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what is the medical term for a sx approach to the stomach?
gastrotomy
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what is the sx approach on the body for a gastrotomy?
ventral midline from xyphoid process, as far caudally as needed
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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
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what is the holding layer in the GI?
submucosa
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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
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why is the stomach packed off with laparotomy sponges?
avoid spillage or drying
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What is "mushroom effect" referring to?
lumen tends to fold out/exteriorize itself
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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
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which suture pattern in inverting and perforates the lumen?
Connell
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Which suture pattern(s) are inverting and do not perforate the lumen/partial thickness?
Cushing and Lembert
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what is the purpose of the first layer closure of the gastrotomy?
hemostasis/stops oozing
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What kind of suture material is used for gastrotomy closure?
monofilament, absorbable (like PDS)
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if suture line has zig-zag effect, is this desired?
yes, indicates good inversion, good serosa-serosa contact and will not leak
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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)
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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
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List 4 sx disorders of the stomach.
- foreign body
- pyloric stenosis/hypertrophy
- neoplasia
- hiatal hernia
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What is the most common foreign body in dog? in cat?
- dog: bone
- cat: linear (string)
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Would you expect water and electrolyte balances to be severely disrupted?
not necessarily, incomplete obstructions causes less frequent vomiting
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What would be main clinical sign for patient with partial obstruction?
anorexia/weight loss
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Will patient have metabolic alkalosis or acidosis with gastric/pyloric vomiting?
alkalosis w/hypOchloremia
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Why would patient with obstruction present with hematemesis or melena?
mucosal erosion/ulceration/necrosis
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What must be considered before using contrast for radiographs of possible obstruction?
never use barium if suspect perforation
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What is prognosis for foreign body sx if mucosal damage is present?
still good
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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)
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Which layer(s) are involved in congenital v. acquired pylorus hypertrophy?
- C: muscular layer only
- A: mucosa + muscular layer (full thickness)
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When does congenital pyloric stenosis become apparent? why?
at weaning, vomiting occurs w/in24 hours of eating and may have ravenous appetite
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What breeds are more prone to congenital pyloric stenosis?
- brachycephalic dogs
- Siamese cats
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what would radiographs show in patient with pyloric stenosis?
enlarged stomach w/delayed gastric emptying (>8-12 hrs)
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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)
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Which breeds are more prone to acquired pyloric stenosis?
- small breeds like lhasa apso and shih-tzu
- (rare in cats)
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If endoscopy revealed hypertrophy of the mucosa/submucosa, would this indicate acquired or congenital pyloric stenosis?
acquired (congenital only muscularis layer)
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What medical treatment is available for pyloric stenosis?
no effective medical tx; need sx
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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)
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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)
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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
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What are indications for partial gastrectomy?
neoplasia, ischemic injury (GDV), penetrating injury (ulcer/trauma)
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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)
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Which vessels should be ligated during a partial gastrectomy?
branches of gastroepiploic vessels to affected area
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What type of closure pattern with partial gastrectomy?
- 2 layers
- (simple continuous w/ inverting non-perf pattern OR inverting perforating then invert. non-perf)
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what are 2 common BENIGN gastric neoplasias?
- ademona (older dog, often pedunculated -easy to excise)
- leiomyosarcoma (very old dog)
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what are 2 common MALIGNANT gastric neoplasias?
- adenocarcinoma (most common gastric cancer in dog)
- lymphosarcoma (most common gastric cancer in cat)
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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
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Which part of the stomach is often the location of malignant neoplasia?
lesser curvature or pyloric antrum
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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
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What should be included on Ddx when considering gastric neoplasia?
- pyloric hypertrophy
- pythiosis/phycomycosis
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70-80% of adenocarcinoma metastisis is found where?
regional lymph nodes
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Adenocarcinoma may be scirrhous or infiltrative. Which is better prognosis?
scirrhous (firm and white on serosal surface)
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What vessels should be ligated with pylorectomy and gastrojejunostomy (Billroth II)?
branches of right and left gastric and gastroepiploic vessels
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While there is no effective chemotherapy for adenocarcinoma, what is the prognosis after surgical removal?
can be curative after complete excision
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What is prognosis for leiomyoma?
mean survival is 1 year
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What is the medical term for protrusion of abdominal esophagus through the diaphragm into the caudal mediastinum?
hiatal hernia
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Are hiatal hernias usually acquired or congenital? What breeds are prone?
- congenital (may be assoc. w/upper airway obstruction)
- male shar-pei and bulldogs
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When should sx be considered with a hiatal hernia patient?
when symptomatic only (regurge, vomiting, dysphagia, hematemesis, anorexia, wt loss)
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What are surgical options for hiatal hernia?
- gastropexy (left sided fundus)
- hiatal reduction and esophagopexy
- gastrostomy tube
- nissen fundoplication (only if reflux present)
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