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SA Sx - GDV 2

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drraythe's version from 2017-09-13 18:43

Pexys

Question Answer
Hiatal hernia vs GDV pexyGDV: pexy on Rt at pyloric antrum
HERNIA: pexy on Lt at fundus
5 different options for gastropexy?(1) Circumcostal gastropexy
(2) Belt loop gastropexy
(3) Incisional gastropexy
(4) Tube gastrostomy
(5) Incorporation abdominal closure
When do you want to consider doing an incorporation abdominal closure? What exactly are you doing?If your PTx is crashing & you need to get out of there. When you are closing the abdominal wall, do a suture through the sera muscularis to prevent rotation
Which is the strongest gastropexy?Circumcostal gastropexy
Which gastropexy is usually used prophylactically?The incisional pexy
**A ___ sided gastropexy reduces ___% risk of recurrence in GDVR sided, 92%
Explain what's going on in a Tube Gastropexy?Use a Foley catheter (mushroom tip ie has an inflatable balloon). Tube will create an adhesion btwn stomach & abdominal wall & communication btwn lumen & outside. Then when tube is removed, it will heal by 2nd intention from inside out.
Where exactly is the tube placed in a tube gastropexy? Where should you make sure is not obstructed?Behind last rib, lateral to nipple line (L of mammaries if female) must not obstruct pylorus!
When do you remove a tube gastropexy?5-7 days
What is an awesome thing you can do w/ a tube gastropexy that you can't do w/ the other ones?Easy access to medicate & feeding, can bypass the esophagus in case of esophageal Sx
How do you suture the tube (in a tube gastropexy) into (___)<-where?Use purse string on the pyloric antrum. Be sure not to occlude the pylorus
What kind of "tube" for a tube gastropexy? If you want it to show up on rads, what can you do?A "mushroom/balloon" tip Foley catheter which is BIG (24, 26, 28, 30) bc large means you can decompress rapidly. Can fill little balloon w/ various materials to see it better on rads
Talk over how to place a gastropexy tubeL to mammary glands if female... push abdominal wall & make incision from protruding wall in...Then from out-in, put cath in (Foley has balloon which can be inflated) at level of antrum, put in purse string suture. Make circle big enough bc will make stab incision in center. once cath inserted, tie purse string & then inflate balloon. 32Fr is the gauging of the tube-bigger number is a bigger tube. Can fill balloon w/ a little contrast material so can radiograph & see where tube is. Lastly 3-4 stitches btwn stomach & abdominal wall to keep things in place
1st the tube in a tube gastropexy is used to _________, then _________1st use big tube bc used to DECOMPRESS (large tube = big number like a 32Fr). Then once tube is in, inflate balloon & then it will be used as an anchor to help antrum adhere to the body wall
What should you keep in mind when placing your purse string in the pyloric antrum?Make sure it is big enough so when you make a stab incision into the antrum, you do not accidentally knick the suture you just put in
How can you inc the adhesiveness of the tube gastropexy even more?Pass the tube 2-3 times through the greater omentum
How can you make sure the tube is anchored to the body wall very well from the outside?Place Chinese finger trap (can then lavage stomach/give meds/whatever)
How do you perform an incisional gastropexy (in short)At level of antrum make incision 4cm long though seromuscularis, let mucosa pop out, then bring that piece of stomach close to abdominal wall, make a same incision on abdominal wall on transversus abdominaus then suture distal wounds together. Suture half incision & then tie, then suture proximal end
Which is the strongest gastropexy?Circumferential/circumcostal
What is the minimum size you can make the incision in the incisional gastropexy?No less than 3-4 cm bc shrink & dont want it to break
If you do an incisional gastropexy, you might have to free up what ligament?Gastrohepatic
Does "scraping" the abdominal wall instead of incising & stitching it over work just as well but is less invasive?NO - it doesnt hold, dont do it
Which gastropexy is the only 1 to enter the lumen?Tube gastropexy
Explain the process of a circumcostal gastropexy (in short)Make tongue shaped flap or H shaped flap on the sera muscularis. Incision over the last rib, place a stay suture on flap & pass it around the rib & suture it back. Problems: time consuming bc you have to be careful to not puncture the diaphragm & cz pneumothorax
Which ribs do you usually use for the circumcostal gastropexy? What precaution should you take?Dissect around 12th-11th ribs near the costo-chondral jnxn (go close to rib - if you go farther, could be in thorax)
Do you place the incision forward, behind, or on top of the rib for the circumcostal pexy?There is a nerve & vessel bundle behind each rib - just use the natural groove on the inner side of each rib to make a cut there & then separate off to both sides to slide flap under rib
Explain a "blunt dissection" circumcostal gastropexyBluntly dissect part of stomach you want to thread detached rib through
How do you do a belt-loop pexy?**Using transversus mm not the rib to loop the belt through
**What is the minimum size you should make the flap in the belt-loop circumcostal pexy? What important thing should you keep in mind?BASE OF FLAP should be 1.5 to 2 times the width of other end - need GOOD BLOOD SUPPLY.
**Why must the base of the flap of the belt loop technique be ___ (size?) why?1.5 times the width of the tip. If not, there is not good blood supply → ischemia → necrosis → dehiscence
Which technique/method of pexy is usually done for the prophylactic pexys?LAPROSCOPIC procedure, which usually uses the incisional technique (prophy procedure usually done during OVH of predisposed breeds)
What is the prog of the PTx if they require partial gastrectomy?35% of PTxs requiring partial gastrectomy die
