surgery of the stomachkisallatsebeszet.hu/media/file/eaanggyomor-2012.pdf · 2016. 11. 6. ·...

SURGERY OF THE SURGERY OF THE STOMACHSTOMACH

SURGERY OF THE SURGERY OF THE STOMACHSTOMACH

Dr. T. Németh, DVM, PhDDr. T. Németh, DVM, PhDAssociate Professor and Head of SurgeryAssociate Professor and Head of Surgery

Dr. T. Németh, DVM, PhDDr. T. Németh, DVM, PhDAssociate Professor and Head of SurgeryAssociate Professor and Head of Surgery

Surgical AnatomySurgical AnatomySurgical AnatomySurgical Anatomy

�� LocalisationLocalisation�� TopographyTopography

–– cardia cardia -- fornixfornix

–– fundus fundus -- corpuscorpus

–– antrum antrum -- pylorus pylorus

�� HistologyHistology–– mucosa (str. compactum mucosa (str. compactum –– in carnivores)in carnivores)

–– submucosasubmucosa

–– muscularis (3 layers)muscularis (3 layers)–– serosaserosa
























�� Blood supplyBlood supply–– coeliac a. and v. (splenic, hepatic)coeliac a. and v. (splenic, hepatic)

–– left and right gastric and gastroepiploic a.,v. left and right gastric and gastroepiploic a.,v.

–– venous drainage venous drainage -- portal systemportal system

�� Lymphoid drainageLymphoid drainage–– lnn. gastr., hepat., lien., pancr.duod.lnn. gastr., hepat., lien., pancr.duod.

–– duct. thor., venous systemduct. thor., venous system

�� InnervationInnervation–– n. vagus (parasymp.)n. vagus (parasymp.)

–– coeliac plexus, gastric n. (symp.) coeliac plexus, gastric n. (symp.)

�� Blood supplyBlood supply–– coeliac a. and v. (splenic, hepatic)coeliac a. and v. (splenic, hepatic)

–– left and right gastric and gastroepiploic a.,v. left and right gastric and gastroepiploic a.,v.

–– venous drainage venous drainage -- portal systemportal system

�� Lymphoid drainageLymphoid drainage–– lnn. gastr., hepat., lien., pancr.duod.lnn. gastr., hepat., lien., pancr.duod.

–– duct. thor., venous systemduct. thor., venous system

�� InnervationInnervation–– n. vagus (parasymp.)n. vagus (parasymp.)

–– coeliac plexus, gastric n. (symp.) coeliac plexus, gastric n. (symp.)

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Physiology of the StomachPhysiology of the StomachPhysiology of the StomachPhysiology of the Stomach

�� FunctionsFunctions–– prefermentation, mixingprefermentation, mixing

–– choppingchopping

–– control of chymus quantitycontrol of chymus quantity

�� GastroGastro--oesophageal sphincter oesophageal sphincter �� MotilityMotility�� FermentationFermentation(mucin, pepsinogen, HCl)(mucin, pepsinogen, HCl)�� Gastric emptying Gastric emptying (antrum(antrum--pylorus) pylorus)

�� FunctionsFunctions–– prefermentation, mixingprefermentation, mixing

–– choppingchopping

–– control of chymus quantitycontrol of chymus quantity

�� GastroGastro--oesophageal sphincter oesophageal sphincter �� MotilityMotility�� FermentationFermentation(mucin, pepsinogen, HCl)(mucin, pepsinogen, HCl)�� Gastric emptying Gastric emptying (antrum(antrum--pylorus) pylorus)

General surgical considerations General surgical considerations of the stomach Iof the stomach I

General surgical considerations General surgical considerations of the stomach Iof the stomach I

�� Anatomic features Anatomic features ((rich vascularisationrich vascularisation, , good resecabilitygood resecability, , limited limited surgical mobilisation and availabilitysurgical mobilisation and availability););

�� Physiological features Physiological features ((gastricgastric pH 2pH 2 to to 3, 3, not significant presence of not significant presence of bacteria)bacteria)

�� Wound Wound healinghealing(erosio:epitheli(erosio:epithelialal regenerregenerationation, submucosa, submucosalldefedefect/ulcerct/ulcer: : with scar formationwith scar formation, , full thickness defectfull thickness defect: : about 1about 1--week week healing buthealing but 22--week regeneration of tensile strengthweek regeneration of tensile strength););

�� PPreoperative reoperative duties duties (8(8 to to 12 12 hr fasting or little soft food 3 hrs before sx, hr fasting or little soft food 3 hrs before sx, prophylactic iprophylactic iv antibiotv antibiotics in case of bacterial overgrowthics in case of bacterial overgrowth););

�� Anatomic features Anatomic features ((rich vascularisationrich vascularisation, , good resecabilitygood resecability, , limited limited surgical mobilisation and availabilitysurgical mobilisation and availability););

