Gastrointestinal surgery in small animals. Clinical cases

Medicina pediátrica en pequeños animales

Presentation

Surgery atlas, a step-by-step guide

The gastrointestinal tract

Small animal surgery

brochure

Small animal surgery Rodolfo Brühl Day (Coordinator) María Elena Martínez Pablo Meyer José Rodríguez Gómez

Lips Tongue Oesophagus Stomach Pancreas Liver Gallbladder Mesentery Intestines

Surgery atlas, a step-by-step guide

The gastrointestinal tract CliniCal Cases

LIBR0559

Small Animal Surgery

Small animal surgery Rodolfo Brühl Day (Coordinator)

The gastrointestinal tract. Clinical cases

María Elena Martínez Pablo Meyer José Rodríguez Gómez

Lips Tongue Oesophagus Stomach Pancreas Liver Gallbladder Mesentery Intestines

Surgery atlas, a step-by-step guide

The gastrointestinal tract CliniCal Cases

Authors: Rodolfo Brühl Day (coord.),

María Elena Martínez, Pablo Meyer and José Rodríguez Gómez.

Format: 23 x 29.7 cm.

Number of pages: 208.

Number of images: 480.

Binding: hardcover.

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83 €

This new book on veterinary surgery focuses on the gastrointestinal

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tract and accessory organs of digestion in small animals. Its educational approach, through the description of 30 surgical cases, provides the reader with a better understanding when it comes to perform surgeries in dogs and cats with gastrointestinal disorders.

Both simple cases and more complex ones are addressed, covering a wide range of situations that the veterinary surgeon may be faced with in the practice.

For each case, the authors include the case history, the physical examination, the surgical preparation and technique, as well as additional considerations and tips when necessary.

The gastrointestinal tract. Clinical cases

Presentation of the book It is the intention of the authors of this book to present a series of assorted surgical cases related to the digestive system. Surgical situations of dogs and cats with more frequent presentation, but because of that none less challenging, will be included. Some less commonly presentations, with their own puzzling demands, will be also addressed.

The surgical procedures described will comprise those related to the head and neck, those related to the thoracic cavity, and those involving the abdomen.

Specialised surgeons in this field with several years in academia and private practice will explain, in most cases step by step, how these procedures were diagnosed, and later solved with the use of surgery.

Referral cases can sometimes be demanding and a team work, gathering different specialties, will be looked for. This means that continuous training, effort and updating are a must in order to accomplish many more successful cases. The team work includes internists and staff support as well. Without them, little chance will the patients have in several instances.

Rodolfo Br端hl Day

The authors Rodolfo Brühl Day (coord.)

Dr Brühl Day (DVM) graduated from the Facultad de Ciencias Veterinarias (University of Buenos Aires, Argentina) in 1977, with honours (Magna cum Laude) and Gold Medal for best GPA. After a Residency in Small Animal Surgery in the Veterinary Medical Teaching Hospital (University of California, Davis) in 1984, he has become a Charter Diplomate in Small Animal Surgery from the Universidad de Buenos Aires (1998), specialist in University Teaching with orientation to Veterinary and Biological Sciences (2000), and a Diplomate of the Latin-American College of Veterinary Ophthalmologists (2002).

He has taught in several universities throughout his extensive career (Universidad de Buenos Aires, Facultad de Ciencias Veterinarias, Buenos Aires; University of California, Davis, School of Veterinary Medicine, California, United States; and Ross University, School of Veterinary Medicine, Saint Kitts, West Indies). Since 2008 he is Professor of Small Animal Surgery, Director of the Small Animal Medicine and Surgery Academic Program , and Staff Surgeon at the Small Animal Clinic in St. George’s University (School of Veterinary Medicine, Grenada, West Indies).

Dr Brühl Day has been awarded with many scholarships, awards and distinctions and has contributed in a number of publications in books, journals and handouts. He has also participated in courses, seminars and taken several CE courses throughout his career. Since 1995 he is a member of the Editorial Board of the scientific section Selecciones Veterinarias of Editorial Intermédica, Buenos Aires.

María Elena Martínez Dr Martínez (DVM) graduated from the Facultad de Ciencias Veterinarias (University of Buenos Aires, Argentina) in 1991. As a specialist in Small Animals Surgery and Anaesthesiology, she has been tutoring and teaching in the University of Buenos Aires from 1998 to 2006. In 2002, she became a Diplomate in Small Animal Surgery and is currently Head of the Surgery Service in the course on Veterinary Neurology. She has gained experience in several countries like United States (Missouri University), Brasil (Universidade do Estado de Santa Catarina), and Colombia (Fundación Universitaria San Martín). She is a member of Neurolatinvet and a founding member of Neurovet-Argentina (Argentinean Association of Veterinary Neurologists).

