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RUSVM Small Animal Surgery 1 > Spleen And Pancreatic Srugery > Flashcards

Spleen And Pancreatic Srugery Flashcards

1
Q

What is the anatomy of the spleen?

A

Within leafy of greater omentum
Attached to stomach —> gastrosplenic ligament

Blood in —> celiac artery —> splenic artery
Blood out —> splenic v. —> gastrosplenic v. —> portal v.

Capsule
Fibromuscular trabeculae

Parachyma: white and red pulp

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2
Q

What are non-pathologic anatomic alterations of the spleen?

A

Siderotic plaques (Ca/iron deposits)

Ectopic splenic tissue
— splenosis - usually from seeding of cells after sx/trauma (usually in omentum)
— accessory spleen - incidental congenital issue

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3
Q

What are the functions of the spleen?

A

RBC storage and maturation

Senescent/sick RBC removal
Hematopoiesis
Immune fun

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4
Q

What pathology can lead to diffuse splenomegaly?

A

Drug induced - thiopental or acepromazine

Congestion (torsion)
Infiltrative diseases (LSA/MCT)
Immune-mediated disease (opsonizing bacteria)

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5
Q

What pathology causes a mass in the spleen

A 
Neoplasia 
Hematoma 
Nodular hyperplasia/ EMH 
Trauma —> splenosis 
Abscess
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6
Q

Splenic torsion most commonly is associated with GDV, but can be an isolated event. What usually is the cause of this torsion when isolated?

A

Stretch or congenital absence of gastrosplenic ligament

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7
Q

Breeds predisposed to splenic torsion?

A

Great Dane
Greater Swiss mountain dog
German shepherd
English bulldog

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8
Q

What are acute clinical signs of splenic torsion?

A 
Acute abdomen - similar to GDV or because of GDV 
—acute abdominal pain/shock 
—abdominal distention 
—cardiovascular collapse 
—dysrythmia 
—DIC
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9
Q

What are chronic signs of splenic torsion?

A 
Vague/intermittent signs for up to 2weeks 
—vomiting/diarrhea 
—weakness/depression 
—anemia 
—hematuria/hemoglobinuria 
—PU/PD
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10
Q

How do you diagnose splenic torsion?

A

Radiographs

  • mid abdominal mass
  • abdominal effusion
  • gas bubbles in spleen
  • C shaped spleen

U/S

  • mottled/diffuse hypoechonic areas
  • intraluminial echogenic densities in veins
  • now flow in splenic vessels (Doppler)

CT scan

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11
Q

What is the treatment for splenic torsion?

A

Pre op stabilization

  • fluids
  • transfusions
  • antibiotics

Exploratory laparotomy
-splenectomy

Gastropexy
- at risk breed for GDV or to address GDV

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12
Q

T/F: you should derotate the spleen prior to splenectomy

A

False

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13
Q

What are the risk factors associated with death from splenic torsion?

A

Septic peritonitis at initial examination
Intraoperative hemorrhage
PO development of respiratory distress

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14
Q

T/F: neoplasia can cause splenic torsion

A

False

Not a cause

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15
Q

If you have splenic infarction, should immediately do splenectomy surgery?

A

No

Think of other problems associated with thrombosis or hyperocagulable states

  • renal dz
  • hyperadrenocorticisom
  • neoplasia
  • DIC
  • heart disease

Prior splenic torsion —> devascularized area may turn into mass-effect (hematoma)

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16
Q

What are caudses of diffused splenic hyperplasia

A

Immune simulation (eg rickettsial infection)

Splenic hyperactivity (IMHA - removing abnormal cells)

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17
Q

What are causes of nodular splenic hyperplasia?

A

Sites of extramedullary hematopoiesis — can be single or multiple SIBCAPUSALAR nodules

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18
Q

T/F: FNA is a poor method for diagnosing splenic hyperplasia

A

False

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19
Q

How would you manage rupture of the spleen from blunt force trauma?

A

Conservative management is preferred — compression bandage and supportive care

Splenectomy — in ALL at risk breeds for splenic dz (labs/Golden’s/ GSD)

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20
Q

Top DDX for splenic neoplasia in dog?

A

Hemangiosarcoma

Sarcoma

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21
Q

Top DDX for spenic neoplasia in cats?

A

Mast cell tumor

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22
Q

What is the rule of 2/3rds for splenic neoplasia?

A

2/3 of dogs with splenic mass will have a malignancy

2/3 of those dogs with malignancies will be hemangiosarcoma (HSA)

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23
Q

What are risk factors for HSA?

A

Older
Large dog > 21kg
Breed - GSD, labs, Golden’s, poodles
Presence of hemoperitonum —> chance of malignancy > 80%

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24
Q

How does mass size correlate to malignant vs benign splenic neoplasia??