�� Physiological features Physiological features ((gastricgastric pH 2pH 2 to to 3, 3, not significant presence of not significant presence of bacteria)bacteria)

�� Wound Wound healinghealing(erosio:epitheli(erosio:epithelialal regenerregenerationation, submucosa, submucosalldefedefect/ulcerct/ulcer: : with scar formationwith scar formation, , full thickness defectfull thickness defect: : about 1about 1--week week healing buthealing but 22--week regeneration of tensile strengthweek regeneration of tensile strength););

�� PPreoperative reoperative duties duties (8(8 to to 12 12 hr fasting or little soft food 3 hrs before sx, hr fasting or little soft food 3 hrs before sx, prophylactic iprophylactic iv antibiotv antibiotics in case of bacterial overgrowthics in case of bacterial overgrowth););

General surgical considerations General surgical considerations of the stomach IIof the stomach II

General surgical considerations General surgical considerations of the stomach IIof the stomach II

�� InstrumentationInstrumentation((basicbasic+ + retractorsretractors + + lap spongeslap sponges+ atraumat+ atraumatic/nonic/non--crushing instrumentscrushing instruments + Doyen + Doyen bowel clampsbowel clamps+ + surgical suctionsurgical suction););

�� ClosureClosure: : double layer double layer ((single layer for pylorussingle layer for pylorus!) !) penetratingpenetrating+seromuscular+seromuscular invertinginverting orormucosamucosall/submucosa/submucosal + l + sseromusculareromuscular invertinginverting, 3, 3--4 mm 4 mm inbetweeninbetween;;

�� Suture materialSuture material: monofil: monofilamentament, , synthetic absorbablesynthetic absorbable

(polyglyconate, polyglecaprone 25, PDS II) (polyglyconate, polyglecaprone 25, PDS II) or stapleror stapler; ;

�� postoperatpostoperativeiveduties duties ((starting feeding within 12 hrsstarting feeding within 12 hrs, , +/+/-- nasogastrinasogastric c feeding tubefeeding tube, , gastric protectiongastric protection) )

�� InstrumentationInstrumentation((basicbasic+ + retractorsretractors + + lap spongeslap sponges+ atraumat+ atraumatic/nonic/non--crushing instrumentscrushing instruments + Doyen + Doyen bowel clampsbowel clamps+ + surgical suctionsurgical suction););

�� ClosureClosure: : double layer double layer ((single layer for pylorussingle layer for pylorus!) !) penetratingpenetrating+seromuscular+seromuscular invertinginverting orormucosamucosall/submucosa/submucosal + l + sseromusculareromuscular invertinginverting, 3, 3--4 mm 4 mm inbetweeninbetween;;

�� Suture materialSuture material: monofil: monofilamentament, , synthetic absorbablesynthetic absorbable

(polyglyconate, polyglecaprone 25, PDS II) (polyglyconate, polyglecaprone 25, PDS II) or stapleror stapler; ;

�� postoperatpostoperativeiveduties duties ((starting feeding within 12 hrsstarting feeding within 12 hrs, , +/+/-- nasogastrinasogastric c feeding tubefeeding tube, , gastric protectiongastric protection) )

Surgical Diseases of the StomachSurgical Diseases of the StomachSurgical Diseases of the StomachSurgical Diseases of the Stomach

�� Gastric Dilatation and Volvulus (GDV)Gastric Dilatation and Volvulus (GDV)

�� Gastric Foreign BodyGastric Foreign Body

�� Gastric Ulceration / Gastric PerforationGastric Ulceration / Gastric Perforation

�� Gastric emptying disordersGastric emptying disorders



�� Gastric Ulceration / Gastric PerforationGastric Ulceration / Gastric Perforation





�� Gastric Ulceration / PerforationGastric Ulceration / Perforation






Gastric Dilatation and VolvulusGastric Dilatation and Volvulus(G.D.V.)(G.D.V.)


�� Gastric Dilatation Gastric Dilatation -- Volvulus (G.D.V.)Volvulus (G.D.V.)

�� Gastric Dilatation Gastric Dilatation -- Torsion SyndromeTorsion Syndrome

�� Gastric Dilatation Gastric Dilatation -- Volvulus (G.D.V.)Volvulus (G.D.V.)

