Surgery Of The Stomach

Question 1

What artery supplies the greater curvature of the stomach?

Answer 1

Left gastroepiloic a (branch of the splenic artery —> celiac artery)

Right gastroepiloic a (branch of the gastroduodenal —> hepatic artery—>celiac artery)

Question 2

What are the layers of the stomach. Which of these is the holding layer?

Answer 2

Serosa
Muscular
Submusoca holding layer
Mucosa (glandular)

Question 3

What are the healing characteristics of the stomach?

Answer 3

Standard phases of wound healing

Short duration of healing

• > extensive and redundant blood supply
• > reduced bacterial numbers
• > rapidly regenerating epithelium
• > omentum

Smooth muscle cells contribute to collagen production

Question 4

How should you prepare a patient for a gastric surgery?

Answer 4

Correct electrolyte imbalances

Correct hydration

Fast 8-12hrs

H2 antagonists
PPI -omeprazole

Question 5

What is the approach used in gastric surgery?

Answer 5

Dorsal recumbency

Ventral midline celiotomy (xyphoid to pubis)

Question 6

When doing an abdominal exploratory, when you enter the abdomen through a ventral midline celiotomy, you encounter the _____________ which can be ligated and resected if needed for visualization

Answer 6

Falciform ligament

Question 7

What instruments can help hold open the abdomen for visualization?

Answer 7

Balfour retractors

Self retaining/ non traumatic retractors

Question 8

How is the stomach traditionally closed?

Answer 8

Double inverting

• cushing pattern: serosa, muscularis, and submucosa
• lembert pattern: serosa and muscularis

Alternately can do a simple continuous to decrease bleeding into lumen followed by cushing or Lembert

Question 9

When is a single layer gastric closure indicated?

Answer 9

Pyloric outflow tract 
Reduced gastric volume 
Thickened gastric wall 
—> simple interrupted 
—> simple continuous

Question 10

What suture material is used in gastric closure?

Answer 10

Material resistant to degradation for 14 days (time needed to regain gastric wall strength)

Monofilament, absorbable

Polydioxanone
Polyglyconate
Poliglecaperone 25

OR
Stables

Question 11

What subjective criteria can be used to determine gastric viability?

Answer 11

Gastric wall thickness “Slip”
Serosal surface colour
Serosal capillary perfusion
Peristalsis

Non viable - thinning of wall, grey- green- black colour

Question 12

What are the indications for gastric biopsy? How is it performed>?

Answer 12

Gross disease
Clinical signs of upper GI disease

Mucosal - endoscopy
Submucosal - surgical

Question 13

What is the most common indication for gastrotomy?

Answer 13

Gastric foreign body

Dog>cat

Question 14

What is the signalment for gastric foreign body?

Answer 14

Younger
Previous history of FB ingestion

Conditions that predispose to PICA
—> iron deficiency
—> hepatic encephalopathy
—> pancreatic exocrine insufficiency

Visualized FB ingestion

Question 15

Clinical signs of gastric foreign body?

Answer 15

Vomiting - not always or can be intermittent
—> outflow obstruction
—>gastric distention
—> mucosal irritation

Lethargy
Abdominal pin
Anorexia

Question 16

What laboratory findings can be associated with gastric foreign body?

Answer 16

Hemoconcentration (dehydration) 
Anemia 
Leukocytosis 
Pre-renal azotemia 
Metabolic alkalosis vs acidosis 
Hypokalemia, hypochloremia

Question 17

If you suspect a gastric foreign body, what diagnositics would you do?

Answer 17

Rads
US
Contrast studies
Endoscopy

Question 18

How can you medically manage gastric foreign bodies?

Answer 18

Fluid therapy - rehydrate and correct electrolyte imbalances

Monitor -serial radiographs

Induction of vomiting - apomorphine in dogs and xylazine in cats

Question 19

How do you perform a gastrotomy?

Answer 19

Isolate stomach, secure with stay sutures

Incision into hypovascular area on ventral aspect (between greater and lesser curvature)

Stab incision into gastric lumen and enlarged with Metzenbaum scissors

Suction
Removal of FB

Double closure
Lavage with sterile saline (warm) -300ml/kg
Change gloves before closing abdomen

Question 20

How will manage your patients post op gastrotomy?

Answer 20

Fluid therapy

Food and water within 12hours —> protein helps healing

If vomiting — ID cause and treat (prokinentics and antiemetic)

H2 blockers

Question 21

What is congenital pyloric stenosis? What breeds is it usually seen in?

Answer 21

Hypertrophy of the circular muscles of the pyloris

Brachiochephalic (boxers and bulldogs)
Siamese cats

Question 22

What is the possible etiology for congenital pyloric stenosis ?

Answer 22

Excess gastric production (trophic for gastric smooth muscle and mucosa)

Clincial signs at weaning

Question 23

Clinical signs of congenital pyloric stenosis ?

