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TOBIAS VETERINARY SURGERY > LIVER, PANCREAS: 95, 96, 97 > Flashcards

LIVER, PANCREAS: 95, 96, 97 Flashcards

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1
Q

Liver anatomy

A

442

4 lobes (right, left, quadrate, caudate)
4 sublobes (right, left lateral and medial)
2 processes (caudate, papillary)
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2
Q

is it more difficult to access surgically the left or right lobe? why?

A

easier the LEFT (sustantial cleft separating the medial and lateral portions

the right medial lobe has a substantial attachment to the quadrate lobe
the right lateral lobe is fused at it’s base with the caudate lobe

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3
Q

blood supply and O2 supply to the liver

A

HEPATIC ARTERY: 20% volume, 50% O2

PORTAL VEIN: 80% volume, 50% O2

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4
Q

possible conformation of the Heparic artery

A

1- common trunk
2- right lateral + left
3- right lateral + right medial + left

left always the larger

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5
Q

where the cystic artery of the gallbladder originates from?

A

from the left branch of the hepatic artery

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6
Q

DOG vs CAT: difference in anatomy beetween intrahepatic portal vein

A

CANINE: usually divide in right and left main branch
FELINE: usually divide in 3 branches ( right, central, left)

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7
Q

how it is called the manouvre to stop the the blood inflow to the liver?

A

pringle manouvre

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8
Q

number of hepatic ducts in dog

A

2-8

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9
Q

DOG vs CAT: major and minor papilla differences

A

DOG:
major papilla: CBD. Adjacent to CBD enters the pancreatic duct
minor papilla: accessory pancreatic duct (larger)

CAT:
major papilla: CBD + pancreatic duct (conjoined with the CBD)
minor papilla: 20% cats have accessory pancreatic duct (smaller)

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10
Q

compensatory hypertrophy and hyperplasia of liver after 70% resection

A

usually reached after 6 days. may take up to 6-10 weeks

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11
Q

factors that impede liver regeneration

A

diabetes mellitus: insulin is one of the most potent hepatotrophic factors in protal blood

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12
Q

most common cause of extrahepatic biliary tract injury

A

blunt abdominal trauma

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13
Q

most common causes of extrahepatic biliary obstruction

A

pancreatitis, neoplasia, mucoceles, cholangitis, cholelitiasis

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14
Q

possible consequences of extrahepatic biliary tract obstruction

A 
hypotension
decreased myocardial contractility 
AKI
coagulopaties
gastrointestinal hemorrage
delayed wound healing

absence of bile salts lead to bacterial overgrowth?

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15
Q

mortality rates beetween sterile-septic bile peritonitis

A

higher mortality rates with septic bile peritonitis

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16
Q

RX visualization of coleliths

A

50% radiopaque in dogs

80% radiopaque in cats

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17
Q

first US sign of extrahepatic biliary tract obstruction

A 
CBD dilation (normal: 3-4 mm) 
begins to dilate as soon as 48 h after obstruction
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18
Q

prevalence of coagulation abnormality in dogs with liver desease

A

up to 57% of dog with at least one abnormality

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19
Q

is there a concrete risk of hemorrage with liver desease?

A

in human no increased bleeding tendencies have been seen in patients with coagulation abnormalities due to liver desease

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20
Q

degree of liver resection at wich we can observe hypoglicemia

A

when up to 70% of liver is resected

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21
Q

most common bacteria isolated in liver culture

A

clostridium perfringens

staphylococcus spp

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22
Q

oxidized regenerated cellulose VS gelatin sponge

A

ORC seem to have antibacterial properties

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23
Q

name the 3 technique to control extensive hemorrage from hepatic surgery

A

1- control of central venous pressure
2- occlusion of liver inflow
3- occlusion of liver inflow and outflow

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24
Q

time of liver inflow occlusion tolerated

A

20 min: dogs are less tolerant than humans because they have reduced intrinsic portosystemic collateral circulation