�� Gastric Dilatation Gastric Dilatation -- Torsion SyndromeTorsion Syndrome



�� Clinical forms:Clinical forms:�� Dilatation Dilatation withoutwithout torsion (GD)torsion (GD)

–– independent form independent form ororinitial phase of DTinitial phase of DT–– primary or secondaryprimary or secondary

�� Dilatation with torsion (GDV)Dilatation with torsion (GDV)–– „Classic” form„Classic” form–– large, deep chested breedslarge, deep chested breeds–– peracute / acute form (4peracute / acute form (4--6 h)6 h)

�� ChronicChronic dilatation with partial torsiondilatation with partial torsion–– rarerare–– usually intermittentusually intermittent

�� Clinical forms:Clinical forms:�� Dilatation Dilatation withoutwithout torsion (GD)torsion (GD)

–– independent form independent form ororinitial phase of DTinitial phase of DT–– primary or secondaryprimary or secondary

�� Dilatation with torsion (GDV)Dilatation with torsion (GDV)–– „Classic” form„Classic” form–– large, deep chested breedslarge, deep chested breeds–– peracute / acute form (4peracute / acute form (4--6 h)6 h)

�� ChronicChronic dilatation with partial torsiondilatation with partial torsion–– rarerare–– usually intermittentusually intermittent



�� Physical changes of the stomachPhysical changes of the stomach–– dilatation/torsiondilatation/torsion

–– perfusion of the stomach wall perfusion of the stomach wall ↓↓–– stomach wall necrosisstomach wall necrosis

�� General consequencesGeneral consequences–– Thoracic compressionThoracic compression

–– Cardiogenic shockCardiogenic shock

–– ARDSARDS

–– Portal hypertensionPortal hypertension

–– Circulatory hypotensionCirculatory hypotension

–– Bacteriemia/SIRSBacteriemia/SIRS

–– Reperfusion syndrome Reperfusion syndrome

�� Acute abdomen!Acute abdomen!

�� Physical changes of the stomachPhysical changes of the stomach–– dilatation/torsiondilatation/torsion

–– perfusion of the stomach wall perfusion of the stomach wall ↓↓–– stomach wall necrosisstomach wall necrosis

�� General consequencesGeneral consequences–– Thoracic compressionThoracic compression

–– Cardiogenic shockCardiogenic shock

–– ARDSARDS

–– Portal hypertensionPortal hypertension

–– Circulatory hypotensionCirculatory hypotension

–– Bacteriemia/SIRSBacteriemia/SIRS

–– Reperfusion syndrome Reperfusion syndrome

�� Acute abdomen!Acute abdomen!

AetiologyAetiologyAetiologyAetiology�� Aethiology is still not certainAethiology is still not certain

–– „what comes first:chicken or egg” dilemma„what comes first:chicken or egg” dilemma

�� Proven risk factorsProven risk factors–– Large and giant breedsLarge and giant breeds

–– Deep chestedDeep chested

–– history of GDV in the family (firsthistory of GDV in the family (first--degree relative)degree relative)

–– Decreasd food particle sizeDecreasd food particle size

–– Fewer meals per dayFewer meals per day

–– Eating rapidlyEating rapidly

–– Aggressive or fearful temperamentAggressive or fearful temperament

–– Excercise or stress after mealExcercise or stress after meal

–– long hepatogastric ligamentlong hepatogastric ligament

�� Aethiology is still not certainAethiology is still not certain–– „what comes first:chicken or egg” dilemma„what comes first:chicken or egg” dilemma

�� Proven risk factorsProven risk factors–– Large and giant breedsLarge and giant breeds

–– Deep chestedDeep chested

–– history of GDV in the family (firsthistory of GDV in the family (first--degree relative)degree relative)

–– Decreasd food particle sizeDecreasd food particle size

–– Fewer meals per dayFewer meals per day

–– Eating rapidlyEating rapidly

–– Aggressive or fearful temperamentAggressive or fearful temperament

–– Excercise or stress after mealExcercise or stress after meal

–– long hepatogastric ligamentlong hepatogastric ligament



��History, PathogenesisHistory, Pathogenesis––typical (“classic”)typical (“classic”)

––atypical (also frequent)atypical (also frequent)

��History, PathogenesisHistory, Pathogenesis––typical (“classic”)typical (“classic”)

––atypical (also frequent)atypical (also frequent)

Gastric Dialtation and VolvulusGastric Dialtation and Volvulus(G.D.V.)(G.D.V.)

Gastric Dialtation and VolvulusGastric Dialtation and Volvulus(G.D.V.)(G.D.V.)

