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163 Cards in this Set

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CS of esophageal sx
-regurgitation
-dysphagia
-coughing
-dyspnea
-salivation
anatomy of the esophagus (layers, holding layer, vasculature)
-NO SEROSA
-thick mucosa
-holding layer = submucosa
-vascular supply: submucosal plexus + segmental extrinsic vasculature
2 layer closure of the esophagus
--traditionally used what suture material?
-mucosa and submucosa - simple interrupted
-submucosa, muscularis, adventitia - simple interrupted
--prolene (though PDS will work too)
eso sx approach (direction): cervical
ventral midline
eso sx approach (direction): thoracic, cranial to heart
right lateral thoracotomy @ 3rd, 4th, or 5th interspace
eso sx approach (direction): thoracic, caudal to heart
right or left lateral thoracotomy at 10th, 11th, or 12th IC space
indications for esophageal resection and anastomosis
-severe trauma or necrosis of eso
-eso stricture >3-5cm in length not successfully treated by bouginage
-eso neoplasia (rare)
up to how much of the eso can be resected?
up to 1/3
what do you do if >3-5cm of eso need to be resected?
may require tension relieving sutures
how many layer closure of eso resection/anastomosis?
1 or 2
what are two tension relieving techniques for during eso resection and anastomosis?
-partial myotomy: circumferential incision thru longitudinal muscle layers 2-3cm cranial and caudal to site of anastomosis
-cranial mobilization of stomach
indication fo eso patching
-what 3 things can be used?
reinforcement of esophagotomy or esophagectomy site
-muscle pedicle graft (sternohyoid, sternothyroid, or diaphragm)
-omentum
-pericardium or gastric wall can be used on occasion
feeding postoperatively (eso sx)
-NPO for 24 hrs to 10 days (depdning on condition of eso)
-if feeding per os, liquid diet for 3-5 days
-bypass eso (gastrostomy)
thoracostomy tube for 24-48 hrs
-antibiotics until all drains are removed, longer if infection present
when would you need to use a thoracostomy tube for longer than 48 hrs after eso sx?
if there is pleuritis or mediastinitis present
what can cause stricture after eso sx?
gastro-esophageal reflux
factors predisposing eso to rupture
-lack of serosa
-pressure gradient across eso wall caused by changes in pleural pressure w/breathing
-rapid dilitation assoc w/swallowing
site of eso obstruction
-pharyngeal eso
-thoracic inlet
-base of the heart
-eso hiatus
the most common site of esp obstruction
-if they're too big, they can't pass where?
cranial to the diaphgragm (caudal thoracic eso)
-sometimes they're so big they cannot pass beyond the heard
if perforation is probable, what medium would you use for contrast radiography to assess a foreign body in the eso?
water-soluble iodinated contrast medium
what two things can you use to asses the integrity of the eso after removal of foreign body?
endoscopy and contrast radiograph
two non-surgical methods for removal of fb from eso
-esophagoscopy
-balloon catheter retrieval
two surgical methods for removal of fb from eso
-push into stomach and remove if necessary by gastrotomy
-esophagotomy
morbidity and mortaliry rates are higher for what type of removal of fb from eso?
surgical removal by esophagotomy
how does balloon catheter retrieval work from the eso?
catheter is advanced beyond fb, inflated, and the catheter withdrawn
ex. Foley catheter
treatment following nonsurgical retrieval of foreign bodies from eso if:
1. no perforation
2. minor perforation
3. major perforation
1. soft diet, antibiotics at your discretion
2. gastrostomy tube feeding w/antibiotics
3. thoracotomy, thoracostomy tube w/gastrostomy tube feeding and antibiotics
eso stricture happens as a complication to what?
-can be secondary to inflammation and trauma (rough handling during sx)
-can be secondary to gastro-esophageal reflux
-possibly after anesthesia
3 ways to treat esophageal stricture
-bouginage (hard plastic used to try and dilate the esophagus): get progressively larger, need general anesthesia
-resection and anastomosis if it's a short area of stricture
-esophageal reconstruction if stricture too long
problem w/bouginage of esophagus
-multiple procedures may be required
-good chance the stricture will reoccur
what is cricopharyngeal achalasia
bolus of food is not passed from oropharynx to cranial esophagus bc of failure of relaxation of the cricopharyngeal muscle in coordination w/contraction of pharyngeal mm
-uncommon, treatable
signalment/hx of cricopharyngeal achalasia
-unknown etoplogy, puppy, congenital
-normal until eating solid food
-gaggin, retching, forceful expulsion of bolus of food
-regurgitation immediate after swallowing
best too to diagnose cricopharyngeal achalasia
-fluroscopy during barium swallow (evaluate esophageal motility)
txs for cricopharyngeal achalasia
-when is this contraindicated?
cricopharyngeal myectomy (take a strip of muscle in order to prevent healing and keep stricture from forming)
-for other forms of pharyngeal dysplasia
what causes congenital megaesophagus?
