Surgery Of The Stomach Flashcards
What artery supplies the greater curvature of the stomach?
Left gastroepiloic a (branch of the splenic artery —> celiac artery)
Right gastroepiloic a (branch of the gastroduodenal —> hepatic artery—>celiac artery)
What are the layers of the stomach. Which of these is the holding layer?
Serosa
Muscular
Submusoca holding layer
Mucosa (glandular)
What are the healing characteristics of the stomach?
Standard phases of wound healing
Short duration of healing
- > extensive and redundant blood supply
- > reduced bacterial numbers
- > rapidly regenerating epithelium
- > omentum
Smooth muscle cells contribute to collagen production
How should you prepare a patient for a gastric surgery?
Correct electrolyte imbalances
Correct hydration
Fast 8-12hrs
H2 antagonists
PPI -omeprazole
What is the approach used in gastric surgery?
Dorsal recumbency
Ventral midline celiotomy (xyphoid to pubis)
When doing an abdominal exploratory, when you enter the abdomen through a ventral midline celiotomy, you encounter the _____________ which can be ligated and resected if needed for visualization
Falciform ligament
What instruments can help hold open the abdomen for visualization?
Balfour retractors
Self retaining/ non traumatic retractors
How is the stomach traditionally closed?
Double inverting
- cushing pattern: serosa, muscularis, and submucosa
- lembert pattern: serosa and muscularis
Alternately can do a simple continuous to decrease bleeding into lumen followed by cushing or Lembert
When is a single layer gastric closure indicated?
Pyloric outflow tract Reduced gastric volume Thickened gastric wall —> simple interrupted —> simple continuous
What suture material is used in gastric closure?
Material resistant to degradation for 14 days (time needed to regain gastric wall strength)
Monofilament, absorbable
Polydioxanone
Polyglyconate
Poliglecaperone 25
OR
Stables
What subjective criteria can be used to determine gastric viability?
Gastric wall thickness “Slip”
Serosal surface colour
Serosal capillary perfusion
Peristalsis
Non viable - thinning of wall, grey- green- black colour
What are the indications for gastric biopsy? How is it performed>?
Gross disease
Clinical signs of upper GI disease
Mucosal - endoscopy
Submucosal - surgical
What is the most common indication for gastrotomy?
Gastric foreign body
Dog>cat
What is the signalment for gastric foreign body?
Younger
Previous history of FB ingestion
Conditions that predispose to PICA
—> iron deficiency
—> hepatic encephalopathy
—> pancreatic exocrine insufficiency
Visualized FB ingestion
Clinical signs of gastric foreign body?
Vomiting - not always or can be intermittent
—> outflow obstruction
—>gastric distention
—> mucosal irritation
Lethargy
Abdominal pin
Anorexia
What laboratory findings can be associated with gastric foreign body?
Hemoconcentration (dehydration) Anemia Leukocytosis Pre-renal azotemia Metabolic alkalosis vs acidosis Hypokalemia, hypochloremia
If you suspect a gastric foreign body, what diagnositics would you do?
Rads
US
Contrast studies
Endoscopy
How can you medically manage gastric foreign bodies?
Fluid therapy - rehydrate and correct electrolyte imbalances
Monitor -serial radiographs
Induction of vomiting - apomorphine in dogs and xylazine in cats
How do you perform a gastrotomy?
Isolate stomach, secure with stay sutures
Incision into hypovascular area on ventral aspect (between greater and lesser curvature)
Stab incision into gastric lumen and enlarged with Metzenbaum scissors
Suction
Removal of FB
Double closure
Lavage with sterile saline (warm) -300ml/kg
Change gloves before closing abdomen
How will manage your patients post op gastrotomy?
Fluid therapy
Food and water within 12hours —> protein helps healing
If vomiting — ID cause and treat (prokinentics and antiemetic)
H2 blockers
What is congenital pyloric stenosis? What breeds is it usually seen in?
Hypertrophy of the circular muscles of the pyloris
Brachiochephalic (boxers and bulldogs)
Siamese cats
What is the possible etiology for congenital pyloric stenosis ?
Excess gastric production (trophic for gastric smooth muscle and mucosa)
Clincial signs at weaning
Clinical signs of congenital pyloric stenosis ?