�� HistoryHistory–– varied, individual featuresvaried, individual features

–– „blowing„blowing--up”up”

–– salivationsalivation

–– improductive retching, regurgitationimproductive retching, regurgitation

–– rapid deteriorationrapid deterioration

–– the time of the last feeding is crucial!!! (prognosis)the time of the last feeding is crucial!!! (prognosis)

�� HistoryHistory–– varied, individual featuresvaried, individual features

–– „blowing„blowing--up”up”

–– salivationsalivation

–– improductive retching, regurgitationimproductive retching, regurgitation

–– rapid deteriorationrapid deterioration

–– the time of the last feeding is crucial!!! (prognosis)the time of the last feeding is crucial!!! (prognosis)



�� DiagnosticsDiagnostics�� General examinationGeneral examination

–– apathy, weakness (seldom restlessness)apathy, weakness (seldom restlessness)

–– given stage of shockgiven stage of shock

–– weak, frequent pulse, pulseweak, frequent pulse, pulse--deficitdeficit

–– elevated CRT elevated CRT

–– redish or pale or cyanotic mucous membranesredish or pale or cyanotic mucous membranes

–– superficial polypnoe superficial polypnoe

�� DiagnosticsDiagnostics�� General examinationGeneral examination

–– apathy, weakness (seldom restlessness)apathy, weakness (seldom restlessness)

–– given stage of shockgiven stage of shock

–– weak, frequent pulse, pulseweak, frequent pulse, pulse--deficitdeficit

–– elevated CRT elevated CRT

–– redish or pale or cyanotic mucous membranesredish or pale or cyanotic mucous membranes

–– superficial polypnoe superficial polypnoe



�� DiagnosticsDiagnostics�� Detailed physical examinationDetailed physical examination

–– barrelbarrel--like distention of the epilike distention of the epi-- and mesogastriumand mesogastrium

–– drumdrum--like gastric tympanylike gastric tympany

–– palpable splenomegaly and dislocationpalpable splenomegaly and dislocation

–– no gastric and intestinal motilityno gastric and intestinal motility

�� DiagnosticsDiagnostics�� Detailed physical examinationDetailed physical examination

–– barrelbarrel--like distention of the epilike distention of the epi-- and mesogastriumand mesogastrium

–– drumdrum--like gastric tympanylike gastric tympany

–– palpable splenomegaly and dislocationpalpable splenomegaly and dislocation

–– no gastric and intestinal motilityno gastric and intestinal motility



�� DiagnosticsDiagnostics�� Supplementary examinationsSupplementary examinations

––gastrocentesisgastrocentesis

––orogastric tubationorogastric tubation

––XX--rayray

––blood gas analysisblood gas analysis

––cardiologic examinationcardiologic examination

�� DiagnosticsDiagnostics�� Supplementary examinationsSupplementary examinations

––gastrocentesisgastrocentesis

––orogastric tubationorogastric tubation

––XX--rayray

––blood gas analysisblood gas analysis

––cardiologic examinationcardiologic examination


XX--rayray


XX--rayray

180180°° clockwise torsionclockwise torsion180180°° clockwise torsionclockwise torsion

Left lateral recumbencyLeft lateral recumbencyLeft lateral recumbencyLeft lateral recumbency Right lateral recumbencyRight lateral recumbencyRight lateral recumbencyRight lateral recumbency

FundusFundus--corpuscorpusFundusFundus--corpuscorpus

PylorusPylorusPylorusPylorus



�� Therapeutic protocol Therapeutic protocol �� vein catherisationvein catherisation

�� fluid therapy (80fluid therapy (80--100 ml/bwkg)100 ml/bwkg)

�� alkalisationalkalisation

�� Potassium Potassium -- additionaddition

�� antiarrhytmic treatment (lidocain)antiarrhytmic treatment (lidocain)

�� glucocorticoids (?)glucocorticoids (?)�� antibiotics (?)antibiotics (?)

�� Therapeutic protocol Therapeutic protocol �� vein catherisationvein catherisation

�� fluid therapy (80fluid therapy (80--100 ml/bwkg)100 ml/bwkg)

�� alkalisationalkalisation

�� Potassium Potassium -- additionaddition

�� antiarrhytmic treatment (lidocain)antiarrhytmic treatment (lidocain)

�� glucocorticoids (?)glucocorticoids (?)�� antibiotics (?)antibiotics (?)



�� TherapeuticTherapeutic protocolprotocol ((contcont.).)�� gastrocentesisgastrocentesis�� anesthesiaanesthesia

––sedationsedation: : benzodiazepinesbenzodiazepines

–– inductioninduction: : ketamineketamine, , propofolpropofol

–– inttratrachealinttratracheal intubationintubation

––oxygenoxygen, , halothanhalothan ((izofluránizoflurán))�� orogastricorogastric tubationtubation / / gastricgastric lavagelavage and and

emptyingemptying

�� TherapeuticTherapeutic protocolprotocol ((contcont.).)�� gastrocentesisgastrocentesis�� anesthesiaanesthesia

––sedationsedation: : benzodiazepinesbenzodiazepines

–– inductioninduction: : ketamineketamine, , propofolpropofol

–– inttratrachealinttratracheal intubationintubation

––oxygenoxygen, , halothanhalothan ((izofluránizoflurán))�� orogastricorogastric tubationtubation / / gastricgastric lavagelavage and and

emptyingemptying

GastrocentesisGastrocentesisGastrocentesisGastrocentesis

GastrocentesisGastrocentesisGastrocentesisGastrocentesis Gastric Dilatation and VolvulusGastric Dilatation and Volvulus(G.D.V.)(G.D.V.)