The gastrointestinal tract. Clinical cases

Pablo Meyer Dr Pablo Meyer (DVM) graduated from the Facultad de Ciencias Veterinarias (University of Buenos Aires, Argentina) in 1986. Since 2003, he is a Diplomate in Small Animal Surgery, and lecturer on skin surgery and reconstruction in the specialisation course on Surgery in small animals. He is also a surgeon of the Surgery Service of the Teaching Hospital of the Facultad de Ciencias Veterinarias of the University of Buenos Aires (HEMV-UBA), and lecturer at the Service of Oncology. Author of various works in this field, he has participated in several conferences and contributed in specialised journals focusing in surgery and oncology.

Collaborators José Rodríguez, DVM, PhD Graduate in Veterinary Medicine from the Complutense University of Madrid, Spain. Head Tutor of the Department of Animal Pathology, University of Zaragoza, Spain. Veterinary surgeon, Hospital Veterinario Valencia Sur, Valencia, Spain.

Sandra Mattoni, DVM Resident Limited Status, Emergency and Critical Care, UC-Davis, California, US. Assistant Professor, Small Animal Medicine, St. George’s University - School of Veterinary Medicine.

Grenada, West Indies. Medical Director, Centro de Cuidados Intensivos y Emergencias, Buenos Aires, Argentina.

Eduardo Durante, BVSc, BVSc(Hons), MedVet, DVSc Professor, Small Animal Surgery, Universidad Nacional de la Plata, Provincia de Buenos Aires, Argentina. Professor, Small Animal Surgery and Senior Associate Dean, St. George’s University - School of Veterinary Medicine, Grenada, West Indies.

Francesca Ivaldi, DVM, MSc Associate Professor, Small Animal Surgery, St. George’s University - School of Veterinary Medicine, Grenada, West Indies.

Communication services Web site Online visualisation of the sample chapter.

Presentation brochure in PDF format.

Author´s CV. Sample chapter compatible with iPad.

www.grupoasis.com/promo/gastrointestinal_surgery_cc

Small animal surgery Rodolfo Brühl Day (Coordinator) María Elena Martínez Pablo Meyer José Rodríguez Gómez

Lips Tongue Oesophagus Stomach Pancreas Liver Gallbladder Mesentery Intestines

Surgery atlas, a step-by-step guide

The gastrointestinal tract CliniCal Cases

Table of contents 1. Cases involving the oral cavity and pharynx

3. Cases involving the digestive organs in the abdomen

Lip neoplasia

Stomach foreign body

Zygomatic gland mucocoele

Canine acute gastric dilatation-volvulus

Linear foreign body entrapped under the tongue in a cat

Y-U pyloroplasty

Severe facial trauma

Chemical peritonitis due to traumatic rupture of the pancreas

Cricopharyngeal achalasia

Mesenteric torsion

Glossectomy

Duodenal foreign body

Transverse glossectomy

Extrahepatic shunt

Wedge glossectomy

Multiple extrahepatic shunts and intrahepatic shunt

2. Cases involving the thoracic oesophagus Oesophageal foreign body in a dog Linear foreign body in a cat Combined technique for removal of a foreign body Megaoesophagus Hiatal hernia

Biliary peritonitis associated with extrahepatic biliary rupture Biliary mucocoele Rupture of the gallbladder Gallbladder lithiasis Caecal neoplasia Splenic torsion

4. Techniques applied in gastrointestinal disorders Mouth examination Oesophagostomy tube placement for feeding (E-tube) Jejunostomy tube placement for feeding (J-tube)

Oral cavity and pharynx / Zygomatic gland mucocoele

Zygomatic gland

Parotid gland

9

Sublingual gland

Mandibular gland

Fig. 2. Salivary glands of the dog (with the zygomatic bone excised). Note the position of the zygomatic salivary gland in the orbital area.

Surgical preparation After the placement of a peripheral intravenous catheter, anaesthesia was induced and, with the patient ready for intubation, a non-painful bulge with an uneven surface was observed in the aboral buccal vestibule of the oral cavity. The oral mucosa in the bulging area was slightly oedematous and damaged due to self-chewing (Fig. 3).

Fig. 3. Patient intubated and mucocoele located at the buccal vestibule of the oral cavity (arrow).

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The gastrointestinal tract CliniCal Cases

Glossectomy

Rodolfo Brühl Day, María Elena Martínez, Pablo Meyer

Prevalence Technical difficulty

■■ ■■

Partial or total resection of the tongue.

Indicated for wounds, neoplasia, and/or necrosis.

Case history Name

Helga

Species

canine

Breed

Clinical signs: difficulty to eat, intermittent bleeding from the mouth.

Samoyed

Sex

female, spayed

Age

8 years old

Physical examination A short-acting anaesthesia allowed a thorough evaluation of the patient, including the aspect of the lesion, its extent (Fig. 1), the presence of other disease manifestations and involvement of regional lymph nodes.

34

Fig. 1. A thorough examination under general anaesthesia is required in these cases.

The tumour occupied about 30 % of the length of the tongue (left side), while 70 % of it remained unaffected (Figs. 2 and 3).

Fig. 2. Detail of the tumour occupying the tongue.

