Surgery of the small intestine Flashcards
(48 cards)
1
Q
What is the pathophysiology associated with intestinal FBs/obstruction?
A
- Proximal gas and fluid accumulation
- Air and fermentation
- Inc. salivary, biliary, pancreatic, intestinal
- Decreased absorption due to lymphatic and venous congestion
- Intestinal wall edema
- Prevents vein drainage
- Wall ischemia
- Mucosal sloughing
- Bacterial translocation
2
Q
How does the pathophysiology of linear FBs differ from non-linear FBs?
A
- Linear
- Peristalsis carries FB down GIT to form accordian like pleats
- FB embeds in mesenteric border and can perforate intestines
3
Q
What are the clinical signs of non-linear foreign bodies?
A
- Vomiting
- Anorexia
- Depression
- Abdominal pain
- Diarrhea
4
Q
What are the radiographic signs of non-linear FBs?
A
- Multiple loops of gas-filled dilated intestines
- Ratio–SI diameter/L5 height
- < 1.6 = no obstruction
- > 2 = likely obstruction
5
Q
What are the clinical signs of a linear FB?
A
- Vomiting
- Anorexia
- Depression
- Abdominal palpation
- Pain
- Clumping and pleating of intestine
6
Q
What are the radiographic signs of a linear FB?
A
- Plicated intestines
- Bunched in central abdomen
- Contrast study
- More obvious pleating
- Teardrop shaped air bubbles
7
Q
What are the conservative management options for linear foreign bodies?
A
- Asymptomatic cats
- Free FB from tongue
- 47% success w/o surgery
- Must monitor closely
- Dogs
- Not recommended
- Lodged at pylorus
- 40% have peritonitis at time of sx
8
Q
What does surgical management of linear FBs consist of?
A
- Enterotomy
- Free FB cranially from base of tongue or by gastrotomy
- Examine mesenteric border for perforation
- Remove FB through enterotomy
- Catheter technique
- Make 1cm enterotomy in antimesenteric border of proximal duodenum
- Tie FB to catheter and milk down intestines
- Come out anus or enterotomy incision
9
Q
What are the potential short- and long-term complications of linear FBs?
A
- Septic peritonitis
- Adhesions
- Dehiscence
- Intestinal ileus
- Short bowel syndrome
- Intussusception
10
Q
What can cause septic peritonitis from linear FBs?
A
Dehiscence
11
Q
How do adhesions occur following linear FB ingestion?
A
- Caused by disruption of fibrinolytic system
- Ischemia, hemorrhage, infection
- Gentle tissue handling and keep tissue moist to minimize contamination
12
Q
What are the dehiscence risk factors following linear FB ingestion/removal?
A
- Technical errors
- Multiple intestinal procedures
- Pre-existing peritonitis
- Lack of omentum
13
Q
How does intestinal ileus occur following linear FB removal?
A
- Stimulation of SNS
- Rough tissue handling
- Long surgical time (tissues dry out)
- Extensive
14
Q
What is intussusception? What are the parts?
A
- Invagination of one portion of the GIT into the lumen of an adjacent segment
- Parts
- Intussuscipiens = section of intestine on the outside
- Intussusceptum = section of intestine on the inside
- Neck = part of smaller section of intestine protruding from intussusception
- Apex = furthest point of invagination into larger segment of intestine
15
Q
What are the common locations for intussusception/certain parts?
A
Proximal and distal?
16
Q
How is intussusception managed?
A
- Surgically
- Attempt manual reduction
- If necrotic: resection and anastomosis
- Assess viability
- Perform enteroplication
- Plicate entire intestine except duodenum
17
Q
What is an enteroplication? What are some complications?
A
- Suture intestinal loops at 3-5cm intervals w/ interrupted suture along lateral wall
- Avoid tight turns
- Complications
- Obstruction
- Strangulation
- Perforation
18
Q
What/where are the common intestinal tumors in dogs? Cats?
A
- Dogs
- Colon and rectum
- Adenocarcinoma most common intestinal malignancy
- Adenomatous polyp most common rectal
- Cats
- SI
- Lymphosarcoma and adenocarcinoma
19
Q
What are the principles of intestinal surgery suture choices/tissue handling?
A
- Monofilament synthetic absorbable or non-absorbable
- Less susceptible to infection
- Surgical staples
- Multifilament absorbable
- More tissue drag
- Potentiates infection
- Handle tissues gently
- Intestinal occlusion
- Grasp as little tissue as possible
20
Q
What are the principles of intestinal surgery closure?
A
- Submucosa is the layer of strength
- Submucosa apposition results in stronger closure
- Double layer closure not recommended
- Poorer submucosal apposition
- Avascular tissue necrosis
- Increased intraluminal protrusion
21
Q
What are the principles of suture patterns for intestinal surgery?
A
- Simple continuous
- Inversion, eversion, or mal-alignment in 38%
- Simple interrupted
- Eversion in 66%
- Modified Gambee
- Approximating pattern
- Inverts mucosa while approximating tissue
- Minimize mucosal eversion–increases risk of infection and adhesion formation
22
Q
What is omentalization? Why should you perform it?
A
- Place omentum around area that you have performed a surgical procedure on
- Reasons:
- Angiogenic–faster healing
- Immunogenic–less risk of infection
- Adhesive
- Controls infection
- Lymphatic drainage
- Minimizes leakage
23
Q
What are the 4 stapling techniques used for intestinal anastomosis?