-incomplete nerve development (little can be done)
causes of megaesophagus
-incomplete nerve development
-vascular ring anomaly
-myasthenia gravis (adult dogs)
-possibly hypothyroidism or addison's dz)
why would you do blood testing for megaesophagus?
to look for secondary complications
when will you find spirocerca lupi? (usually in eso)
--what will it cause
-necropsy
-associated w/sarcomas
0hypertrophic osteopathy (look in abdomen if this is found in legs)
--will cause sudden death
esophagostomy tube should be directed where?
cranially (not caudally)
the severity of signs of intestinal obstruction depends on what 3 things?
--which is the most severe?
-completeness (complete or partial)
-location (high or low)
-blood supply (strangulated vs non-strangulated)
--complete, high, or strangulated
when is intussusception most common?
young dogs
mesentieric torsion is most common in which spp and breed?
adult dog
-german shepherd
where do linear foreign bodies get stuck?
around tongue or pylorus
when does ileus most happen?
post-operative or post-obstruction
how long does it take for hypoxia to take affect on certain parts of the GI:
1. superficial villus injury
2. destruction of villus
3. transmucosal necrosis
4. transmural infarction
5. wall edema, hemorrhage, and mucosal sloughing
6. affected segment turgid, whole blood collects in the lumen
7. affected gut appears black, distended, and elongated
8. gross necrosis
1. after 20 minutes
2. after 60 minutes
3. after 4 hours
4. after about 8 hours
5. w/i 1-3 hours
6. after 4 hrs
7. 8-12 hours
8. evident by 20 hours
when does gaseous bowel destruction develop and what is it followed by
-w/i the initial 12-36 hrs
-followed by loss of fluid into the intestinal lumen
if untreated, when would death to do hypovolemia follow in GI obstruction?
w/i 3-4 days
what can pyloric/proximal duodenal obstruction cause?
metabolic alkalosis
what can mid-duodenal to ileal obstruction cause?
metabolic acidosis
in intestinal obstruction, what causes fluid loss?
-vomiting
-sequestration of intestinal lumen (incr secretion, decr absorption)
-edema of intestinal wall (esp the venus occlusion of intestine)
what does simple obstruction plus occlusion of blood supply of the intestines result in?
-bacterial overgrowth
-incr bowel permeability
-perforation and escape of bowel contents
-peritonitis (inflamming serosa --> peritoneal irritation --> peritonitis)
what will you see on blood work w/intestinal obstruction?
acid base abnormalities, electrolyte imbalance
how do you treat intestinal obstruction?
-correct acid-base imbalance, fluid, and electrolyte abnormalities
-IV antibiotics
-treat for shock if necessary
-correct underlying condition surgically
radiographic signs of linear foreign body
-intestine plicated in cranial abdomen
-teardrop shape of gas bubbles in intestine
what could a linear fb do and what may be required?
-may lacerate the mesenteric border of the intestine
-may have to do multiple enterotomies to remove it and possibly an intestinal resection and anastomosis if intestine is perforated
in an intussesception, which is usually telescoped into the other: the proximal portion or the distal portion?
the proximal portion is usually the intussusceptum (telescopes into the intussuscipiens)
-can happen reversed if reverse peristalsis occurs
insussusception is usually assoc w/?
hypermotility of the gut
insussusception is more common in?
puppies
can you palpate insussusception?
often
which has more of a problem w/reperfusion injury: GDV or insussusception?
GDV
what does the cecum usually do during insussusception?
acts as a stopper (though can sometimes become occluded)
in what spp/breeds does mesenteric torsion commonly occur?
-medium to large breed dogs, esp german shepherds and pointers
-adult males
how bad can a mesenteric torsion get?
may evolve from clinically normal to dead in a few hours
predisposing factors to mesenteric torsion
practically everything:
-vigorous activity
-dietary indiscretion
-trauma
-recent GI sx
-foreign bodies
-parasites
-GDV
-exocrine pancreatic deficiency
-enteritis
what would a radiograph look like w/mesenteric torsion?
entire SI filled w/gas
mesenteric torsion mortality rate
-in most cases, what is not viable at the time of sx?
