SA Sx, E1, Gastric Sx
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what is the medical term for a sx approach to the stomach?
what is the sx approach on the body for a gastrotomy?
ventral midline from xyphoid process, as far caudally as needed
What can be used to elevate the stomach to the cranial midline of the abdomen?
- stay sutures (use big bites, include submucosa)
- or babcock forceps
what is the holding layer in the GI?
where should the stomach be entered? And near or far from pyloric antrum?
- stab incision through hypovascular area on ventral body btwn greater and lesser curvature
- as far from pyloric antrum as possible
why is the stomach packed off with laparotomy sponges?
avoid spillage or drying
What is "mushroom effect" referring to?
lumen tends to fold out/exteriorize itself
what are options for closing gastrotomy?
- a. two inverting layers (connell then cushing or lembert)
- b. simple continuous in mucosa/submucosa then cushing or lembert
which suture pattern in inverting and perforates the lumen?
Which suture pattern(s) are inverting and do not perforate the lumen/partial thickness?
Cushing and Lembert
what is the purpose of the first layer closure of the gastrotomy?
What kind of suture material is used for gastrotomy closure?
monofilament, absorbable (like PDS)
if suture line has zig-zag effect, is this desired?
yes, indicates good inversion, good serosa-serosa contact and will not leak
What are 3 important things to do before closing abdomen? Then how do you close abdomen?
- remove all lap sponges
- check for bleeders
- lavage abdominal cavity
- -routine 3 layer closure (external fascia, SQ, skin)
When should food/water be offered post-op?
small amount of water 12-24 hours post, no vomit then small amt of bland food (like AD) an hour later; frequent small meals; normal diet in 2-3 days
List 4 sx disorders of the stomach.
- foreign body
- pyloric stenosis/hypertrophy
- hiatal hernia
What is the most common foreign body in dog? in cat?
- dog: bone
- cat: linear (string)
Would you expect water and electrolyte balances to be severely disrupted?
not necessarily, incomplete obstructions causes less frequent vomiting
What would be main clinical sign for patient with partial obstruction?
Will patient have metabolic alkalosis or acidosis with gastric/pyloric vomiting?
Why would patient with obstruction present with hematemesis or melena?
What must be considered before using contrast for radiographs of possible obstruction?
never use barium if suspect perforation
What is prognosis for foreign body sx if mucosal damage is present?
What is the medical term for narrowing of the lumen of the pylorus, causing partial obstruction? Is this more common in dogs or cats?
- pyloric hypertrophy/stenosis
- dogs (etiology unknown)
Which layer(s) are involved in congenital v. acquired pylorus hypertrophy?
- C: muscular layer only
- A: mucosa + muscular layer (full thickness)
When does congenital pyloric stenosis become apparent? why?
at weaning, vomiting occurs w/in24 hours of eating and may have ravenous appetite
What breeds are more prone to congenital pyloric stenosis?
- brachycephalic dogs
- Siamese cats
what would radiographs show in patient with pyloric stenosis?
enlarged stomach w/delayed gastric emptying (>8-12 hrs)
How do clinical signs differ between congenital and acquired pyloric stenosis?
- C: vomit at weaning, related to eating
- A: vomit at any age, not related to eating (incr. frequency over time)
Which breeds are more prone to acquired pyloric stenosis?
- small breeds like lhasa apso and shih-tzu
- (rare in cats)
If endoscopy revealed hypertrophy of the mucosa/submucosa, would this indicate acquired or congenital pyloric stenosis?
acquired (congenital only muscularis layer)
What medical treatment is available for pyloric stenosis?
no effective medical tx; need sx
What are 3 commonly used sx procedures used to correct pyloric stenosis? (note which procedures enter the lumen of the stomach)
- Fredet-Ramstedt pyloromyotomy (not in lumen)
- Heineke-Mikulicz pyloroplasty (enter lumen)
- Y-U antal advancement flap pyloroplasty (best; enter lumen)
Which sx procedure is indicated for congenital pyloric stenosis? How is the incision made?
- Fredet-Ramstedt pyloromyotomy
- Partial thickness longitudinal incision from antrum to duodenum across pylorus (mucosa can bulge through incision for pyloric enlargement)
Which sx procedure is indicated for either congenital or acquired pyloric stenosis? How is the incision made?
- Heineke-Mikulicz pyloroplasty
- full-thickness longitudinal incision crosses ventral surface of pylorus then closed TRANSVERSELY w/1 layer simple interrupted sutures
What are indications for partial gastrectomy?
neoplasia, ischemic injury (GDV), penetrating injury (ulcer/trauma)
What part of the stomach usually suffers ischemic injury (as with GDV)? What presentation is NOT a cadidate for sx?
- greater curvature
- (injury to greater and lesser curvature is not a candidate for sx)
Which vessels should be ligated during a partial gastrectomy?
branches of gastroepiploic vessels to affected area
What type of closure pattern with partial gastrectomy?
- 2 layers
- (simple continuous w/ inverting non-perf pattern OR inverting perforating then invert. non-perf)
what are 2 common BENIGN gastric neoplasias?
- ademona (older dog, often pedunculated -easy to excise)
- leiomyosarcoma (very old dog)
what are 2 common MALIGNANT gastric neoplasias?
- adenocarcinoma (most common gastric cancer in dog)
- lymphosarcoma (most common gastric cancer in cat)
Why is icterus a possible clinical sign of gastric neoplasia? what are other clinical signs?
- obstruction of common bile duct
- hematemesis, abd. pain, anemia, melena, signs of pyloric obstruction
Which part of the stomach is often the location of malignant neoplasia?
lesser curvature or pyloric antrum
what is an "apple core" radiographic finding of gastric neoplasia? What may be a physiologic result of tumor in this area?
- tumor obstructing pyloric antrum
- -obstruction of biliary outflow causeing icterus and vomiting/hematemisis
What should be included on Ddx when considering gastric neoplasia?
- pyloric hypertrophy
70-80% of adenocarcinoma metastisis is found where?
regional lymph nodes
Adenocarcinoma may be scirrhous or infiltrative. Which is better prognosis?
scirrhous (firm and white on serosal surface)
What vessels should be ligated with pylorectomy and gastrojejunostomy (Billroth II)?
branches of right and left gastric and gastroepiploic vessels
While there is no effective chemotherapy for adenocarcinoma, what is the prognosis after surgical removal?
can be curative after complete excision
What is prognosis for leiomyoma?
mean survival is 1 year
What is the medical term for protrusion of abdominal esophagus through the diaphragm into the caudal mediastinum?
Are hiatal hernias usually acquired or congenital? What breeds are prone?
- congenital (may be assoc. w/upper airway obstruction)
- male shar-pei and bulldogs
When should sx be considered with a hiatal hernia patient?
when symptomatic only (regurge, vomiting, dysphagia, hematemesis, anorexia, wt loss)
What are surgical options for hiatal hernia?
- gastropexy (left sided fundus)
- hiatal reduction and esophagopexy
- gastrostomy tube
- nissen fundoplication (only if reflux present)
What would you like to do?
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