Veterinary gastrointestinal surgery

• Veterinary Gastrointestinal surgeryVeterinary Gastrointestinal surgery

• Presented byPresented by• Dr. Rekha PathakDr. Rekha Pathak• Senior scientist , IVRISenior scientist , IVRI

The photographs have been collected from different sources i.e. Internet,

text books etc

Gastric ulcer / Abomasal ulcer: Gastric ulcer / Abomasal ulcer: • assoc. with chronic assoc. with chronic

renal / hepaticrenal / hepatic

• mast cell neoplasiamast cell neoplasia

• gastrin producing gastrin producing neoplasianeoplasia

• gastric neoplasiagastric neoplasia

• coagulation disordercoagulation disorder

• FB / gun shot woundFB / gun shot wound

• ICHICH

• UremiaUremia

• PoisonPoison

• SnakebiteSnakebite

• Primary ulcers are Primary ulcers are less commonless common

• Ulcers secondary – Ulcers secondary – commoncommon

• Aspirin: Aspirin: experimentally to experimentally to produce ulcersproduce ulcers

• Pathophysiology: Pathophysiology:

• Gastric/ Gastric/ duodenal duodenal mucosa/ covered mucosa/ covered with mucus layer with mucus layer (sulfated mucin (sulfated mucin bound to epi. bound to epi. cells)cells)

• Offers protection Offers protection – against – – against – corrosive / corrosive / digestive effects digestive effects of gastric acid of gastric acid and pepsin (auto and pepsin (auto digestion and digestion and ulceration)ulceration)

• Reduced mucosal Reduced mucosal bl. Flow- local bl. Flow- local ischemia – sepsis/ ischemia – sepsis/ hemorrhagic hemorrhagic shock – sudden shock – sudden expulsion of expulsion of apical mucin – apical mucin – circumscribed circumscribed popn of cellspopn of cells

• Reflux of bile salts Reflux of bile salts from duodenum to from duodenum to stomach – bile salts stomach – bile salts – more destructive – more destructive than pancreatic than pancreatic juices- act as juices- act as detergents that detergents that solubilize lipid - cell solubilize lipid - cell memb and inhibit memb and inhibit the ion transport the ion transport sys.sys.

• bile content – greatest – pyloric bile content – greatest – pyloric antrum – ulcer region of stomachantrum – ulcer region of stomach

• hyper secretion of HCL hyper secretion of HCL – gastrinoma ie non beta islets cell gastrinoma ie non beta islets cell

tumour of pancreas and tumour of pancreas and hypergastinemiahypergastinemia

– in renal failure (gastrin is removed by in renal failure (gastrin is removed by kidneys)kidneys)

– increased histamine: mastocytoma and increased histamine: mastocytoma and Endotoxemia and hemorrhagic shockEndotoxemia and hemorrhagic shock

– NSAIDS- reduced secretion of mucusNSAIDS- reduced secretion of mucus• alters the biochemical composition of mucinalters the biochemical composition of mucin

• ingestion of chemicals(arsenic ,cresote)ingestion of chemicals(arsenic ,cresote)• Signs: vomiting (not immediately after Signs: vomiting (not immediately after

ingestion)ingestion)• eating – gastric pain- relieved by vomitingeating – gastric pain- relieved by vomiting• Hemet emesis and melenaHemet emesis and melena• slow bleeding: coffee colored bloodslow bleeding: coffee colored blood• sudden - massive and semi clotted bloodsudden - massive and semi clotted blood

• generalized peritonitis: gastric perforation generalized peritonitis: gastric perforation (mostly doesn’t occur due to effective (mostly doesn’t occur due to effective sealing with omentum)sealing with omentum)

• wt. loss – hepatic/ neoplasticwt. loss – hepatic/ neoplastic

• additionally in calves : due to bleeding additionally in calves : due to bleeding ulcers – recumbent suddenly – cold ulcers – recumbent suddenly – cold extremity- subnormal temp. tachycardia extremity- subnormal temp. tachycardia and dehydration- hypovolemic shock and and dehydration- hypovolemic shock and death 24 hrsdeath 24 hrs

• Abomasal ulcers Abomasal ulcers : : suckling calves and suckling calves and adult cattle adult cattle (buffaloes)(buffaloes)

• adult: 1st few wks of adult: 1st few wks of partu.(stress and partu.(stress and lactation)lactation)

• Stress related Stress related (summer months (summer months independent of independent of partu.)partu.)