-problem w/sx
-consequence w/resection
approaches 100%
-entire jejunum and ileum
-reperfusion in jury may be LETHAL
-short bowel syndrome (malabsorption)
in enterotomy, where do you want to make your incision?
in the healthy tissue, usually distal to foreign body
what fingers should you use to clamp w/in an enterotomy?
-what sutures do you use to close an enterotomy?
--suture technique
---what layer do you need to be sure to include?
forefinger and middle finger
-simple interrupted or continuous (w/4-0 absorbable monofilament)
--each suture should be placed 2mm from edge of tissue, 2-3mm apart, and should appose the mucosa directly (to incr diameter of lumen, close transversely, placing first suture at ends of incision) (wrap w/greater omentum once leak tested)
---submucosa
"when in doubt...
take it out"
things that are critical for evaluating intestinal viability:
-color
-wall texture and thickness
-motility
-pulsation of mesenteric arteries
-bleeding of mucosa when incised
-pulsox (normal should be w/i 1cm of normal peripheral O2 saturation)
-fluorescein dye (IV) - accurate in detecting viable and nonviable bowel
3 reasons why end-to-end approximating pattern using simple continuous or interrupted suture is good for enterectomy
--how far around do you go w/sutures?
-technically easy
-maximizes luminal diameter
-results in rapid mucosal regeneration
--180 degrees, NOT 360)
crushing clamps may be used when on resection and anastomoses of the intestines?
only on the section removed
what should you do if you are doing an end-to-end anastomosis w/lumens of the intestine that are two different sizes?
-transect smaller segment at acute angle and alrge segment at a more obtuse angle
-space sutures on lg segment farther apart
-incise antimesenteric border of smaller segment to spatulate or "fish mouth" larger segment
when suturing an enterectomy, in what order are the sutures placed?
-mesenteric border first
-second suture places in antimesenteric border
-remaining sutures places 3mm from the edge of tissue and 3mm apart
what suture pattern to do you use to suture the mesentery back together?
continuous
indications for serosal patching in enterotomy or resectiona nd anastomoses
-questionable area of suturing:
--tension at suture line
--damage to serosa
--repair of dehiscence
-superficial trauma to intestinal wall
serosal patching technique
-placement of antimesenteric border of SI over a suture line or organ defect
-adjacent loop of intesting is sutured over damaged area
-sutures engage submucosa but to NOT penetrate mucosa
-avoid twisting, stretching, or kinking the intestine and mesenteric vessels
two ways of doing a staple anastomosis in the intestines
-side to side (functional end to end) (GIA and TA staplers)
-inverting end to end (EEA stapler)
anther name for intestinal plication
enteropexy
what was intestinal plication/enteropexy developed for
to prevent recurrence of insussusception
how is intestinal plication done?
SI is places in gentle loops and seromuscular layers are sutured w/small interrupted sutured (questionable efficacy)
why is a colopexy done?
to prevent caudal movement of the colon and rectum - esp useful w/recurrent rectal prolapse cases)
postop care of colopexy
1. when is water introduced?
2. food?
3. normal diet?
1. 8-12 hrs after sx
2. 12-24 hrs after sx
3. 48 hrs after sx
reasons for dehiscence and peritonitis after intestinal sx
-result of poor suturing technique, non-viable bowel, use of chromic gut, delayed healing
***when does dehiscence and peritonitis occur after intestinal sx?
between 3rd and 5th day after sx
rate of dehiscence of SI
16%
how many patients (%) w/intestinal dehiscence die?
75%
why is metronidazole used for GI surgery patients?
anaerobes
complication of intestinal sx
-ileus (frequent feedings of small meals and early ambulation decr severity)
-adhesions
-stricture (rare, associated w/inverting or everting suture patter or excessive tension)
dogs with 2 or more of what risk factors are at high risk for developing anastomotic leakage?
-preoperative peritonitis
-intestinal fb
-serum albumin <2.5g/dl
complications of intestinal sx
--what do you do?
-short bowel syndrome
-weight loss, diarrhea, malnutrition
-anemia secondary to folic acid deficiency
--supportive therapy until remaining intestine adapts (1-2 months)
what % of the intestines must be taken out to get short bowel syndrome?
70-80%
neoplasia is most common in what part of the intestines in dogs and cats
-are most malignant or benign?
-what % have metastasis?
dog: colon and rectum
cat: SI
-malignant
-dogs: 86%, cats: 71%
1. most common intestinal malignancy in dogs?
