E2: Intestinal surgery (incl rectum and anus) Flashcards Preview

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Flashcards in E2: Intestinal surgery (incl rectum and anus) Deck (65)
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1

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

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 

2

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

Increases

Decreases

3

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

Dilation

4

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

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)

5

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

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. 

6

How are linear foreign bodies managed surgically?

May require gastrotomy and multiple enterotomies 

7

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

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 

8

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

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

9

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

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 

10

What is the typical signalment for an intussusception?

Young puppies 

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

11

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

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 

12

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

Which tumors are common in dogs? Cats?

Dogs: Colorectal

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

Cats: Small intestine 

  • Duodenal polyps
  • Adenocarcinoma
  • Lymphosarcoma 

13

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

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

14

How is fluroscein infusion used to determine intestinal viability?

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

15

How is surface oximetry used to determine intestinal viability?

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

16

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

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 

17

What must you do before cutting or clamping any bowel?

Determine extent of excision 

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

18

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

Scissors: more control, more traumatic

Scalpel: less control, less traumatic 

19

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

Eversion increases risk of infection and adhesion formation.

20

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

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

21

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?

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

22

How is a leak test performed for an anastomosis?

Occlude using Doyens (or fingers) proximally and distally

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

Compress and look for leakage 

23

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

Mucosal eversion (less accurate/precise apposition)

Speed

24

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

  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 

25

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

Wrapping with omentum

26

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

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

27

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

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

Which heals faster, small or large intestines?

Small intestines 

29

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

Enterotomy

Colotomy

30

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

Colopexy