• Calves: dietary Calves: dietary transition from low transition from low DM to high DMDM to high DM

• TrichobezoarsTrichobezoars

• Asso. With Asso. With impaction alsoimpaction also

• Type I erosion and Type I erosion and ulcers with slight ulcers with slight hemorrhagehemorrhage

• Type II bleeding Type II bleeding ulcersulcers

• Type III perforation Type III perforation with acute with acute circumscribed circumscribed peritonitisperitonitis

• Type IV perforation Type IV perforation with diffuse with diffuse peritonitisperitonitis

• Diagnosis: Diagnosis:

• TRP ; pain on left TRP ; pain on left of xiphoidof xiphoid

• Abomasal ulcer: Abomasal ulcer: pain on rt. sidepain on rt. side

• RG: double RG: double contrast: create contrast: create pneumoperitoneupneumoperitoneum and give m and give barium mealbarium meal

• Barium: ulcers Barium: ulcers appear as appear as outpouchings from outpouchings from lumen containing lumen containing the contrast the contrast materialmaterial

•Fluoroscopy: helps in variable Fluoroscopy: helps in variable positioning and pin point the sitepositioning and pin point the site

•Endoscopy: Endoscopy: not in not in threatened threatened bleeding cases bleeding cases (allows (allows biopsies)biopsies)

•Exploratory: Exploratory: laparotomylaparotomy if if life life threatening threatening hemorrhagehemorrhage

Treatment Treatment

• Surgical excisionSurgical excision

• Cranial midline incisionCranial midline incision

• Carefully palpate from fundus to Carefully palpate from fundus to pyloruspylorus

• If ulcers then – adhesion, serosal If ulcers then – adhesion, serosal scarring and irregular thickened scarring and irregular thickened areas on gastric wall areas on gastric wall

• Inspect the Inspect the pancreas- pancreas- gastrinoma- p. gastrinoma- p. nodules nodules

• If gastrinoma- en If gastrinoma- en block resection block resection of a lobe or of a lobe or complete complete pancreas(90% pancreas(90% removal – no removal – no endocrinal endocrinal insufficiency)insufficiency)

• If no ulcers foundIf no ulcers found

• Open stomach- find the bleeding site- Open stomach- find the bleeding site- also on pyloric antrum(equidistant also on pyloric antrum(equidistant from lesser / greater curvature)from lesser / greater curvature)

• Extend to duodenum if necessaryExtend to duodenum if necessary

• Small ulcers : Small ulcers : elliptical incision- elliptical incision- mucosa closed – mucosa closed – simple continuous simple continuous – 3/0 or 4/0 – 3/0 or 4/0 absorbable absorbable chromic and chromic and interrupted interrupted Lambert on serosa Lambert on serosa and muscularis and muscularis

• Multiple ulcers on Multiple ulcers on pyloric part – pyloric part – bilroth I bilroth I gastrectomy gastrectomy techniquetechnique

• Bilroth technique I : Bilroth technique I : ligate the rt. Gastric ligate the rt. Gastric artery near pylorus artery near pylorus on the lesser on the lesser curvaturecurvature

• Rt. Gastroepiploic Rt. Gastroepiploic vessels ligated vessels ligated

• Take care not to Take care not to injure the pancreasinjure the pancreas

• Pyloric and gastric Pyloric and gastric branches supplying branches supplying the area to be the area to be resected are ligated resected are ligated

• 2 st. intestinal 2 st. intestinal clamps are placed clamps are placed across the pyloric across the pyloric antrumantrum

• another 2 are another 2 are placed distal to placed distal to the pylorus and the pylorus and avoid the avoid the common bile common bile duct.duct.