�� Therapeutic protocol (cont.)Therapeutic protocol (cont.)�� gastrocentesisgastrocentesis�� anaesthesiaanaesthesia

––sedation: benzodiazepines sedation: benzodiazepines

–– induction: ketamine, propofolinduction: ketamine, propofol

–– IT tubeIT tube

––oxygen, izoflurane/sevofluraneoxygen, izoflurane/sevoflurane�� orogastric tubation / gastric lavage and orogastric tubation / gastric lavage and

emptyingemptying

�� Therapeutic protocol (cont.)Therapeutic protocol (cont.)�� gastrocentesisgastrocentesis�� anaesthesiaanaesthesia

––sedation: benzodiazepines sedation: benzodiazepines

–– induction: ketamine, propofolinduction: ketamine, propofol

–– IT tubeIT tube

––oxygen, izoflurane/sevofluraneoxygen, izoflurane/sevoflurane�� orogastric tubation / gastric lavage and orogastric tubation / gastric lavage and

emptyingemptying


Orogastric tubation / Gastric lavageOrogastric tubation / Gastric lavage









��Therapeutic protocol (cont’d)Therapeutic protocol (cont’d)

��Conservative wayConservative way

��SurgerySurgery

��Therapeutic protocol (cont’d)Therapeutic protocol (cont’d)

��Conservative wayConservative way

��SurgerySurgery



�� Conservative way Conservative way (rarely!!!)(rarely!!!)–– rarely effective, frequent recidivararely effective, frequent recidiva

–– basicly in very good clinical state, stable basicly in very good clinical state, stable circulation and respiration, easy and effective circulation and respiration, easy and effective orogastric tubation, normal gastric contentorogastric tubation, normal gastric content

–– Diet (2Diet (2--3 meals a day)3 meals a day)

–– metoclopramide metoclopramide –– H2 antagonistsH2 antagonists

–– Proton pump inhibitorsProton pump inhibitors

�� Conservative way Conservative way (rarely!!!)(rarely!!!)–– rarely effective, frequent recidivararely effective, frequent recidiva

–– basicly in very good clinical state, stable basicly in very good clinical state, stable circulation and respiration, easy and effective circulation and respiration, easy and effective orogastric tubation, normal gastric contentorogastric tubation, normal gastric content

–– Diet (2Diet (2--3 meals a day)3 meals a day)

–– metoclopramide metoclopramide –– H2 antagonistsH2 antagonists

–– Proton pump inhibitorsProton pump inhibitors



�� Surgery (!!!)Surgery (!!!)–– usually effective in the long runusually effective in the long run

–– indicationindication

–– ventral midline exposureventral midline exposure

–– gastricgastric--decompression / decompression / --emptyingemptying

–– repositionreposition

–– assessment of the viability of the gastric wallassessment of the viability of the gastric wall(gastrectomy, euthanasia)(gastrectomy, euthanasia)

–– checkingchecking--up of the spleen (splenectomy)up of the spleen (splenectomy)

–– gastropexy, tubegastropexy, tube--gastrostomygastrostomy

�� Surgery (!!!)Surgery (!!!)–– usually effective in the long runusually effective in the long run

–– indicationindication

–– ventral midline exposureventral midline exposure

–– gastricgastric--decompression / decompression / --emptyingemptying

–– repositionreposition

–– assessment of the viability of the gastric wallassessment of the viability of the gastric wall(gastrectomy, euthanasia)(gastrectomy, euthanasia)

–– checkingchecking--up of the spleen (splenectomy)up of the spleen (splenectomy)

–– gastropexy, tubegastropexy, tube--gastrostomygastrostomy

Partial gastrectomyPartial gastrectomy(Fundus(Fundus--resection)resection)







Partial gastrectomyPartial gastrectomy(Fundus(Fundus--resection)resection) GastropexyGastropexy

-- incisionalincisional

-- midlinemidline

-- „belt„belt--loop”loop”

-- circumcostalcircumcostal

-- tubetube--gastrostomygastrostomy

-- preventivepreventive (video assisted) gastropexy(video assisted) gastropexy

GastropexyGastropexy-- incisionalincisional

-- midlinemidline

-- „belt„belt--loop”loop”

-- circumcostalcircumcostal

-- tubetube--gastrostomygastrostomy

-- preventivepreventive (video assisted) gastropexy(video assisted) gastropexy

Incisional gastropexyIncisional gastropexyIncisional gastropexyIncisional gastropexy Incisional gastropexyIncisional gastropexyIncisional gastropexyIncisional gastropexy

Incisional gastropexyIncisional gastropexyIncisional gastropexyIncisional gastropexy Incisional gastropexyIncisional gastropexyIncisional gastropexyIncisional gastropexy