A
- Triangular end-to-end (TA stapler)
- Triangular end-to-end (Skin stapler)
- Inverting end-to-end
- Side-to-side anastomosis (
24
Q
Describe the triangular end-to-end stapling technique
A
- TA stapler
- Very expensive
- 3 equidistant stay sutures
- Apply tension between sutures
- Fire 3 rows of staples
25
Describe the triangular skin-to-skin (skin stapler) technique
* Inexpensive
* 3 equidistant stay sutures
* Apply tension between sutures
* Place staples 3mm apart
* Use staples that close tightly
26
Describe the inverting end-to-end stapling technique
* Uses an EEA and TA stapler
* Place cartridge in enterotomy site 3-4cm from transection
* Place anvil in opposite end
* Tie purse string and fire
* Inverts tissue
27
Describe the side-to-side anastamosis GIA stapling technique
* Place stay sutures
* Oppose antimesenteric surfaces
* Place stapler in lumen and fire
* TA stapler used to close lumen
* Crotch suture--extra suture sometimes placed down side to prevent leakage
* Quick and easy method
28
What is short bowel syndrome? What is the pathophysiology?
* Malabsorption and malnutrition that occurs after extensive resection
* Pathophysiology
* Decreased mucosal SA
* Gastric and intestinal hypersecretions
* Decreased intestinal tract transit time
29
What are the signs of short bowel syndrome?
* Persistent watery diarrhea
* Weight loss
* Contrast agent has 5-12 min transit time
30
How do you manage short bowel syndrome?
* Fluids and electrolytes
* Parental nutrition
* Small frequently highly digestible meals
* **May never resolve**
31
How does the intestine adapt following development of short bowel syndrome?
* Increased enterocyte number and size
* Intestinal diameter
* Increased villus height and crypt depth
32
What should you aim for when taking an intestinal biopsy? What are the various techniques?
* Full-thickness biopsy wide enough that all layers remain intact
* Sample 3-4mm wide
* Techniques
* Longitudinal biopsy w/ longitudinal closure
* Longitudinal biopsy w/ transverse closure
* Transverse biopsy
* Dermal punch
33
What are the characteristics of a longitudinal biopsy with longitudinal closure?
* Most common
* Very simple technique
* Elliptical, full thickness incision in the antimesenteric border
34
How is the longitudinal biopsy w/ transverse closure different than the longitudinal biopsy w/ longitudinal closure (why is it performed)?
* Procedure the same, but close on transverse axis
* Thought to widen intestinal luminal in that area
* Almost impossible if there is any gross pathology of the intestine
* Will actually make the lumen smaller
35
Describe the transverse wedge biopsy technique
* Full thickness wedge 3-4mm wide taken perpendicular to long axis of intestine
* No more than 20-25% of circumference
36
What are the advantages/disadvantages of the ultrasound-guided intestinal biopsy technique?
* Advantages
* Obtain sample from any part of the intestine
* Safe and quick
* Can sample lymph nodes or other masses
* Disadvantages
* Insensitive in detecting mucosal lesions
* Can miss focal lesions
* Tumor seeding
* **Not used for bladder tumors**
37
What are the advantages/disadvantages to endoscope-guided intestinal biopsies?
* Advantages
* Least invasive
* Able to visualize mucosa
* Disadvantages
* Jejunum out of reach
* No muscular layer
38
What are the advantages/disadvantages of laparoscopic-assisted intestinal biopsies?
* Advantages
* Can biopsy jejunum and other organs
* Full thickness biopsies
* Disadvantage
* Cannot visualize mucosal lesions
39
How do you perform an intestinal resection?
* Pack off segments
* Determine extent and ligate blood supply
* Cut mesentery close to vessels of segment
* Occlude proximal and distal segments as atraumatically as possible
* Angle cut to enlarge lumen size to account for 10-20% narrowing during healing
* Minimize mucosal eversion
* Begin at mesenteric border
* Close mesenteric rent
* Omentalize
40
T/F: Scissors allow for more control but are more traumatic to tissues while a scalpel allows for less control but is less traumatic
TRUE
41
How can disparity of lumen size be managed when performing an intestinal anastomosis?
* Place sutures farther apart on larger lumen--\>causes lumen to crinkle a bit to better suit smaller end
* Cut smaller end of intestine at an angle to increase the SA so it will better line up with the larger diameter lumen
* Fish mouthing--make small incision parallel to long axis of intestine so SA of cut edges lines up better with larger ends
* Suture up excess lumen of larger end so it'll line up better with smaller end
42
What is mesenteric torsion? What is the signalment?
* Intestine twisting on mesenteric axis
* Compression of cranial mesenteric arteries
* Ischemic necrosis of **all** intestine
* Signalment: male german shepherd of any age
43
What is the etiology of mesenteric torsion?
* Unknown
* Lymphocytic enteritis
* Ileocolic carcinoma
* GIT foreign body
44
What are the clinical signs of mesenteric torsion?
* Abdominal distension
* Hematochezia
* Collapse and death
45
How do you diagnose mesenteric torsion?
* Shock patients with distended abdomen not relieved with tube
* Radiographs show gas-filled intestines with **normal stomach position**
* Necropsy
* D/D GDV
46
What is the treatment for mesenteric torsion?
* Crystalloids and colloids
* **Immediate sx to untwist torsion**
* Determine intestinal viability and resect if necessary
47
What is the prognosis for mesenteric torsion?
* Rare disease with high mortality
* Once thought to be nearly 100%
* Early sx leads to higher survival rate
48
What is serosal patching and when is it used?
* Securing an antimesenteric border of small intestine over a suture line or defect
* Indications
* When omentum is unavailable
* Closure integrity is questionable
* Non-resectable duodenal defects
* Enterotomy, colostomy, urinary bladder
* Mucosa spans defect within 8wks