Intermittent vomiting
- chronic
- horse after feeding
- partially digested
- does fine with liquid
Normal to decreased body condition
What diagnostics can you do for congenital pyloric stenosis?
Radiographs
- gastric distention
- delayed gastric emptying —> still has contents after fast of >8hrs
Contrast rads — “apple core”
Ultrasound Endoscopy (cant see muscle)
What are the methods of managing congenital pyloric stenosis?
Pyloromyotomy AKA Fredet-Ramstedt procedure : 1-2cm incision though the serosa and muscularis layers of long axis of pylorus
Transverse pyloroplasty AKA Heineken-Mikuicz procedure: 3-5cm full thickness incision over pylorus, biopsy, then orient incision transverse and Close appositional
What is the prognosis for congenital pyloric stenosis?
Outcome after surgical correction of benign conditions of pylorus
What is chronic hypertrophic pyloric gastropathy? What is the usual signalment ?
Acquired mucosal and/or muscular hypertrophy
Small dogs - shih-tzu, Lhasa apso, Maltese
Male>female
Middle aged to older
What is the etiology of chronic hypertrophic pyloric gastropathy (CHPG)?
Increased gastrin secretion
Acute stress
Inflammatory dz
Trauma
How can you differentiate congenital pyloric stenosis from chronic hypertrophic pyloric gastropathy?
Similar clinical signs
Differentiate by signalment
Congenital — young brachycephalic breed, beginning after weaning
Chronic — middle aged small dogs
What would you see on rads of a dog with CHPG?
Gastric distention
Delayed gastric emptying
What diagnostic method can you evaluate muscle wall thickness of the pylorus?
Ultrasound
How is CHPG graded?
Grade 1 - muscular hypertrophy ONLY
Grade 2- mucosal hyperplasia with glandular cystic dilation ONY
Grade 3- muscular hypertrophy AND mucosal hyperplasia
How is CHPG managed?
Heineke-Mikulicz pyloroplasty
Y-U pyloroplasty
Pylorectomy with gastroduodenostomy (Bilroth I)
What procedure for CHPG involved a single pedicle advancement from the antrum across the pylorus?
Y-U advancement pyloroplasty
What are the advantages and disadvantages of a Y-U advancement pyloroplasty?
Advantages
- increase diameter of pylorus
- access to excise hypertrophied mucosa
Disadvantage
-potential necrosis of flap tip
What is a Bilroth 1 ?
Pylorectomy- gastroduodenostomy
Removal of the pylorus and sphincter and stomach attaches to the duodenum
What is the prognosis for CHPG?
Good to excellent
Poor outcome associated with technical failures
Selection of most appropriate technique important
Ability to recognize and treat underlying cause
What are indications for gastrectomy?
Neoplasia
- location determines type of resection
Ulceration
Significant pyloric outflow obstruction
What is the best method for removal of a slow growing leiomyoma in the cardia?
Submucosal resection
What type of surgery is indicted when there is a lesion with extensive ulceration in the fundus of the stomach
Partial gastrectomy
—> GDV often clues tear and revitalization of the greater curvature of the stomach.. remove this section and close
What is a Bilroth II?
Partial gastrectomy followed by gastroenterostomy
When is a Bilroth II indicated?
Extensive gastric resection required making gastroduodenostomy impossible
Complications to a Bilroth II?
Alkaline gastritis - bile and pancreatic secretion flow into stomach
Blind loop syndrome — gastric contents move orally and putrefy
Marginal ulceration — ulceration of jejunal mucosa (not used to seeing acid contents)
What is the pathophysiology of phycomycosis?
Aquatic oomycete (pythium sp) —> ingestion —> severe inflammatory and infiltrative lesion —> induce intense fibrotic reaction —> transmural thickening (gastric outflow area most commonly affected)
Clinical signs of phycomycosis ?
Vomiting Inappetence Weight loss Diarrhea Palpable mass
How can you diagnose phycomycosis ?
Endoscopy - difficult to find organism (submucosal and muscularis affected)
Histopath - eosinophilic phygranulomatous inflammation (deep tissue samples of fibrotic material)
ELISA for P. Insidiosum AB
Treatment for phycomycosis ?
Wide surgical excision
Medical therapy ineffective - antifungals
Poor prognosis
