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SAS scs RUSVM COPY > E2: Intestinal surgery (incl rectum and anus) > Flashcards

E2: Intestinal surgery (incl rectum and anus) Flashcards

1
Q

What suture pattern(s) or closure techniques is/are most commonly used in intestinal surgery?

A

Appositional (simple interupted or simple continuous)

Modified Gambee (to help w/everted mucosa)

Using monofilament absorbable suture w/tapered needle

Stapling devices

Holding layer = SUBMUCOSA (so always incorporate), when in doubt go full thickness

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2
Q

When a mechanical obstruction of the intestinal lumen occurs, secretions from the bowel wall _____ and absorption across the bowel wall ______.

A

Increases

Decreases

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3
Q

(Dilation/Compression?) occurs proximal to an obstruction.

A

Dilation

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4
Q

What are the clinical and radiographic signs of linear foreign body?

A

Clinical: Vomiting, depression, abdominal pain, palpable BUNCHING of intestines in central abdomen (occurs when foreign body becomes fixed at some point cranially, typically around tongue or at pylorus)

Rads: Pilcation, Bunching, comma-shaped gas bubbles, could have no obvious lesions (esp cats)

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5
Q

How does the pathophysiology of linear and non-linear FBs differ?

A

Linear FBs cause obstruction due to peristaltic waves attempting to advance the object resulting in the intestines gathering around it (bunching, plicating). Continues peristalsis may cause cuts to the mucosa, lacerations to the mesenteric border of the intestines and result in peritonitis. Multiple performations can occur as can concurrent intissesceptions.

Non-linear FBs also cause complete or partial obstructions however the obstruction is due to the foreign body itself. Large FBs apply pressure and can cause venous stasis and edema, followed by arterial flow compromise, ulceration, necrosis and perforation.

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6
Q

How are linear foreign bodies managed surgically?

A

May require gastrotomy and multiple enterotomies

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7
Q

What are potential short and longterm complications of linear foreign bodies?

A

Inflammatory changes can impare intestinal function

Extensive resections(>70-80% removal) can cause Short Bowel syndrome - weightloss, diarrhea, malnutrition

Risk of anastomotic leakage (esp if also hypoALB)

Poor surgical technique can result in intestinal necrosis, perforation, leakgae dehiscence, peritonitis, endotoxic shock, and/or stenosis

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8
Q

What are some characterstic radiographic findings of non-linear FBs? (how would you differentiate a functional from an anatomic ileus?)

A

Radiolucent objects often surrounded by gas

Obstructed loops often become distended with air, fluid and/or ingesta

Anatomic ileus: Stacking of distended loops, Sharp turns/bends in dilated intestine, stacking

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9
Q

What is an intussusception and what are the parts called? Where do they occur most commonly?

A

Definition: telescoping or invagination of one intestinal segment (intussusceptum) into the lumen of an adjacent segment (intussuscipiens)

Occur most commonly ileocolic, jejuno-jejunal, and cecum

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10
Q

What is the typical signalment for an intussusception?

A

Young puppies

(with acute episode of enteritits, e.g. due to parvo) has peristent diarrhea

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11
Q

What is intestinal enteroplication? What are advantages and disadvantages of this procedure?

A

Aka Enteroenteropexy- surgical fixation of one intestinal segment to another

Advantages: Even if can manually reduce intussesception should do this to prevent recurrence

Disadvantages: Can cause obstruction, strangulaton, perforation

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12
Q

Where in the GIT is intestinal neoplsia most common in dogs? Cats?

Which tumors are common in dogs? Cats?

A

Dogs: Colorectal

  • Leiomyoma/sarcoma (GIST- gastrointestinal stomal tumors)
  • Adenocarcinoma
  • Lymphosarcoma

Cats: Small intestine

  • Duodenal polyps
  • Adenocarcinoma
  • Lymphosarcoma
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13
Q

How can viability of the intestine be assessed? What is the most reliable physical criterion?

A

Most reliable: PulsOx

Intestinal color (pink/red rather than blue/black)

Wall texture

Peristalsis

Pulsation of arteries

Bleeding when incised

Doppler

Fluoroscein stain (good accuracy for non-viable)

  • Electromyography*
  • Radioactive microspheres*
  • Microtemperature probes*
  • pH measurement*
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14
Q

How is fluroscein infusion used to determine intestinal viability?