2. most common rectal tumor in dogs
3. most common intestinal tumor in cats
1. adenocarcinoma
2. adenomatous polyp
3. lymphosarcoma (benign tumors are rare)
intestinal adenocarcinoma:
1. ave age in dogs
2. ave age in cats
3. male:female ratio
4. specific breeds
1. 9yrs
2. 10 yrs
3. 12:11 (dogs), 5:9 (cats)
4. boxers, collies, german shepherds, siamese
what does an adenocarcinoma in the intestines look like?
"napkin ring" appearance
what will you see int he hx w/SI neoplasia?
weight loss, anorexia, depression, diarrhea, signs of obstruction, including vomiting
what will you see in the hx w/LI neoplasia?
tenesmus, hematochezia (maroon colored feces), dyschezia (difficulty defecating), weight loss
w/intestinal neoplasia, when will you see signs of peritonitis?
w/perforation of the gut or necrosis of tumor
with which intestinal neoplasia will you see anemia?
leiomyosarcoma
what will you see on radiography w/intestinal neoplasia?
-abd mass
-dilated intestinal loops
-contrast radiography will show intramural or annular lesion, diffuse filling defects in the bowel wall)
what will you see on US w/intestinal neoplasia?
enlarged lns or hepatic masses
w/neoplasia, only do intestinal resection and anastomosis when ...
single mass
-resection will be <70% of the SI
-no metastatic lesions present
on which type of intestinal neoplasia does chemotherapy SOMETIMES work?
lymphosarcoma (poor results on adenocarcinoma)
tx if rectal polyps and why
-submucosal resection per anus bc most are w/i 2cm of the anus
3 ways to reach annular or mroe cranial tumors in colorectal neoplasia
-dorsal approach to rectum
-rectal pull-through approach
-ventral approach to rectum (pretty invasive - have to cut through pelvic bone)
prognosis w/colorectal tumors
-large or sessile tumors more likely to recur
-euthanasia usually due to failure to control dyschezia or hematochezia
how do you shrink a rectal prolapse for tuck it back in?
sugar it!! no ice bc it burns and damages mucosa
at which age is rectal prolapse most common?
puppies and kittens
feline idiopathic megacolon results in ?
-cause?
--sex? breed? age?
chronic constipation
-unknown but neural or smooth muscle defects are possible (aganglionosis and histo abnormalities rarely seen)
-adults, any age, either sex
cats w/feline idiopathic megacolon usually show what cs?
-these cats usually have what?
-constipation, tenesmus, inappetance, depression, weight loss, poor hair coat
--usually have Rickets (esp femur not properly mineralized)
w/feline idiopathic megacolon, what do we need to rule out?
-narrowing of pelvic canal
-stricture (can to barium enema)
-pelvic mass (can to barium enema)
to do a barium enema, what must happen?
colon must be empty
which is quicker and easier: barium enema or protoscopy?
protoscopy
how do you manage feline idiopathic megacolon and what is the problem with the management?
-warm water enemas, lubrication and digital breakdown of feces, general anesthesia required
-problem: only short-term relief
how do you manage feline idiopathic megacolon surgically?
-recommended?
-colectomy or subtotal colectomy
--colectomy is NOT recommended
what is a colectomy?
removal of colon plus ileocolic valve and cecum - ileorectal end-to-end anastomosis
what is a subtotal colectomy?
-removal of colon only - colorectal anastomosis
surgical considerations for colectomy
-use prophylactic antibiotics (high bacterial content - aerobes and anaerobes)
-no bowel prep necessary
-**avoid preoperative enemas (2-3 days before)
-colon is carefully packed off
when doing a colectomy, how do you determine the extent of resection?
-extent of proximal resection determined by extent of dilation
-location of distal resection is 2-3cm cranial to the pubis
what type of anastomoses do you do for a colectomy? sutures?
end to end w/3-0 or 4-0 monofilament, single or double layer closure
-can use EEA stapler for double layer inverting closure
what can you find post-operatively w/a colectomy and when?
-tarry feces for 2-3 days
-tenesmus for 5-7 days
-anorexia (use nasogastric of PEG tube if needed for feeding) - appetite usually returns around 7-10 days
what diets may help cats after colectomy?
low residue diets may improve fecal consistency and decrease fecal volume
what else can be a useful tx for cats w/megacolon?
cisapride or subtotal colectomy
increased collagenase activity occurs how long after colotomy or anastomosis?