• Excise the pyloric Excise the pyloric sphincter and sphincter and canal canal

• Gastric mucosa Gastric mucosa is apposed with is apposed with 3-0 synthetic 3-0 synthetic absorbable absorbable suture in an suture in an Cushing pattern Cushing pattern starting from the starting from the lesser curvature lesser curvature and continuing and continuing towards the towards the greater greater curvaturecurvature

• Equal in size to the Equal in size to the duodenal diaduodenal dia

• Apposed – 3-0 – Apposed – 3-0 – synthetic synthetic absorbable, absorbable, polypropylene, or polypropylene, or nylon – lamberts nylon – lamberts patternpattern

• Duodenum is then Duodenum is then anastamosed with anastamosed with stomachstomach

Gastric acute dilatation and Gastric acute dilatation and torsiontorsion

• Gastric dilatation- Gastric dilatation- volvulus (GDV)volvulus (GDV)

• Only dilation Only dilation common in puppies common in puppies

• Overeating/ Overeating/ parasitismparasitism

• Larger and giant Larger and giant breeds – deep breeds – deep chestedchested

• Overeating – Overeating – relieved by relieved by induced induced vomiting or vomiting or passing stomach passing stomach tubetube

• Parasitism Parasitism

• Pica Pica

• Postprandial Postprandial activity activity

• Delayed gastric Delayed gastric emptying- emptying- pyloromyotomypyloromyotomy

• PathophysiologyPathophysiology

• Rotation after dilationRotation after dilation

• Aerophagia – source of Aerophagia – source of intragastric gasintragastric gas

• Distended stomach (gas Distended stomach (gas + fluid) – more prone to + fluid) – more prone to rotationrotation

• Prevents eructation – Prevents eructation – esophagus and emptying esophagus and emptying from duodenumfrom duodenum

• Distension increasesDistension increases

•Presses the caudal vena/ portal Presses the caudal vena/ portal vein – reduced venous return – vein – reduced venous return – red. CO. – red. Tissue perfusion red. CO. – red. Tissue perfusion and shockand shock

•Ischemic bowel – release toxins- Ischemic bowel – release toxins- endotoxemia-shock and endotoxemia-shock and hypotensionhypotension

•Red. Ventilation- pressure on Red. Ventilation- pressure on diaphragmdiaphragm

•Acid base and electrolyte Acid base and electrolyte disturbancedisturbance

•Myocardial ischemiaMyocardial ischemia

•Rotation of stomach – Rotation of stomach – strangulation of gastric vessels- strangulation of gastric vessels- edema and anoxia –gastric wall edema and anoxia –gastric wall ulceration and necrosisulceration and necrosis

• Clinical signsClinical signs• Acute onset of cranial abd. DistentionAcute onset of cranial abd. Distention• VomitingVomiting• Profuse salivation-painProfuse salivation-pain• Prolonged CRT, Pallor, weak pulseProlonged CRT, Pallor, weak pulse• Shock (pooling of blood in spleen due to Shock (pooling of blood in spleen due to

rotation of splenic vessels, hypovolemia rotation of splenic vessels, hypovolemia and hypotension)and hypotension)

• DyspneaDyspnea

• RG signs: differentiate simple gastric RG signs: differentiate simple gastric distension from GDVdistension from GDV

• Gas filled stomach- 50-75% - splenic Gas filled stomach- 50-75% - splenic position is normal if no volvulus position is normal if no volvulus

• In GDV –pylorus is located In GDV –pylorus is located cranial/dorsal – fundus cranial/dorsal – fundus

• Position of spleen may not be normal Position of spleen may not be normal

• A tissue density A tissue density line dividing the line dividing the gas filled stomach gas filled stomach into compartmentsinto compartments

• VD - pylorus is VD - pylorus is near or near to the near or near to the left of the midlineleft of the midline

• Gastric perforation- Gastric perforation- pneumoperitoneupneumoperitoneumm

• Clockwise 270 Clockwise 270

• Anticlockwise 90Anticlockwise 90

• Preoperative Preoperative carecare

• Gastric Gastric decompressiondecompression

• Needle Needle trocarization 18 trocarization 18 G needleG needle

• Thrust on rt. Or Thrust on rt. Or left wall – point left wall – point of greatest of greatest distensiondistension