Midline gastropexyMidline gastropexyMidline gastropexyMidline gastropexy Midline gastropexyMidline gastropexyMidline gastropexyMidline gastropexy

„Belt„Belt--loop”loop”--gastropexygastropexy„Belt„Belt--loop”loop”--gastropexygastropexy „Circumcostal”„Circumcostal”--gastropexygastropexy„Circumcostal”„Circumcostal”--gastropexygastropexy

TubeTube--gastrostomygastrostomyTubeTube--gastrostomygastrostomy PreventivePreventive ((videovideo--assistedassisted laparoscopiclaparoscopic) ) gastropexygastropexy**PreventivePreventive ((videovideo--assistedassisted laparoscopiclaparoscopic) ) gastropexygastropexy**

**RungeRunge J, J, MayhewMayhew P, P, RawlingsRawlings C: C: Surgical Views Surgical Views —— LaparoscopicLaparoscopic--Assisted and Laparoscopic Prophylactic Assisted and Laparoscopic Prophylactic GastropexyGastropexy: :

Indications and TechniquesIndications and Techniques. Vet . Vet CompComp 2009 2009 FebFeb, ,

PreventivePreventive ((videovideo--assistedassisted laparoscopiclaparoscopic) ) gastropexygastropexy**PreventivePreventive ((videovideo--assistedassisted laparoscopiclaparoscopic) ) gastropexygastropexy**



PreventivePreventive ((videovideo--assistedassisted laparoscopiclaparoscopic) ) gastropexygastropexy**PreventivePreventive ((videovideo--assistedassisted laparoscopiclaparoscopic) ) gastropexygastropexy**





�� Postoperative managementPostoperative management–– stabilisation of the circulation and respirationstabilisation of the circulation and respiration

–– acidacid--base and electrolyte balance maintainance base and electrolyte balance maintainance

–– ECG, antiarrhytmic treatmentECG, antiarrhytmic treatment

–– metoclopramidemetoclopramide

–– H2 antagonists / proton pump inhibitorsH2 antagonists / proton pump inhibitors

–– dietdiet

�� Postoperative managementPostoperative management–– stabilisation of the circulation and respirationstabilisation of the circulation and respiration

–– acidacid--base and electrolyte balance maintainance base and electrolyte balance maintainance

–– ECG, antiarrhytmic treatmentECG, antiarrhytmic treatment

–– metoclopramidemetoclopramide

–– H2 antagonists / proton pump inhibitorsH2 antagonists / proton pump inhibitors

–– dietdiet










Gastric Foreign BodyGastric Foreign BodyGastric Foreign BodyGastric Foreign Body

�� IncidenceIncidence–– young, playful dogs and catsyoung, playful dogs and cats

–– dysphagia (abdomainal pain, CNS disorders)dysphagia (abdomainal pain, CNS disorders)

�� DiagnosticsDiagnostics–– historyhistory (regular vomiting, disappearance of (regular vomiting, disappearance of

toys, )toys, )

–– physical examination physical examination (usually not (usually not pathognomistic)pathognomistic)

–– suppl. examinationsuppl. examination: X: X--ray (double contrast), ray (double contrast), gastroscopy, US gastroscopy, US

�� IncidenceIncidence–– young, playful dogs and catsyoung, playful dogs and cats

–– dysphagia (abdomainal pain, CNS disorders)dysphagia (abdomainal pain, CNS disorders)

�� DiagnosticsDiagnostics–– historyhistory (regular vomiting, disappearance of (regular vomiting, disappearance of

toys, )toys, )

–– physical examination physical examination (usually not (usually not pathognomistic)pathognomistic)

–– suppl. examinationsuppl. examination: X: X--ray (double contrast), ray (double contrast), gastroscopy, US gastroscopy, US

Gastric Foreign BodyGastric Foreign BodyXX--rayray

Gastric Foreign BodyGastric Foreign BodyXX--rayray

Gastric Foreign BodyGastric Foreign BodyGastric Foreign BodyGastric Foreign Body

�� TherapyTherapy–– provocation of vomiting (conditions!)provocation of vomiting (conditions!)

–– gastroscopic manipulationgastroscopic manipulation

–– expl. laparotomy / gastrotomyexpl. laparotomy / gastrotomy

–– H2H2--antagonists antagonists �� cimetidine, ranitidine, famotidine cimetidine, ranitidine, famotidine

–– (antibiotics)(antibiotics)

�� TherapyTherapy–– provocation of vomiting (conditions!)provocation of vomiting (conditions!)