A

Dogs with benign -> higher mean mass to splenic volume

Smaller masses —> more likely to be malignant

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25
Q

What is the prognosis for HSA?? KNOW THIS

A

Poor

Surgery alone: 1-3months survival

Surgery + chem (doxorubicin): 5-6 months (only 10% survive to a year)

Surgery + chemo +immunotherapy:
—> stage I non ruptured spleen - 425days
—> stage II no benefit

Issue is that nearly ALL cases have microscopic mets at time of diagnosis

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26
Q

What are Dr Cavagnah’s recommendation for surgery on HSA?

A

Careful staging pre op
INFORM client of survival stats

Do not feel good about surgery if…

  • obvious grossly visible mets present pre-op
  • very sick dog (coagulothatic/ those needing high volume transfusion)
  • owner is not informed
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27
Q

What are some alternative therapies to surgery and chemo for HSA?

A

C. Versicolor mushroom (turkey tail) —> contains polysaccharopepide causing cell cycle arrest and induce apoptosisi

eBAT= bispecific urokinase angiotoxin designed to target EGFR (HSA has mutation in EGFR that triggers continuous growth) - 6month survival

28
Q

What are the two possible techniques for splenectomy?

A

Ligation of individual hilar vessels

Ligation of the splenic and short gastric aa. (Decreased surgical time but must not compromise blood flow to greater curvature of the stomach )

29
Q

What is the preferred technique for splenectomy if there is anatomic distortion of vascular d/t adhesions or size of mass?/

A

Hilar dissection

30
Q

What are the advantages and disadvantages of hemostatic clips for splenectomy?

A

Advantage — faster and easier than hand sewn

Disadvantages — clip instability, use limited to vessels <4mm diameter and implantation of non-absorbable materials

31
Q

What type of stapler is classically used for splenectomy?

A

Ligate divide stapler (LDS)

Staples on either side of blood vessel and then clips between
Size limited, not generally able to use in large breed dogs

32
Q

What is the Ligasure system?

A

Electrothermal bipolar system

Handles vessels up to 7mm with minimal thermal damage to surrounding tissue

Local hemostasis by vessel compression and obliteration
Safe to use in splenectomy with minimal complications

33
Q

What are indications for partial splenectomy?

A

Trauma
Focal abscess
Partial infarction

remove whole spleen in at risk breeds

34
Q

What techniques can be used for partial splenectomy?

A

Cross claps — cut inbetween — oversew capsule

Thoracoabdominal stapler (fast but expensive)

35
Q

Possible complications to splenectomy?

A

Hemorrhage — most common

Pancreatitis/necrosis
Gastric wall compromise (iatrogenic :()

Subclinical hemoparasite infections — Bartonella

Portal vein thrombosis

Arrhythmias -2x increased risk of death if present

36
Q

Arrhythmias are common post op from splenectomy. How should this be monitored?

A

Holter monitor

37
Q

Why do we see arrhythmias with splenectomy?

A

Compromised venous return to the heart caused by intra-abdominal hemorrhage and compression of the caudal vena cava

Typically ventricular

38
Q

What is the anatomy of the pancreas?

A

Right (along duodenum) and left limbs (in greater omentum) with central body

Left limb - brach of splenic a.
Right limb- cadual pancreaticoduodenal a. —> branch of cranial mesenteric a.

39
Q

How does the pancreatic duct system differ between cats and dogs?

A

Dogs and cats: Pancreatic duct (drains R lobe) enters duodenum and major duodenal papilla

Dog only: accessory PD (drains left lobe) —> into duodenum at minor duodenal papilla

40
Q

What cell types make up the endocrine pancreas?

A

A - glucagon
B - insulin
D- somatostatin
F (or P) - pancreatic polypeptide

41
Q

What are the diseases of the pancrease?

A

Pancreatitis — very common but not a surgical disease

Pancreatic pseudocyst

Pancreatic abscess

Exocrine pancreatic neoplasia

Endocrine pancreatic neoplasia — usually a result of excess or deficiency in production of one of the hormones

42
Q

Techniques that can be used to obtain a biopsy from the pancreas?

A

Laparoscopic

Guillotine

Partial pancrease Tony

Total pancreatectomy - rarely performed (high morbidity and mortality)

43
Q

When is guillotine technique used for pancreatic biopsy/

A

Diffuse disease

Individual lobule dissection for small central body lesion

44
Q

Indications for a partial pancreatectomy? How is this done?

A

Tumor removal

Incise omentum and capsule

Dissect between lobules to isolate vessel and ducts in portion of gland to be removed

Hemoclips or bipolar capture for ligation (BEST)

If remaining ducts are patent - 80% of pancreas can be removed

45
Q

Complications to partial pancreatectomy?