Answer 23

Intermittent vomiting

• chronic
• horse after feeding
• partially digested
• does fine with liquid

Normal to decreased body condition

Question 24

What diagnostics can you do for congenital pyloric stenosis?

Answer 24

Radiographs

• gastric distention
• delayed gastric emptying —> still has contents after fast of >8hrs

Contrast rads — “apple core”

Ultrasound 
Endoscopy (cant see muscle)

Question 25

What are the methods of managing congenital pyloric stenosis?

Answer 25

Pyloromyotomy AKA Fredet-Ramstedt procedure : 1-2cm incision though the serosa and muscularis layers of long axis of pylorus Transverse pyloroplasty AKA Heineken-Mikuicz procedure: 3-5cm full thickness incision over pylorus, biopsy, then orient incision transverse and Close appositional

Question 26

What is the prognosis for congenital pyloric stenosis?

Answer 26

Outcome after surgical correction of benign conditions of pylorus

Question 27

What is chronic hypertrophic pyloric gastropathy? What is the usual signalment ?

Answer 27

Acquired mucosal and/or muscular hypertrophy Small dogs - shih-tzu, Lhasa apso, Maltese Male>female Middle aged to older

Question 28

What is the etiology of chronic hypertrophic pyloric gastropathy (CHPG)?

Answer 28

Increased gastrin secretion Acute stress Inflammatory dz Trauma

Question 29

How can you differentiate congenital pyloric stenosis from chronic hypertrophic pyloric gastropathy?

Answer 29

Similar clinical signs Differentiate by signalment Congenital — young brachycephalic breed, beginning after weaning Chronic — middle aged small dogs

Question 30

What would you see on rads of a dog with CHPG?

Answer 30

Gastric distention | Delayed gastric emptying

Question 31

What diagnostic method can you evaluate muscle wall thickness of the pylorus?

Answer 31

Ultrasound

Question 32

How is CHPG graded?

Answer 32

Grade 1 - muscular hypertrophy ONLY Grade 2- mucosal hyperplasia with glandular cystic dilation ONY Grade 3- muscular hypertrophy AND mucosal hyperplasia

Question 33

How is CHPG managed?

Answer 33

Heineke-Mikulicz pyloroplasty Y-U pyloroplasty Pylorectomy with gastroduodenostomy (Bilroth I)

Question 34

What procedure for CHPG involved a single pedicle advancement from the antrum across the pylorus?

Answer 34

Y-U advancement pyloroplasty

Question 35

What are the advantages and disadvantages of a Y-U advancement pyloroplasty?

Answer 35

Advantages - increase diameter of pylorus - access to excise hypertrophied mucosa Disadvantage -potential necrosis of flap tip

Question 36

What is a Bilroth 1 ?

Answer 36

Pylorectomy- gastroduodenostomy Removal of the pylorus and sphincter and stomach attaches to the duodenum

Question 37

What is the prognosis for CHPG?

Answer 37

Good to excellent Poor outcome associated with technical failures Selection of most appropriate technique important Ability to recognize and treat underlying cause

Question 38

What are indications for gastrectomy?

Answer 38

Neoplasia - location determines type of resection Ulceration Significant pyloric outflow obstruction

Question 39

What is the best method for removal of a slow growing leiomyoma in the cardia?

Answer 39

Submucosal resection

Question 40

What type of surgery is indicted when there is a lesion with extensive ulceration in the fundus of the stomach

Answer 40

Partial gastrectomy —> GDV often clues tear and revitalization of the greater curvature of the stomach.. remove this section and close

Question 41

What is a Bilroth II?

Answer 41

Partial gastrectomy followed by gastroenterostomy

Question 42

When is a Bilroth II indicated?

Answer 42

Extensive gastric resection required making gastroduodenostomy impossible

Question 43

Complications to a Bilroth II?

Answer 43

Alkaline gastritis - bile and pancreatic secretion flow into stomach Blind loop syndrome — gastric contents move orally and putrefy Marginal ulceration — ulceration of jejunal mucosa (not used to seeing acid contents)

Question 44

What is the pathophysiology of phycomycosis?

Answer 44

Aquatic oomycete (pythium sp) —> ingestion —> severe inflammatory and infiltrative lesion —> induce intense fibrotic reaction —> transmural thickening (gastric outflow area most commonly affected)

Question 45

Clinical signs of phycomycosis ?

Answer 45

``` Vomiting Inappetence Weight loss Diarrhea Palpable mass ```

Question 46

How can you diagnose phycomycosis ?

Answer 46

Endoscopy - difficult to find organism (submucosal and muscularis affected) Histopath - eosinophilic phygranulomatous inflammation (deep tissue samples of fibrotic material) ELISA for P. Insidiosum AB

Question 47

Treatment for phycomycosis ?

Answer 47

Wide surgical excision Medical therapy ineffective - antifungals Poor prognosis