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25
difference beetween stapling technique and dissection and ligation technique
both safe and effective dissection and ligation tough associated with more microscopic hemorrage, necrosis and inflammation
26
serum bilirubin concentration to see icterus
>1.5- 2 mg/dl
27
is there aboundant fluid associated with bile peritonitis? how it is diagnosed?
usually yes, because of hyperosmolar nature of bile diagnosed when bilirubin concentration of peritoneal fluid is 2- > then bil in the serum
28
DOG vs CAT: prevalence of positive culture of bile
17-39% of dogs 30-50% cats
29
best antibiotic choice for septic bile peritonitis
2 gen cephalosporin, it lack efficacy against enterococci -> add ampicillin for enterococcus spp.
30
critical point to decide when medical treatement alone or when perform surgery?
if patency of the CBD can not be demostrated via normograde or retrograde catheterization of the duct, consider a sirgical approach with cholecistoenterostomy.
31
choledochal catheterization approach in order:
1- small antimesenteric duodenotomy to cateterize major papilla 2- establish patency 3- colecistectomy 4- thorough flushing of the duct
32
cholecistectomy tip
always flushing the CBD to ensure that all gelatinous bile is removed from the common bile duct
33
port placement for laparoscopic cholecystectomy
4 PORT: subumbilical camera LEFT: 5-8 lateral, 3-5 cranial umbilicus RIGHT: 3-5 lateral umbilicus RIGHT: 5-8 lateral umbilicus 1 PORT: umbilicus
34
tip to remove the gallbladder laparoscopically from the abdomen
when in the retrival bag, puncture and aspirate it's content to facilitate exteriorization
35
when to perform a cholecystoenterostomy
- when the CBD is too small or fragile to permit choledochoduodenostomy - can't reestablish patency of CBD -not do when suspect pf necrotic gallbladder
36
how to reduce stroma narrowing with cholecystoenterostomy
appose mucosa on mucosa
37
size of stenting fot choledocal stenting
CAT: 3.5-5 Fr DOG: 8-12 Fr
38
choledocal stenting outcome in cats
probably due to reduced diameter it can lead to reobstruction after a few days-weeks from the stenting
39
surgical options for a colecystostomy tube
traditional "open" technique | laparoscopic assisted
40
percoutaneous drainage ad alcoholization of hepatic abscesses (Zatelli et al.)
``` ultrasound guidance place 20 G needle aspirate 95% ethanol 1/2 volume removed left in situ for 3 minutes ```
41
signalment of dogs with liver lobe torsion
middle-old large breed dogs | no gender or underlying desease predisposition
42
endocrinopaties associated with gallbladder mucocele
hypotiroidism, hyperadrenocorticism
43
can you perform a cholecistoduodenostomy in a dog with gallbladder mucocele?
usually no, because gallbladder wall is not healthy enough
44
choleliths composition ad difference with humans
in dogs less saturated with colesterol usually composed of calcium carbonate or calcium bilirubinate, cholesterol in varying quantities
45
what are the 4 possible general type hepatic tumors
hepatocellular cholangiocellular neuroendocrine mesenchymal metastatic
46
what's the most common liver neoplasm? DOG VS CAT
DOG: hepatocellular carcinoma (50-70%) of non hematopoietic CAT: bile duct tumors most common primary hepatic tumor (biliary duct adenomas 2 more common than biliary duct carcinomas). hepatocellular adenomas more common than carcinomas
47
possible forms of diffusion of liver tumors
massive (61%) nodular (29%) diffuse (10%) left lobe in 67% cases
48
tributaries of the portal vein from caudal to cranial
CRANIAL MESENTERIC : jejunal+caudal pancreaticoduodenal CAUDAL MESENTERIC: ileocolic+left colic+right colic+middle colic SPLENIC: splenic+left gastroepiploic+left gastric+branch from pancreas GASTRODUODENAL: pancreas+duodenum +stomach (right gastric and right gastroepiploic)
49
portal vein anatomy
RIGHT BRANCH caudate process+right lateral lobe LEFT BRANCH RIGHT VENTROLATERAL BRANCH right medial lobe PAPILLARY BRANCH to papillary process DIVIDE IN quadrate, left medial, left lateral
50
how many hepatic veins usually a dog have?
5 to 8
51
how many pairs of cardinal veins develop in the embryonic trunk?
3 caudal cardinal subcardinal sopracardinal
52
a congenital portocaval or portoazygos shunt is an abnormal connection beetween the .................... and ............................system
cardinal vitelline
53
left sided IHPSS usually result from patency of
the ductus venosus
54
name the 3 categories of liver vascular desease
1- congenital PSS 2- primary hypoplasia of the portal vein (PVH) PVH with portal hypertension (idiopatic noncirrhotic portal hypertension) PVH without PH (microvascular dysplasia MVD) 3- disturbances in portal outflow
55
prevalence of PSS in dogs with PVH-MVD
58% dogs and 87% cats with PVH-MVD have a congenital PSS
56
what is a hepatic arteriovenous malformation?
multiple high pressure vessel connecting hepatic artery with portal vein through multiple (tens to hundreds) shunting vessels
57
name some of the toxins implicated with hepatic encephalopathy
14: ammonia aromatic amino acids bile acids decrease alpha ketoglutarate endogenous benzodiazepines GABA false neurotransmitters ``` tyrosine phenylalanine methionine glutamine tryptophan phenol SCFAs ```
58
coagulopaties in patients with PSS
43% found coagulation abnormalities | 40 times more lijely when hepatic encephalophaty present
59
breed associated with increase in PSS prevalence