A

Pancreatitis (most common)

Exocrine pancreatic insufficiency ((EPI) - if pancreatic drainage is completely obstructed

Endocrine pancreatic insufficiency

Devitalization of duodenum —> caudal pancreaticoduodenal a. Raised from the cranial mesenteric a. —> vessel also supplies branches of duodenum —> both closely associated with right lobe of pancreas —> if damaged, then duodenum can be compromised

46
Q

What is the preferred method or dissection/resection for pancreas with the lowest incidence of pancreatitis ?

A

Liagsure — bipolar sealing device

47
Q

Indications for total pancreatectomy?

A

Acute trauma
Severe, chronic fibrosis
Extensive neoplasia

48
Q

Total pancreatectomy is usually done in conjunction with what procedure ?

A

Resection and anastomosis of proximal duodenum, ligation of common bile duct and cholecystojejunostomy (Bilroth II)

49
Q

What is a pancreatic pseudocyst?

A

Collections of pancreatic secretions and cellular debris w/in fibrous sac or wall of granulation tissue

Lacks epithelial wall = not true cyst (fluid not from lining but from damaged pancreatic duct)

50
Q

Signalment and presentation associated with pancreatic pseudocyst

A

Middle aged to older dogs mostly

Usually asymptomatic
Vague signs of abdominal discomfort, anorexia and vomiting

51
Q

What diagnostics can you do for pancreatic pseudocyst?

A

US - test of choice

Percutaneous FNA
- diagnostic and therapeutic

52
Q

What is the treatment for pancreatic pseudocyst ?

A

Percutaneous aspiration
-1st line tx especially if no clinical signs

If clinically ill

  • resection
  • debridement, drain, ometalize (rx of choice for “cure”)
53
Q

T/F: most pancreatic abscesses are sterile. - ie no bacteria

A

True

Caused by enzyme except into surrounding tissue causing inflammation and fibrous tissue formation — secondary to pancreatitis

54
Q

How will you diagnose pancreatic abscess?

A

Radiographs - increased soft tissue density in right cranial or central cranial abdomen (ascities/peritonitis)

US - mass lesions (focal hypoechoic areas) —> can do guided FNA

Lab data is variable

  • leukocytosis, neutrophilia
  • electrolyte abnormalities if vomiting
  • amylase and lipase (little value)
  • hyperbilirubinemia elevated LEZ to to EHBO
55
Q

How are pancreatic abscesses managed?

A

Resect - often very challenging as disease is NOT localized

Debridement, drain, and omentalize (better outcome then open drainage)

PO enteral nutrition plan = NEED post gastric feeding

56
Q

What is the prognosis of pancreatic abscess?

A

Guarded in dogs
High perioperative mortality
—> septic
—> generalized peritonitis

Long and intensive ICU

57
Q

Types of pancreatic neoplasia?

A

Exocrine pancreatic adenocarcinoma

Insulinoma - adenocarcinoma of Bcells

Gastrinoma -adenocarcinoma of non B-islet cells

58
Q

T/F: Exocrine adenocarcinoma are malignant and locally invasive

A

True

59
Q

Clinical signs associated with pancreatic neoplasia?

A

Vomiting
Abdominal pain
Weight loss

Signs of extrahepatic biliary tact obstruction (EHBO)

60
Q

Treatment and prognosis of exocrine pancreatic adenocarcinoma ?

A

Surgical resection if possible (usually diffuse disease in cats)

Poor prog

  • 3month survival in dog
  • <7 days in cats
61
Q

T/F: insulinoma is usually malignant

A

True 90% of the time

Rare in cats and dogs

62
Q

Clinical signs of insulinoma?

A

Weakness, seizure

Polyneuropathy — chronic hypoglycemia

63
Q

What is whipples triad?

A

Clinical signs associated with hypoglycemia

Fasting blood glucose concentration of 40mg/dL or lower

Relief of neuro signs with feeding/glucose admin

64
Q

What is diagnostic for whipples triad??

A

Fasting insulin -glucose ratio diagnostic for condition

— insulin HIGH despite hypoglycemia

65
Q

What is the medical management of insulinoma ?

A

Glucocorticoids therapy
Oral hyperglycemic agents
—diazoxide (inhibit pancreatic insulin secretion and glucose uptake by tissue)

If severe = ICU and dextrose supplementation in fluid

66
Q

Surgical management for insulinoma?

A

Partial pancreatectomy — gold standard

Gets complicated when no nodules seen at surgery or with perioperative imaging —> contrast CT scan (best chance to ID tumor)

50% mets — often recurrent hypoglycemic d/t mets

RUSVM Small Animal Surgery 1 (39 decks)

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