Date post: | 21-Nov-2014 |
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Earl F. Calfee, III (Trey) DVM, MS
Diplomat American College of Veterinary Surgeons
CSU Surgical Oncology Fellow
Nashville Veterinary Specialists, PLLC
Abdominal Exploration and GI Surgical Techniques
Thanks to our sponsorsPfizer IDEXX
Thanks to Becky DanCoordinator of all things
detailedResource to your clinics
Marketing materialsCo-marketing magnets
Recycling2 hour talk – break around 8PM
Logistics first
To explore or not to explore?Anatomic ReviewEquipmentSurgical techniquesPeri-operative managementQuestions
Stop me at any point.
Goals of presentation
VomitingRetchingAbdominal distensionAbdominal painGeneralized discomfort/restlessnessOwner reports ingestion of somethingPalpation of mass effectMass identified on rads or U/S
Situations leading to exploratory celiotomy
Often obviousMass identified with palpation or imaging
Pre-op diagnosticsCBC // Serum chemistryThoracic radiographsAbdominal ultrasoundFNA with cytology - lymphoma
GDVUsually clear indication for surgeryDiscussion of prognosis with ownerMentation is keyPre-operative prognostic indicators
Plasma lactate
To explore of not to explore
Septic abdomenClear indication to explore Owner communication key
Sick animalsHigh mortality – 40-70%High costsIntensive case managementProlonged hospitalization
To explore or not to explore
The “cloudy ones”StableInconsistent
vomiting, anorexia, lethargy
Variable historyVariable signalment
To explore or not to explore
How do you decide on “cloudy cases”What we know
Lots of differentialsForeign body, inflammatory bowel disease, non-specific
gastroenteritis, liver or kidney failure, toxicity, pancreatitis, viral enteritis, GI neoplasia, intussusception, esophageal foreign body, IVDD, pyelonephritis etc., etc., etc.
If you do much surgery you will wait too long on some and go in too early on others
What are we trying to avoid?Operating patient that has readily identifiable non-
surgical conditionPyelonephritis, Addison’s disease, IVDD, etc.
To explore or not to explore
How do you decide on “cloudy cases”Multifactorial decision
Signalment // HistoryPhysical examDiagnostics
To explore or not to explore
SignalmentTypically young but can be older with polyphagia
from concurrent disease (i.e. hyperadrenocorticism)History
Owner missing somethingOwner witnessed chewingAlready vomiting foreign materialFrequent chewer – maybe operated previouslyMedically induced polyphagia
HyperadrenocorticismEpileptic on medsExogenous corticosteroid admin.
To explore or not to explore
History (cont.)Frequency and duration of vomiting
Increased suspicion of need for surgeryHigh frequency = upper GI obstructionChronic intermittent vomiting combined with anorexia,
possible diarrhea, weight loss = lower GI obstructionDecreased suspicion of need for surgery
Chronic, intermittent – possible IBD candidate
To explore or not to explore
Physical examGeneral exam
Overall conditionConcurrent diseaseCats – look under tongueStable patient?
Abdominal palpation is keyPalpable mass = surgery
Watch out for kidney in sight hounds
Make sure not fecesSevere splinting in calm or
depressed animals highly suspicious for peritonitis
To explore or not to explore
Radiographs alone = “Let’s go to surgery”1 – 2 – 3 –4 -
To explore or not to explore
Radiographs alone = “Let’s go to surgery” 1 - Visible foreign material2 – 3 –4 -
To explore or not to explore
Radiographs alone = “Let’s go to surgery”1 - Visible foreign material2 – GDV3 – 4 -
To explore or not to explore
Radiographs alone = “Let’s go to surgery”1 - Visible foreign material2 - GDV3 – Pneumoperitoneum4 -
To explore or not to explore
Radiographs alone = “Let’s go to surgery”1 - Visible foreign
material2 - GDV3 –
Pneumoperitoneum4 - Massive
generalized dilation IntussusceptionMesenteric torsion
To explore or not to explore
Radiographs alone = maybe “Let’s go to surgery”GI distention can be
confusingConcurrent gastric and
small intestinal distention without volvulus
Generalized pure gas distention most consistent with paralytic ileus
To explore or not to explore
To explore or not to exploreGI distention can
be confusingDifferentiation of
paralytic ileus from obstructionNormal
intestinal diameter Dogs - height
of mid-body of L2
Cats – 12-mm
Radiographs alone = maybe “Let’s go to surgery”Evidence of obstruction
Segmental mixed gas dilation patternMid-abdominal intestinal mass effectComma shaped gas patterns
To explore or not to explore
Contrast radiography Who uses here?I basically do not use (ultrasound)
Contrast studies sent here are typically difficult to interpret
Can be very time consumingDon’t over-interpret gastric retention of
contrast
To explore or not to explore
UltrasoundGoals depend on case specifics
If mass identified pre-U/S then evaluating for: Diffuse diseaseTumor originating organFree abdominal fluid
If U/S for non-specific GI signsEvidence of obstruction
Non-propulsive peristalsis Fluid filled bowel loops Visible linear foreign material Free abdominal fluid
User dependent and potential for misinterpretation
To explore or not to explore
Additional diagnosticsCBC/Serum chemistry
WBC countNormal vs mild to moderate leukocytosis vs leukemoid
reactionMajor organ functionThrombocytopeniaHypoalbuminemia
SNAP PLISerum lactate levels
Tissue hypoxia Normal values
<2.5 mmol/L
To explore or not to explore
Additional diagnosticsAbdominocentesis
Paired serum and effusion samples of glucose and/or lactateLactate > 2.5 mmol/LBlood to fluid glucose
difference - >20 mg/dL
Cytology on cytospinBacteria and
neutrophil status
To explore or not to explore
Let’s go to surgery
AnesthesiaMachine // Drugs // Fluids // Monitor
Patient tableInstrument tablePatient prep solutionSterile patient and table drapingInstrument pack with suture
Equipment