–– gastroscopic manipulationgastroscopic manipulation

–– expl. laparotomy / gastrotomyexpl. laparotomy / gastrotomy

–– H2H2--antagonists antagonists �� cimetidine, ranitidine, famotidine cimetidine, ranitidine, famotidine

–– (antibiotics)(antibiotics)

Gastric Foreign BodyGastric Foreign BodyGastrotomyGastrotomy




GastricGastric ForeignForeign BodyBodyGastrotomyGastrotomy











Gastric Foreign BodyGastric Foreign BodyGastrotomyGastrotomy Surgical Diseases of the StomachSurgical Diseases of the StomachSurgical Diseases of the StomachSurgical Diseases of the Stomach









Gastric Ulceration / Gastric Ulceration / PerforationPerforation


�� IncidenceIncidence–– gastric foreign body (antrumgastric foreign body (antrum--pylorus)pylorus)

–– steroid/non steroid treatment (long lasting steroid/non steroid treatment (long lasting therapy, diclofenac!)therapy, diclofenac!)

–– gastric tumoursgastric tumours

�� DiagnosticsDiagnostics–– anemia, vomiting (bloody), melaena, anemia, vomiting (bloody), melaena,

–– gastroscopygastroscopy

–– pos. contrast Xpos. contrast X--ray (barium is dangerous!)ray (barium is dangerous!)

–– signs of peritonitis (perforation)signs of peritonitis (perforation)

�� IncidenceIncidence–– gastric foreign body (antrumgastric foreign body (antrum--pylorus)pylorus)

–– steroid/non steroid treatment (long lasting steroid/non steroid treatment (long lasting therapy, diclofenac!)therapy, diclofenac!)

–– gastric tumoursgastric tumours

�� DiagnosticsDiagnostics–– anemia, vomiting (bloody), melaena, anemia, vomiting (bloody), melaena,

–– gastroscopygastroscopy

–– pos. contrast Xpos. contrast X--ray (barium is dangerous!)ray (barium is dangerous!)

–– signs of peritonitis (perforation)signs of peritonitis (perforation)



�� TherapyTherapy–– surgerysurgery

�� explorationexploration

�� to cease the causeto cease the cause

�� ulcerulcer--excisionexcision

�� partial gastrectomypartial gastrectomy

�� Billroth I., II.Billroth I., II.

�� abdominal lavage/drainageabdominal lavage/drainage

–– conservativeconservative�� Gastric protectionGastric protection

�� dietdiet

�� TherapyTherapy–– surgerysurgery

�� explorationexploration

�� to cease the causeto cease the cause

�� ulcerulcer--excisionexcision

�� partial gastrectomypartial gastrectomy

�� Billroth I., II.Billroth I., II.

�� abdominal lavage/drainageabdominal lavage/drainage

–– conservativeconservative�� Gastric protectionGastric protection

�� dietdiet










Chronic gastric emptying disordersChronic gastric emptying disordersChronic gastric emptying disordersChronic gastric emptying disorders

Delayed gastric emptyingDelayed gastric emptyingDelayed gastric emptyingDelayed gastric emptying

Chronic Hypertrophic Pylorus Gastropathy (CHPG)Chronic Hypertrophic Pylorus Gastropathy (CHPG)Chronic Hypertrophic Pylorus Gastropathy (CHPG)Chronic Hypertrophic Pylorus Gastropathy (CHPG)

Congenital Pyloric StenosisCongenital Pyloric Stenosis(CPS)(CPS)

Congenital Pyloric StenosisCongenital Pyloric Stenosis(CPS)(CPS)

Pyloric foreign bodyPyloric foreign bodyPyloric foreign bodyPyloric foreign bodyPyloricPyloric--tumourtumourPyloricPyloric--tumourtumour

Pyloric stricturePyloric stricturePyloric stricturePyloric stricture

Gastric emptying disordersGastric emptying disordersGastric emptying disordersGastric emptying disorders

�� DiagnosticsDiagnostics–– Hx :Hx : chronic vomiting soon after feeding chronic vomiting soon after feeding

(without bile), kachexia(without bile), kachexia–– Px: Px: non typicalsecondary signs (gastric non typicalsecondary signs (gastric

dilatation, megaoesophagus)dilatation, megaoesophagus)

–– Ancillary examination: Ancillary examination: �� Contrast radiography (gastric emptying)Contrast radiography (gastric emptying)�� US: pyloric anatomy US: pyloric anatomy (wall thickness, lumen)(wall thickness, lumen)

�� DiagnosticsDiagnostics–– Hx :Hx : chronic vomiting soon after feeding chronic vomiting soon after feeding

(without bile), kachexia(without bile), kachexia–– Px: Px: non typicalsecondary signs (gastric non typicalsecondary signs (gastric

dilatation, megaoesophagus)dilatation, megaoesophagus)

–– Ancillary examination: Ancillary examination: �� Contrast radiography (gastric emptying)Contrast radiography (gastric emptying)�� US: pyloric anatomy US: pyloric anatomy (wall thickness, lumen)(wall thickness, lumen)

Gastric emptyingGastric emptyingGastric emptyingGastric emptying

Depens on…Depens on…Depens on…Depens on…-- Quality and consistence of foodQuality and consistence of food

(liquid: quicker , solid: slower)(liquid: quicker , solid: slower)-- Quality and consistence of foodQuality and consistence of food

(liquid: quicker , solid: slower)(liquid: quicker , solid: slower)

-- Individual differencesIndividual differences-- Individual differencesIndividual differences-- stressstress-- stressstress-- Stomach contents: fasting!!Stomach contents: fasting!!-- Stomach contents: fasting!!Stomach contents: fasting!!