• 2-3 needles – 2-3 needles – relieves gas relieves gas component of component of distensiondistension

• Alternatively – if Alternatively – if not effectively not effectively reduced – stomachreduced – stomach

• Pass the s.tube Pass the s.tube through mouth through mouth gag- resistance is gag- resistance is encountered in encountered in gastro esophageal gastro esophageal junction –rotate junction –rotate and advanceand advance

• Removal of Removal of intragastric gas – intragastric gas – trocarization- trocarization- corrects the gastro corrects the gastro esophageal angle-esophageal angle-allows passage of allows passage of S. tubeS. tube

• Passage of st Passage of st doesn’t mean doesn’t mean absence of g. absence of g. rotationrotation

• Withdraw the tube Withdraw the tube after after decompressiondecompression

• Sometimes for Sometimes for decompression – decompression – temporary Gastrotomy temporary Gastrotomy is constructedis constructed

• Close the Gastrotomy Close the Gastrotomy wound and proceed for wound and proceed for surgical correction of surgical correction of rotation rotation (Decompression (Decompression doesn’t always result in doesn’t always result in normal gastric position)normal gastric position)

• Shock therapyShock therapy

• Surgical correction of volvulus Surgical correction of volvulus

• If surgery is delayed – gastric necrosis If surgery is delayed – gastric necrosis worsens worsens

• Reposition the stomach by derotating itReposition the stomach by derotating it

• Avoid injury to splenic v. (digital palpation Avoid injury to splenic v. (digital palpation of esophagus reveals the direction of of esophagus reveals the direction of rotationrotation

• Pylorus is a good / useful landmark – firm Pylorus is a good / useful landmark – firm consistency)consistency)

• See the viability of gastric tissue – See the viability of gastric tissue – necrosed and non-viable – esp. the necrosed and non-viable – esp. the greater curvature is damaged greater curvature is damaged

• Serosal color, Serosal color, thickness of wall thickness of wall and vascular and vascular patencypatency

• Partial gastrectomyPartial gastrectomy• Hemoperitoneum - Hemoperitoneum -

centesis of centesis of abdominal cavity- abdominal cavity- splenic torsion and splenic torsion and gastric torsiongastric torsion

• Blue-black Blue-black areas/diffuse areas/diffuse petechial petechial /ecchymotic /ecchymotic stomach- stomach- gastrectomy not gastrectomy not indicated – becomes indicated – becomes normal after normal after decompressiondecompression

• Spleenectomy – Spleenectomy – damageddamaged

• Gastropexy- red. Rate Gastropexy- red. Rate of GDVof GDV

• Pyloric antral region is Pyloric antral region is fixed to the adjacent fixed to the adjacent rt. abdominal wallrt. abdominal wall

• Gastropexy is always Gastropexy is always performed on the rt. performed on the rt. Side of the stomach – Side of the stomach – some rotation – still some rotation – still occur- bet.left gastric occur- bet.left gastric wall and left abd.wallwall and left abd.wall

G. neoplasmG. neoplasm

• Avg. age 8 yAvg. age 8 y• Alimentary tract: oral Alimentary tract: oral

cavity – rarely in cavity – rarely in stomachstomach

• Persistent vomiting Persistent vomiting unrelated to eating unrelated to eating

•Within the antrum on the Within the antrum on the lesser curvature lesser curvature

•Metastasis: liver, lungs, spleenMetastasis: liver, lungs, spleen

•Leiomyoma/ Leiomyoma/ rhabdomyosarcoma/polyps rhabdomyosarcoma/polyps (solitary or multiple)(solitary or multiple)

• Polyps – due to Polyps – due to sharp fragment sharp fragment of bones- resting of bones- resting for long in for long in antrum - injure antrum - injure mucosa – mucosa – herniation of sub herniation of sub mucosamucosa

• Clinical signs; Clinical signs; anorexiaanorexia

•Loss of wt. Loss of wt. Obstructing Obstructing gastric out flow gastric out flow

