokalemia
39
What dogs are predisposed to gastric adenocarcinoma?
- Rough-coated Collies - Staffordshire Terriers - Belgian Shepherds (males > females; 7-10 y/o)
40
Where are gastric adenocarcinomas most commonly found? How do they act?
pyloric antrum or lesser curvature metastasis to regional lymph nodes, liver, and lungs common
41
What are 4 common pathologies associated with gastric adenocarcinomas?
1. diffuse, thickened and nondistensible 2. linitis plastica - leather bottle stomach 3. ulcerate mucosal plaques 4. discrete polypoid
42
How is gastric adenocarcinoma diagnosed on radiographs? What 4 things are seen?
contrast abdominal radiographs ( +/- thoracic rads for metastasis) 1. filling defects 2. delayed gastric emptying 3. loss of normal rugal folds 4. mucosal thickening
43
What is seen on ultrasounds when diagnosing gastric adenocarcinomas?
- mural thickening - loss of normal wall - diminished to absent local motility - lymph node/liver evaluation or biopsy for grading
44
What is the preferred test for diagnosing gastric adenocarcinoma?
endoscopy ---> very diagnostic and can take biopsies
45
How are gastric adenocarcinomas treated? What if it is non-resectable and obstructive?
- aggressive surgical excision with > 5 cm margins - remove regional lymph nodes for biopsy and staging palliative bypass procedure by gastrectomy or Billroth 1/2
46
What are 4 indications for gastrectomies? How are they done?
1. neoplasia 2. ischemic injury (GDV) 3. ulcer 4. trauma ligate vessels or use a TA stapler, providing wide borders, and close like a gastrotomy
47
What is a Billroth 2? What is the most common indication?
partial gastrectomy of the pyloric region and proximal duodenum with gastrojejunostomy to allow extensive removal of damaged tissue without tension on suture when resection of stomach is so proximal to limit end to end anastomosis
48
What are 3 complications associated with Billroth 2 procedures?
1. alkaline gastritis - bile and pancreatic secretions flow into the stomach 2. blind loop syndrome - gastric contents move orally and putrefy 3. marginal ulceration - jejunal mucosa is not used to acidic contents
49
What is the major advantage to Roux-en-Y anastomosis? What 2 problems still remain?
avoids alkaline reflux gastritis and decreases likelihood of blind loop syndrome 1. marginal ulceration 2. requires one more anastomosis
50
What is the origin of gastric leiomyosarcoma? In what aged animals are they most common? Where are they found?
smooth muscle of the stomach (white muscle) middle-aged ---> around 7 years old cardia
51
How do gastric leiomyosarcomas act? What do they commonly cause?
slow growing ---> often an incidental finding in patients older than 15 y/o, can do submucosal resection gastric outflow signs
52
What causes oomycosis in the stomach? Where is this a problem? What dogs are most afftected?
Pythium insidiosum, an aquatic parasite Southeastern, Gulf Coast states from CA to OH in the fall and winter months young, large breed working dogs (Labs)
53
How does Pythium insidiosum affect the stomach? What clinical signs are associated?
infiltrates the submucosa and muscularis layers of the stomach and small intestines with a rapid growth rate and extensive nature +/- palpable abdominal mass and increased mesenteric LNs weight loss, vomiting, diarrhea, and hematochezia
54
What are the 2 most common diagnostics used for Pythiosis?
1. histopathology - eosinophilic pyogranulomatous inflammation found on a deep tissue sample of fibrotic material 2. ELISA for antibodies
55
How is Pythiosis treated? What combined medical treatment is recommended?
surgical excision with 3-4 cm borders with monitoring of ELISA for recurrence within 2-3 months post-op - Itraconazole and Terbinafine (ergosterol inhibitors) - Capsofungin and Anidulafungin (beta-glucan inhibitors) - immunotherapy with vaccine

Small Animal Surgery (34 decks)

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