EHPSS ``` 35.9% yorkshire terrier maltese pugs miniature schnauzer norwegian terriers havanese ``` IHPSS large breed dogs: irish wolfhounds, retrievers, australian cattle dog, australian sheperd. left divisional considered heritable in irish wolfhounds
60
potential causes of PU-PD in dogs with PSS
poor medullary gradient due to low urea increased GFR increase in ACTH associated with hypercortisolism psycogenic polididpsia
61
hypoalbuminemia in dogs with PSS
most common in dogs with a concurrent PLE GI ulceration or IBD or lymphangectasia heavy intestinal parasite loads
62
liver function tests
bile acids: after 12 h fasting and 2 hour postprandial (up to 100% sensitive with both measurements or only post-prandial) ammonia: abnormal in 62% to 88% of animals ammonia tolerance test? (amonium cloride orally or rectally)
63
common findings in histopatology of PSS liver
``` bile duct proliferation hypoplasia of intrahepatic portal tributaries hepatocellular atrophy arteriolar proliferation or duplication lipidosis cytoplasmatic vacuolar changes smooth muscle hypertrophy increased lymphatics around central veins Ito and Kupffer cell hypertrophy ```
64
is it possible to differentiate PSS from PVH-MVD (without hypertension) from PVH (with hypertension) based on hustopatologhic changes?
usally no | dogs with non cirrothic PH often have more significant fibrosis extending in the parenchima
65
Portal vein to Aorta ratio to detect PSS
PV/Ao 1-2 normal 0,14-',6 suggestive of PSS
66
medical management of PSS
lactulose: entrapment of luminal ammonia in form of ammonium (acidificate colon content) + osmothic effect plasma for coagulopathies antiacids for GI ulcerations seizure control. benzo-amtagonist to reverse hepatic encephalopaty? seizures not caused by hypoglicemia or hyperammoniemia treated with benzodiazepines mannitol to decrease cerebral edema hepatoprotector diuretics for ascites. spironolactome is a potassium sparing drugs, furosemide may potentiate hypokaliemia
67
prognosis IHPSS vs EHPSS
IHPSS: on medical management persistent neuro and urinary signs, nut GI gets better EHPSS: neuro, urinary, GI, same or better with medical therapy
68
for how long should preoperative therapy be used?
at least 2 weeks
69
possible location of EHPSS
phrenic: esophageal hiatus azygos: aortic hiatus epiploic foramen: CVC dorsal, HA PV ventral, celiac artery caudally caudal abdomen: colon caval shunts, falciform ligament, hilus liver to internal thoracic vein
70
determining the degree of shunt attenuation
up to 86% of dogs undergoing acute occlusion require partial attenuation MAX 17-24 mmHg post ligation, or 2x the previous measured pressure closure limited to a degree where the flow become epatopetal
71
how can you classify IHPSS
shunt of the left division shunt of the central division shunt of the right division
72
name the 4 main concearn-complications associated with PSS surgical attenuation
- significant postoperative hypoglicemia: reported in up to 44% of dogs within 4 hours of surgery - hemorrage anemia - portal hypertension: 2-14% with acute ligation, less common in partial. clinical signs can be hypovolemic shock, hypotermia, abdominal pain, abdominal distention, dhiarrea, vomiting.
73
pancreas vascular suppy
CELIAC ARTERY: ``` splenic artery (left limb) hepatic artery: terminates as cranial PD artery (body+proximal right limb) ``` CRANIAL MESENTERIC caudal PD artery
74
name the 2 pancreatic ducts
accessory PD: duct of Santorini (dog bigger, exit at minor papilla) second duct: duct of Wirsung (dog smaller, exit major papilla) 80% cats have only one duct thet fuses with CBD and exit at major papilla
75
what are the 3 mechanism to prevent autodigestion of pancreas
1: stored as inactive zymogens 2: storage of inactuve zymogen inside the rough endoplasmic reticulum of pancreas 3: pancreatic secretory trypsin inhibitor
76
what are the 2 molecules that activate the exocrine pancreas secretion?
secretin (bicarbonates) cholacystokinin (digestive enzymes) released from duodenal cells whan ingesta passes or smell, or food in the stom
77
what anesthetic shouldn't be used in dogs with insulinoma or diabetes mellitus?
a2 agonist: in normal animals produce hypoinsulinemia and hyperglicemia. in diseased animals the impact is unknown
78
based on hystopatologic result, wtah technique beetween blunt dissection and suture fracture technique is the best for pancreatic biopsy?
blunt dissection revealed less severe inflammatory reaction. however, no differences detected on clinical signs beetween two groups
79
bacterial culture in pancreatic abscesses in dog and cats
in humans majority of pancreatic abscesses have positive cultures. dogs majority seems to be sterile.
80
serum lipase correlation with pancreatic carcinoma
when 25 times upper normal limit highly suggestive of malignant carinoma rather tha simply pancreatitis
81
insulinomas: benign or malign?
60% are carcinomas, 40% are adenomas. 50 % metastasis at time of diagnosis MST: no met (18 months) met (7-9 months)
82
insulinomas on TC
insulinomas appear uniformly hypervascular and can be differentiated from usually hypovascular exocrine carcinomas. common false positive results for detection of metastases
83
gastrinoma: what are the cells involved in malignant transformation?
somatostatin-secreting delta cells
84
condition usually associated with glucagonoma
rather than the expected hyperglicemia, usually associated with hepatocoutaneous syndrome (superficial necrolytic dermatitis).

TOBIAS VETERINARY SURGERY (32 decks)

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