•Normal Normal peristalsis is peristalsis is interfered interfered

•AnemiaAnemia•Abd. PainAbd. Pain

• Emesis unrelated to Emesis unrelated to ingestion of food ingestion of food /water/water

• MelenaMelena• palpationpalpation• Exploratory Exploratory

laparotomylaparotomy

• RG: contrast – RG: contrast – filling defectfilling defect

• Endoscope Endoscope • UltrasonographyUltrasonography• Adenocarcinoma: Adenocarcinoma:

most commonmost common• Sex predilection for Sex predilection for

malesmales• Treatment Treatment • Chemotherapy: Chemotherapy:

not successfulnot successful

• SurgicalSurgical

• Gastrectomy: Partial Gastrectomy: Partial gastrectomy is done gastrectomy is done

• Removal of any portion Removal of any portion of the stomach and up to of the stomach and up to (30-40%) in antrectomy(30-40%) in antrectomy

• Partial gastrectomy – 40-Partial gastrectomy – 40-70% 70%

• Subtotal gastrectomy : Subtotal gastrectomy : 70- 90%70- 90%

• Antrectomy: Antrectomy: reconstruction- reconstruction- gastroduodenostomygastroduodenostomy

(bilroth I ) or (bilroth I ) or gastrojejunostomy(II)gastrojejunostomy(II)

• Two variations of partial Two variations of partial gastrectomy gastrectomy

• A-CA-C : stay sutures are : stay sutures are placed to elevate the placed to elevate the stomach and to minimize stomach and to minimize leakageleakage

• Necrotic tissue is excised Necrotic tissue is excised with a rim of viable tissuewith a rim of viable tissue

• A two layer inverting A two layer inverting closure is usedclosure is used

• D-ID-I : atraumatic forceps : atraumatic forceps are placed across viable are placed across viable tissue and necrotic tissue tissue and necrotic tissue is excised is excised

• The stomach body is The stomach body is subsequently closed subsequently closed with a parker- Kerr line with a parker- Kerr line

• The first inverting The first inverting layer suture is placed layer suture is placed over the clampsover the clamps

• Remove clamps, pull Remove clamps, pull and invert the suture and invert the suture lineline

• Second inverting Second inverting suture rowsuture row

• End to end End to end anastomosis of anastomosis of stomach stomach

• Bilroth II – Bilroth II – performed if more performed if more radical radical gastrectomy is gastrectomy is required, if there required, if there is excessive is excessive duodenal duodenal involvement or involvement or bothboth

BloatBloat

• Bloat : Major problems- GIT – cattle Bloat : Major problems- GIT – cattle and buffaloesand buffaloes

• Higher in buffaloesHigher in buffaloes• Acute/chronicAcute/chronic• Gaseous bloat – free gas - dorsal part Gaseous bloat – free gas - dorsal part

of rumenof rumen• Frothy bloat – gas trapped with Frothy bloat – gas trapped with

ingesta- dispersed throughout the ingesta- dispersed throughout the rumen contentrumen content

• Acute: rapid feeding and sudden diet Acute: rapid feeding and sudden diet change – large ruminantschange – large ruminants

• s. ruminants – large quantities of s. ruminants – large quantities of grain ingestion/cerealsgrain ingestion/cereals

• More pressure on diaphragm – More pressure on diaphragm – hypoventilation and red. Venous hypoventilation and red. Venous return to the heartreturn to the heart

• signs: bulge on Para lumbar fossasigns: bulge on Para lumbar fossa

• Abdominal distensionAbdominal distension

• Cyanotic mmCyanotic mm

• v. serious – lying down – asphyxiated v. serious – lying down – asphyxiated – open mouth- protruded tongue and – open mouth- protruded tongue and tachycardiatachycardia

• Treatment: puncture wall – left side with Treatment: puncture wall – left side with trocar and canulatrocar and canula

• if frothy – antifoaming agents – if frothy – antifoaming agents – turpentine oil (80ml) + mustard oil (500-turpentine oil (80ml) + mustard oil (500-1000 ml)1000 ml)