A

Injected IV

Let equilibrate 2-3 min

View intestine w/Wood’s lamp

Viable= smooth, uniform, green-gold color or finely mottled pattern (no areas of non-fluorescence >3mm diameter)

This is a test for VASCULARITY/perfusion and is used to predict viability

Better for determining non-viable tissue - 95% accurate

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15
Q

How is surface oximetry used to determine intestinal viability?

A

Compare PulseOx reader (placed on intestinal wall) wit peripheral O2 saturation

Normal intestine remians within 1cm of normal PulsOx reading

Releable, reproducable means of assessing arterial perfusion or ischemia

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16
Q

What are the major principles of performing intestinal surgery (important precautions, materials

A

Minimize contamination: pack-off affected area with lap sponges, use a separate pack for the intestinal procedure (s)

Be gentle: occlude vessels with intesitnal forceps (Doyen) or fingers

Decompress dilated bowel loops

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17
Q

What must you do before cutting or clamping any bowel?

A

Determine extent of excision

Ligate blood supply (leave 2 ligatures in body and one on what you are removing) - to prevent back-bleeding

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18
Q

What is the advantage and disdvantage of using either a sclapel or scissors to divide the intestine?

A

Scissors: more control, more traumatic

Scalpel: less control, less traumatic

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19
Q

Why must you try to minimize mucosal eversion when doing an anastomosis?

A

Eversion increases risk of infection and adhesion formation.

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20
Q

Why should you angle your cut when performing an end-to-end anastomosis?

A

It enlarges the lumen size initially which accounts for the 10-20% narrowing that typically occurs during healing

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21
Q

When performing an intestinal anastomosis, where do you begin your closure? Why? What is the next thorw you place and then how do you close?

A

At the mesenteric border

Leakage is most common at this site (no serosa)

Fat in the mesentery impairs visualization

Next bite at anti-mesenteric border

Then close with simple continuous pattern (3-4mm apart and 3-4mm bites)

Use mosquitos to check tightness

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22
Q

How is a leak test performed for an anastomosis?

A

Occlude using Doyens (or fingers) proximally and distally

Inject sterile saline a few cm away from closure (6-8mL)

Compress and look for leakage

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23
Q

While skin staples can be used to close an anastomosis, what risk is increased? What is an advantage?

A

Mucosal eversion (less accurate/precise apposition)

Speed

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24
Q

How can disparity in lumen size be managed when performing an intestinal anastomosis (3 methods)?

A
  1. Angle your cut on smaller side
  2. Make incision on antimesenteric border (Fishmouth/Cheattle incision)
  3. Place mesenteric and antimesenteric sutures to stretch the smaller segment
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25
Q

After lavaging your closure, what can you do to protect the site as well as improving vascular and lymphatic supply?

A

Wrapping with omentum

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26
Q

When would you perform a serosal patch after an anatomosis or closure? What does this patch create?

A

When omentum is not avalable

To reinforce suture lines of questionable tissue

To reinforce an area that may be/seem unstable (e.g. diseases intestine that you can’t remove)

Creates a permanent adhesion much stonger than omentum

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27
Q

Describe the pathophysiology, signs and management of Short Bowel Syndrome.

A

Pathophys: Resection of so much intestine that the body cannot compensate without parenteral/enteral nutritional therapy (usually >70-80% of SI)

CS: Weightloss, diarrhea, malnutrition

Tx: Based on severity; correct hydration and e-lyte imbalances, provide adequate nutrition* (enteral, parenteral), control diarrhea (e.g. Famotidine + Loperamide), control intestinal bacterial population (e.g. Tylosin, Metronidazole + Enrofloxacin), growth factors (to facilitate intestinal adaptation and minimize CS)

*most important!

28
Q

Which heals faster, small or large intestines?

A

Small intestines

29
Q

A(n) _______ is an incision into the small intestines while a(n) _______ is an incision into the large intestines.