If you want to possibly try to revive from tissue, how might you do it?Place warm wet cloth on - helps w/ vasodilation
Single or double suture in the pyloric antrum? Body of stomach?Antrum - single bc not enough room. Stomach has lots of room, so double
Describe the closure for a gastrectomyPerforating inverting or nonperforating on top or do simple cont appositional for hemostatic suture pattern then inverting nonperf on top this is a 2 layer closure as opposed in the pyloric antrum theres a lot of room in the stomach to double suture as opposed to pyloric antrum
Explain what gastric Invagination is...what is another name for it? Why would you rather do this than gastrectomy?Aka Gastrorrhaphy. Instead of gastrectomy, you just leave a big chunk of tissue in the stomach lumen that gets debrided by the stomach. Put 2 inverting non-perf suture lines on top of each other. faster than doing the gastrectomy (and dont really go into lumen & less blood loss) [my notes said: instead of removing debilitated tissue, just push it inward & suture on top of it 2 layers of inverting stitches]
Why should you be careful when you are inverting the stomach for a gastrorrhaphy?Careful when invert - usually working towards body of fundus. Careful w/ blood supply from gastric vessels from greater curvature
Describe how you can use staples for a gastrectomyProduces 2 lines of staggered staples, cut over the stapler & remove a piece of tissue that you're taking out, slight eversion of the edges = chance for eventual adhesion
**What is the gastropexy you can do w/o major Sx?Gastropexy via GRID approach (easy & fast)
Describe how you do a gastropexy via GRID approach?Prophylactic method, on the right hand side. Separate the mm fibers along their direction. Incision at the level of pylorus of the sera muscularis w/o entering the lumen. Suture the gastric wall to the transversus abdominus. Good for gastropexy of clients that come for castration. DO THIS 1ST THEN CASTRATION. Put PTx in left lateral recumbency.
With gastropexy, what are the chances of recurrence?LESS THAN 5%!!
Where do you know to make the incision for the gastropexy via GRID approach?Go 1-2 fingers behind the curvature of the last rib w/ a grid approach & make the incision straight there
When do CV problems occur w/ GDV?Post op (remember, MDF from pancreas)
6 important things to do w/ your post op care?Intensive monitoring, fasting / enteral nutrition / bland diet / low residue, ABx, Sx control, cardiologic control (MDF), pain control
Should you be feeding them after GDV Sx?NPO 6-12 hrs but theres a need for *****glutamine to maintain the enterocytes so give AD thats rapidly absorbed & very energetic. Can feed PTx w/ a tube if you did the tube gastrectomy
When do the major post op problems (like dehiscence) happen? When should you do your follow up based on this?3-5 day = dehiscence, contamination, etc so do your rechecks before then like the next day (pts should come back the next day)
How many fluids should you be giving post op & why is it super important to monitor fluids & such?1-2 ml/kg/hr fluids monitor else kidney shutdown due to ups & downs of BP
Should you give ABx? If so, what?DEFINITELY. PTx has been through shock w severe damage to the abdomen. Metronidazole is recommended for the G- bacteria (clostridium live at liver of liver/hilus so kill them off!)
What should you be monitoring the heart for post-op?(Concerned about MDF aka myocardial depressant factor made by the panc when it is in distress) This MDF can cz PVC (premature ventricular contractions) & then fibrillation
How should you educate your clients on how to feed their pet after a GDV?Several meals a day
(3-4 meals a day at 1st & then never less than 2x/day). Special diet (AD is good), high-protein (>30%) diet, particularly of raw meat. if feeding dry food, avoid foods that contain fat as 1 of the 1st 4 ingredients. LOW VOLUME of food. Dry food that inclds rendered meat meal w/ bone product. Reduce carbohydrates (dog biscuits). Adequate amt of fiber, no strong exercise after eating & control water intake after meals
How much does prophylactic Sx reduce mortality?Like 29x
If gastropexy is not performed, ___% of dogs will develop GDV again.75.8
How does the height of the food dish affect the risk of bloat?Raising the food dish more than doubled the risk for bloat
How does the speed at which the dog eat affect bloat?Very fast eaters had a 38% increased risk of bloat
How does age affect the risk of bloat?Risk increased by 20% w/ each yr of age.
How does family Hx affect the risk of bloat?Having a 1st-degree relative (parent, sibling or offspring) that had bloated increased a dog's risk by 63%.
Postop mortality is higher during the 1st ___ days after Sx4
What are 1° sources of postop mortality? 2°?1°: Gastric necrosis (why you dont wanna leave debilitated tissue), rupture & peritonitis
2°: Cardiac arrhythmias (50.6%)
***Describe the Gastropexy for GDV (where w/ what structure)?Gastropexy for GDV is on the RIGHT at the PYLORIC ANTRUM
***Which fits the definition of Gastric Torsion? (a) Rotation of 90°
(b) Rotation of 180°
(c) Rotation of 260°
(d) Rotation of 360°
Rotation of 90° **Gastric Torsion is rotation less than 180° & there is NO COMPLETE OBSTRUCTION**
***What is the term for rotation of the gastro-esophageal jnxn greater than 180° w/ esophageal & pyloric obstruction?Gastric Volvulus
***What 2 things are necessary for GDV to occur?Failure of normal eructation, Acute Pyloric outflow dysfnxn
***When using the belt loop technique in GDV PTx, which is correct? (a) The tip of your flap should be twice as large as the base
(b) The base of your flap should be 1.5-2 times the tip
(c) The base & tip of the flap should be the same size
The base of your flap should be 1.5-2 times the tip
***What percent of PTxs requiring a partial gastrectomy survive?65% survive → **35% of PTxs requiring it Die**
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