• antifroth prepn. – bloatosilantifroth prepn. – bloatosil• gives immediate relief to ailing animalgives immediate relief to ailing animal• avoid conc. – 2-3 days and leguminous avoid conc. – 2-3 days and leguminous

fodderfodder

• Resort to rumenotomy / rumenostomyResort to rumenotomy / rumenostomy

• S. animal: IV- RL or oral soda bicarbS. animal: IV- RL or oral soda bicarb

• Chronic bloat: TRP (FBS) – reticuloperitonitis/ Chronic bloat: TRP (FBS) – reticuloperitonitis/ fibrinous pneumonia – pleuritis involving the fibrinous pneumonia – pleuritis involving the vagus nervevagus nerve

• Liver abscess, splenic cyst and abscess, Liver abscess, splenic cyst and abscess, enlarged mediastinal lymph nodes, pyloric enlarged mediastinal lymph nodes, pyloric stenosisstenosis

• Rumen fistulation / rumenotomy can be doneRumen fistulation / rumenotomy can be done

• Rumen fistulation: Rumen fistulation: • Anesthesia and surgical Anesthesia and surgical

prepn.: standing prepn.: standing positionposition

• Sternal recumb. – Sternal recumb. – CamelCamel

• Left Para lumbar fossa Left Para lumbar fossa • Circular area – ventral Circular area – ventral

to transverse process of to transverse process of lumbar vertebrae- lumbar vertebrae- approx 10 cm dia.- approx 10 cm dia.- infiltrated infiltrated

•A circular piece of A circular piece of skin (4cm) – skin (4cm) – removed to removed to expose the expose the underlying underlying abdominal mus.abdominal mus.

•Bluntly dissect Bluntly dissect and expose and expose rumen – grasp – rumen – grasp – pulled in a cone pulled in a cone fashion to the fashion to the skin surfaceskin surface

•Anchor with 4 Anchor with 4 horizontal horizontal mattress mattress suture through suture through rumen and rumen and skinskin

• Remove central Remove central portion of rumenportion of rumen

• Incised edge of Incised edge of rumen is sutured to rumen is sutured to the skin with the skin with simple interrupted simple interrupted and non- and non- absorbable absorbable

• Alternately – all the Alternately – all the layers – apply layers – apply interrupted interrupted mattress sutures in mattress sutures in circular rimcircular rim

• Rumenotomy: Rumenotomy: • Indications: FB, Indications: FB,

ruminal ruminal impaction, bloat, impaction, bloat, atony of atony of omasum or omasum or abomasumabomasum

• Inverted L – Inverted L – blockblock

• Local infiltration Local infiltration along line of along line of incisionincision

• Para vertebral Para vertebral blockblock

• Surgical Surgical technique: 20 cm technique: 20 cm incision- middle of incision- middle of tuber coxae and tuber coxae and last riblast rib5 cm ventral to 5 cm ventral to lumbar processlumbar process

• Caudal to last rib Caudal to last rib (close to (close to reticulum)reticulum)

• Esp. in deep Esp. in deep bodied animals bodied animals

• Anchor rumen to Anchor rumen to the incision to the incision to avoid avoid contamination of contamination of abdominal m. abdominal m. and peritoneumand peritoneum

• Continuous Continuous inverting pattern – inverting pattern – non-absorbablenon-absorbable

• Alternatively use Alternatively use weingarts ring weingarts ring (quicker)(quicker)

• Incise rumen Incise rumen with scalpelwith scalpel

• Evacuate and Evacuate and explore for FB in explore for FB in reticulum and reticulum and removeremove

• Try to feel for Try to feel for abscess in abscess in reticular areareticular area

• Reticulum is Reticulum is swept with a swept with a magnet to magnet to retrieve the iron retrieve the iron FB FB

• Rumen cud + Rumen cud + soda bicarb= soda bicarb= mineral oil mineral oil

• Scrub and discard Scrub and discard the soiled the soiled instrumentsinstruments

• Close with double Close with double row of lamberts or row of lamberts or inversion suturesinversion sutures

• Antibiotic and fluid Antibiotic and fluid therapy therapy