End of emptyingEnd of emptying

Liquid: Liquid: 4 hrs4 hrs

Solid: Solid: 5 to 13 hrs5 to 13 hrs

End of emptyingEnd of emptying

Liquid: Liquid: 4 hrs4 hrs

Solid: Solid: 5 to 13 hrs5 to 13 hrs

Beginning of emptying

Liquid: Liquid: within minuteswithin minutes

Solid: Solid: within 30 minwithin 30 min

Beginning of emptying

Liquid: Liquid: within minuteswithin minutes

Solid: Solid: within 30 minwithin 30 min

Timing (BaSO4):Timing (BaSO4):

�� TreatmentTreatment–– IndicationIndication

�� gastric outflow disease (pylorusgastric outflow disease (pylorus--obstruction, CHPG, obstruction, CHPG, CPS)CPS)

–– TechniqueTechnique�� pyloromyotomy (Fredetpyloromyotomy (Fredet--Ramstedt)Ramstedt)

�� PylorusPylorus--plasty (Heinekeplasty (Heineke--Mikulitz, YMikulitz, Y--U, Finney)U, Finney)

–– Postoperative managementPostoperative management�� diet, gastric protectiondiet, gastric protection

�� TreatmentTreatment–– IndicationIndication

�� gastric outflow disease (pylorusgastric outflow disease (pylorus--obstruction, CHPG, obstruction, CHPG, CPS)CPS)

–– TechniqueTechnique�� pyloromyotomy (Fredetpyloromyotomy (Fredet--Ramstedt)Ramstedt)

�� PylorusPylorus--plasty (Heinekeplasty (Heineke--Mikulitz, YMikulitz, Y--U, Finney)U, Finney)

–– Postoperative managementPostoperative management�� diet, gastric protectiondiet, gastric protection

Gastric emptying disordersGastric emptying disordersGastric emptying disordersGastric emptying disordersPyloromyotomyPyloromyotomy(Fredet(Fredet--Ramstedt)Ramstedt)

PyloromyotomyPyloromyotomy(Fredet(Fredet--Ramstedt)Ramstedt)

HeinekeHeineke--MikulitzMikulitzHeinekeHeineke--MikulitzMikulitz YY--U pyloroplastyU pyloroplastyYY--U pyloroplastyU pyloroplasty

FinneyFinney--pyloroplastypyloroplastyFinneyFinney--pyloroplastypyloroplasty Surgical Procedures on the Surgical Procedures on the StomachStomach

Surgical Procedures on the Surgical Procedures on the StomachStomach

�� GastrectomyGastrectomy–– IndicationIndication

�� Gastric, duodenal ulcerationGastric, duodenal ulceration

�� gastric neoplasiagastric neoplasia

�� gastric wall necrosis (GDV)gastric wall necrosis (GDV)

�� CHPG/CPSCHPG/CPS

�� infiltrative/proliferative inflammationinfiltrative/proliferative inflammation

–– TechniqueTechnique�� Partial resectionPartial resection

�� Billroth I. gastroduodenostomyBillroth I. gastroduodenostomy

�� Billroth II. gastrojejunostomyBillroth II. gastrojejunostomy

�� GastrectomyGastrectomy–– IndicationIndication

�� Gastric, duodenal ulcerationGastric, duodenal ulceration

�� gastric neoplasiagastric neoplasia

�� gastric wall necrosis (GDV)gastric wall necrosis (GDV)

�� CHPG/CPSCHPG/CPS

�� infiltrative/proliferative inflammationinfiltrative/proliferative inflammation

–– TechniqueTechnique�� Partial resectionPartial resection

�� Billroth I. gastroduodenostomyBillroth I. gastroduodenostomy

�� Billroth II. gastrojejunostomyBillroth II. gastrojejunostomy


Billroth I. gastroduodenostomyBillroth I. gastroduodenostomy












Billroth II. gastrojejunostomyBillroth II. gastrojejunostomy


Billroth II. gastrojejunostomyBillroth II. gastrojejunostomy

surgery of the stomachkisallatsebeszet.hu/media/file/eaanggyomor-2012.pdf · 2016. 11. 6. ·...

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