A

Enterotomy

Colotomy

30
Q

What surgery would be indicated for recurrent rectal prolapse or recurrent perianal hernia?

A

Colopexy

31
Q

What are the causes of megacolon?

A

Idiopathic (most common cause in cats)

Neurologic (e.g. Lumbosacral disease, aganglionic distal colonic segment)

Mechanical or functional colonic obstruction (e.g. pelvic trauma, adesions from OVH)

Self-induced impaction (E.g. too painful to poop due to fistula)

Congenital

32
Q

What defect is associated with idiopathic megacolon in cats?

A

Generalized dysfunction of colonic smooth muscle that involves the activation of smooth muscle myofilaments

33
Q

Which species is more commonly diagnosed with megacolon?

A

Cats

34
Q

What are the treatment options for megacolon?

A

Surgical disssection and removal

Potential resection and anastomosis

Medical management: Diet (low residue), keep well hydrated, edemas/deobstipation, prokinetic drugs (Cisapride), stool softeners (Lactulose)

35
Q

What are the goals of subtotal colectomy in the management of idiopathic megacolon?

A

Alleviate the clinical signs of the disease

Remove as much affected colon as possible

36
Q

T/F: Ileocecal valve preservation in cats with idiopathic megacolon has no real clinical benefit.

A

True

37
Q

Which type of subtotal colectomy/anastomosis, colecolonic or ileocolonic, allows you to remove more colon? Which one involves greater tension?

A

Ileocolonic= can remove more colon

Colecolonic= more tension

38
Q

Wha are expected clinical signs after subtotal colectomy? What is the post-op course/plan?

A

+/- Tenesmus q7 days

Diarrhea, soft stool for weeks

Increased frequency of defecation

Post-op: Offer food and water ASAP (within 12 hours) and taper fluids and e-lytes as oral intake normalizes, pain management

39
Q

What complications can occur after intestinal surgery?

A

Most complications occur in first 3-5days post-op

Dehiscence, leakage: if low ALB increased risk(pre-op ALB <2 = higher potential), monitor CBC for bands (indicating leakage),

Ileus

Adhesions

Obstruction

Peritonitis

Short Bowel Syndrome

40
Q

What are some situations in which the benefits of stabilizing the patient before surgery outway the risks?

A
  1. Penetrating abdominal injury
  2. Large numbers of neutrophils (>25k) or very toxic neutrophils ID’d on cytology of effision
  3. Bacteria in the effusion
  4. Blood-to-peritoneal fluid Glucose difference >20mg/dl
  5. Peritoneal fluid [lactate] >2.5-5.5 mmol.L
  6. Extraluminal gas bubbles or Volvulus ID’d on imaging
  7. Esophageal or gastric intussesception
  8. Bacterial culture of fluid is positive for pathologic bateria
41
Q

List the different intestinal biopsy techniques with advantages and disadvantages of each?

A

Logitudinal BX w/longitudinal or transverse closure

Transverse wedge BX (wedge <20-25% circumference)

Dermal punch

Laproscopic (minimally invasive)

42
Q

What is a cecal inversion? What are the typical clinical signs? What is the treatment?

A

Cecal intussusception

CS: Chronic diarrhea with hematochezia

Tx: Typhlectomy (removal of cecal- Standard), can attempt manual reduction or explose through colotomy

43
Q

What is the “Poster Child” for mesenteric volvulus? What are the CS?

A

German Shepherd (large breed dogs)

CS: similar to GDV, acute abdominal distension, pain, vomiting, shock, nonresponsive orogastric intubation

44
Q

What is the treatment and prognosis of mesenteric torsion?

A

Tx: Rapid fluid resuscitation and immediate abdominal exploration- derotation +/- resection and anastomosis

Problem: Reperfusion injury pretty much inevitable

Prognosis: Better for segmental (which doesn’t need to be derotated)

45
Q

What is the most common cecal tumor? Treatment?

A

Cecal leiomyosarcoma

(also, most common site for this tumor)

Tx: Typhlectomy

46
Q

What are the risk factors for dehiscence after intestinal surgery? What is the overall dehiscence rate? What is the mortality rate when dehiscence occurs?