5-7 days - collagen degradation exceeds collagen synthesis
prognosis after colectomy
good to excellent (recommendation that ileocolic junction be preserved)
OVH - all vessels are located where?
mesovarium and mesometrium
OVH - what can obscure vessels in dogs?
fat
OVH - incision line
--what is uterus is distended?
ventral midline approahc
-incision from umbilicus up to 4-6cm to pubis
--enlarge incision up to pubis
OVH - can use the flank approach in which animal?
cats
OVH - which ligament is clamped to allow manipulation of the ovary and which ligament is torn to allow elevation of the ovary?
-manipulation: proper ligament
-elevation: suspensory ligament
OVH - where do you want to make the window/opening?
in the least vascular portion of the mesovarium
OVH - which clamps are used int he 3 clamp technique?
Rochester Carmalts - placed across the ovarian pedicle through the opening in the mesovarium
OVH - the mesometrium is divided lateral to what?
the uterine vessels
OVH - in dogs, the uterus is ligated and transected where?
directly cranial to the cervix
OVH - in cats, the uterus is ligated and transected where?
-why?
at about the caudal 1/3 body, since there is no obvious cervix
OVH - what is the process for ligating and removing the uterus?
the vessels on both sides of the uterus are ligated, leaving long suture tags for handling
--> 3 rochester-carmalts forceps are placed across the uterine body and the vessels
--> the tissue between the distal and middle forceps is cut
--> the long ends of suture are used to place a circumferential ligature around the tissue crushed by the forceps proximal to the cervix
OVH - how are the ovarian pedicles examined for bleeding?
the mesoduodenum and mesocolon are used to retract the abdominal contents
***OVH - don't forget to check what?
THE URETERS!!! (and sponges)
OVH - why do we isolate patients in estrus after surgery?
mating in early post-operative period can cause severe abdominal bleeding and/or peritonitis
T/F: metabolic disorders of the urinary tract must be corrected before surgery
true
two approaches to nephrectomy
celiotomy (abd cavity) and laparotomy (abd wall)
define nephrolithiasis
the process of forming a kidney stone
CS of nephrolithiasis
-depression
-anorexia
-hematuria
-pain on the flank
-incr BUN if bilateral
what confirms dx for nephrolithiasis?
x-ray
what species is most affected by hydronephrosis and what can cause it?
dogs
-lithiasis
-stenosis
-compression
-parasite (D. renale) - IVP and urinalysis
ectopic ureters are more common in which sex and how much more common?
-more often unilateral or bilateral in dogs?
--specific breeds more common
---more often unilateral or bilateral in cats?
females 25:1
-unilateral
--poodle, husky, labrador
---bilateral
when is nephrotomy indicated and what techniques could be used?
when renal fn is decr by 20-50%
-classic technique
-non-atrophic technique
where may the ureters empty into if ectopic?
urethra, vagina, uterus
is ectopic ureters more common in dogs or cats? females or males?
dogs > cats
females > males
what does it mean when the ureters run an "intramural course?"
-"extramural?"
they run submucosally
-bypasses bladder completely
what can diagnose ectopic ureters and what does it show you?
excretory urogram and pneumocystography
-unilateral or bilateral
-intramural or extramural
how do you surgically correct ectopic ureters?
-ventral cystotomy --> neoureterostomy --> ureteral relocation
(ureteroneocystostomy)
CS, Dx, Tx, and Px of ectopic ureter
CS: incontinence
Dx: IVP w/negative cystourethrogram
Tx: surgical +/- medical management
Px: 60% continent post op
-----may need PPA or other meds
-----may have hypoplastic bladder
what % of patients w/ectopic ureters are continent afterward surgery?
60%
define: neouretercystostomy
takes an intramural ureter and opens it up so it opens into the urinary bladder as well as where it opens into the urethra
define: ureternsocystostomy
ureterneocystostomy takes an extramural ureter and basically moves it to where it should be in the bladder
where in the ureters is trauma most commonly caused?
in the initial 4cm
w/which surgery is accidental kinking or ligation of the ureters a problem?
OVH!!
define: nephrostomy
an artificial opening created between the kidney and the skin which allows for the drainage of urine directly from the upper part of the urinary system (renal pelvis)
what is a ureterocele?
dilation of the ureter at the opening
how do you manage a ureterocele?
by removing the "cyst" structure - it is not a true stricture but it creates a slowing of the flow
what can cause a ureterocele?
duplicated ureter
how do you perform a nephrostomy?
go through the ureter --> through the kidney pelvis --> pull catheter through
--can remove catheter once ureter is healed
what is a pyelotomy and when do you do one?
incision into the renal pelvis
-done when there is a dilation beyond the pelvis (ex to remove stones by opening the ureter)