A

Pre-op albumin <2g/dL (risk leakage)

Pre-op peritonitis

Post-op rise in band neutrophils

Foreign bodies, trauma

Overall dehiscence: 7-15%

Mortality: 74-85%

47
Q

What are the predisposing factors for rectal prolapse?

A

Tenesmus

Rectalanal disease

Urogenital disease

48
Q

How do you differentiate between a rectal prolapse and an intussusception?

A

Probe test: pass between border of anus and protruding mass; if can pass probe then it is intussusception

49
Q

What is the treatment for rectal prolapse?

A

ID and treat underlying cause

If viable: Reduce and place purse-string suture, maintain for 3 days

If not viable: Amputate

If recurrent: Colopexy

50
Q

How are rectal tumors diagnosed? What do you do after you diagnose one?

A

Direct visualization

Palpation on rectal

Proctoscopy/colonoscopy

Either remove or biospy

51
Q

What are the treatment options for rectal tumors?

A

Surgical exicison: Transanal or Dorsal approach

Mucosal resection

Cryosurgery

52
Q

Why should the whole colon be evaluated when you suspect a colorectal adenocarcinoma? How would you do this?

A

50% are abdominal

May be multiple

Via Colonoscopy

53
Q

When would you use an anal/transrectal approach for a tumor? Dorsal approach? When would you do a rectal pull-through?

A

Anal/Transrectal: if involving caudal rectum or anal canal

Dorsal: if involving midrectum, not anal canal

Pull-through: when distal colonic or midrectal lesion is not approachable through abdomen

54
Q

Describe the surgical management of anal sacculitis.

A

Anal sacculectomy: esp for recurrent infectons; wait until inflammation in surrounding tissue resolves - Medical therapy; closed or open technique

Closed: Balloon/Foley catheter or paraffin injection as guide, push external sphincter muscle out of the way

Open: Through duct, cut external sphincter muscle (incontinence more likely)

55
Q

Within which muscle to the anal sacs lie?

A

External anal sphincter muscle

56
Q

If you are removing a tumor of the anal sac, would you use an open or closed surgical technique?

A

Closed

To prevent tumor seeding into surrounding tissue

57
Q

Why could a draining tract form after an anal sacculectomy? What do you do about that?

A

Incomplete removal of sac

Must excise

58
Q

What type of perianal gland tumor is more common in male intact dogs?

A

Adenomas

59
Q

What is the most common malignant tumor of the anal sac? What is the typical appearance of this tumor? What are the paraneoplastic syndromes that is commonly caused by this tumor and what are the clinical signs?

A

Apocrine gland adenocarcinoma

Multiple perianal masses around the anus in the hairless area (may vary in size, could be covered in epithelium or ulcerated, friable and broad based)

Most are invasive (while adenomas tend to be well circumscribed)

PNS: Hypercalcemia of malignancy and Renal dysfunction

CS: anorexia, weight loss, vomiting, PUPD, muscle weakness, constipation

60
Q

To which lymph nodes do perianal adenocarcinomas tend to metastasize?

A

Sublumbar lymph nodes

61
Q

What is/are chronically relapsing suppurative, progressive, deep ulcerating tracts in the perianal tissues called? In what breed of dog do they common occur and what is a likely etiology?

A

Perianal fistulae

German Shepherd

Immune-mediated

62
Q

What is the recommended management for perianal fistulae?

A

Medical mgmt

Diet

Cyclosporin

+/- Ketoconazole, glucorticoids, tacrolimus (topical), azothioprine, metronidazole

63
Q

T/F: Fistulae first appear as small, draining holes in perianal skin that is inflamed and hyperpigmented

A

True

Note- hyperpigmentation

64
Q

What are the management options for perianal gland adenoma?

A

Shrink with short course of Diethylstildestrol (DES)

Castration +/- resection of mass (some adenomas regress completely after castration)

(If large, biopsy is indicated)

65
Q

What is going on in this picture (note that the ventral aspect of the anus is incomplete)? What can this anomaly cause?

A

Anogenital cleft

Fecal incontinence, soiling of the perineum, and perineal irritation

Also, ascending infections, pylonephritis

SAS scs RUSVM COPY (24 decks)

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