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Oral cavity and pharynx / Glossectomy

Surgical preparation This is a clean-contaminated surgery because the surgical procedure is performed in the oral cavity.

See Table 1 in the case Transverse glossectomy

9 01_Head_neck.indd 35

page 41

The surgical field was prepared with an antiseptic solution of povidone iodine 1:10 or chlorhexidine 1:30 diluted in saline. The whole oral cavity was cleaned several times (Fig. 4), being careful enough to block the pharynx with rolled gauze sponges to prevent fluid aspiration.

Physical examination prior to surgery is of utmost importance.

35

Fig. 3. Size of the neoplasm, which affects nearly 30 % of the length of the tongue.

Fig. 4. Preparation for the surgery includes cleaning the mouth with a diluted antiseptic solution.

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The gastrointestinal tract CliniCal Cases

Surgical technique Once the abdominal cavity was entered, the FB was located in the ascending duodenum, which was exteriorised. Moistened laparotomy sponges were placed surrounding the bowel loop to minimise intestinal spillage into the cavity. In this procedure, the laparotomy sponge closer to the surgeon will receive the bowel loop for ease of handling. Holding the intestinal loop close to the midline should be avoided to prevent any intestinal content from leaking into the abdominal cavity.

Once the FB is found (Fig. 3), the rest of the small and large bowel must be examined due to the possible presence of another FB that may go unnoticed otherwise.

This surgical procedure has three stages (aseptic/septic/aseptic) Aseptic stage. Moistened 4 Ă— 4 gauze sponges are placed around the exteriorised duodenum until it is incised.

Septic stage. Duodenotomy and FB removal.

Aseptic stage. Once the sponges are removed and the gloves changed, the duodenum is closed. A new set of instruments, small pack, will be used for the abdominal closure.

116

Fig. 3. The bowel loop is dilated cranial to the FB, but has a normal size caudal to it.

Once the affected duodenum is isolated (Fig. 4), the intestinal content (chyme) is gently milked away from the lumen of the duodenum. This manoeuvre minimises spillage of chyme during the enterotomy procedure.

Fig. 4. Isolated and packed segment of duodenum, prepared to be incised.

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4 03_Abdomen.indd 117

Abdomen / Duodenal foreign body

To reduce the spillage of chyme, the intestinal lumen must be clamped proximally and distally before the enterotomy site is incised.

The assistant surgeon will place the index and middle fingers of both hands in a scissor-like grip at about 4 cm from each end to achieve and carry out an atraumatic lumen occlusion (Fig. 5). Doyen intestinal forceps can also be used for the same purpose.

Fig. 5. Before the duodenum is incised, the assistant uses the index and middle fingers of both hands to clamp the intestinal lumen cranially and caudally to the FB.

Do not use the thumb and index fingers since they can apply too much pressure to the intestinal wall. Small (baby) Doyen intestinal forceps are a better option for the delicate duodenal wall and the occasional lack of adequate space within the abdominal cavity.

The incision is generally made in a healthy segment of the intestine (Fig. 6). Then, the FB has to be gently removed through this opening. The length of the incision has to be made according to the size of the FB to allow a smooth removal without unnecessary traction against the incised edges of the intestinal wall.

117

Fig. 6. Bowel wall incision with scalpel.

In this case, the extent of the incision had to be enlarged. The surgeon extended it along the long axis of the intestine using Metzenbaum scissors to ensure the FB could be removed without tearing the intestinal wall (Figs. 7 and 8). A scalpel can also be used in such cases.

Fig. 7. Enlargement of the incision in the intestinal wall using scissors.

02/06/15 09:14

The gastrointestinal tract CliniCal Cases

The tube should be secured to the skin with a finger-trap suture pattern using non-absorbable material. A syringe needle can be used to thread it through skin and around the tube (Fig. 15).

Using a finger-trap pattern allows overlapping sutures to be tightened when pulling on the tube, thus decreasing any possibility of removal.

a

b

c

d

184

Fig. 15. (a) First, a suture loop is tied loosely to the skin, then around the tube in a finger-trap pattern. (b) Detail of the knot. (c) A cap is placed to close the tube, thus

preventing air from going into the oesophagus and stomach. (d) Completed finger-trap suture.

Neck bandage Next step would be to protect the tube and skin incision with a neck bandage, which has to be loose enough to allow free neck and head movement. Having the distal end of the tube in a dorsal position will facilitate to feed and medicate the patient through the tube.

Figures 17-26 show how to apply a neck bandage step by step.

Fig. 16. Immediate postoperative period. Oesophagostomy tube in place.

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Techniques / Oesophagostomy tube placement for feeding (E-tube)

Fig. 17. Two 4 × 4 gauze sponges are cut as shown.

Fig. 18. Antibiotic ointment is applied to the skin incision.

185

Fig. 19. The gauze sponges are placed around the tube in opposite directions.

Fig. 20. The neck is bandaged to further protect the tube and assist local wound

Fig. 21. The bandage has to be applied in a loose manner.

healing by preventing any contamination.

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The gastrointestinal tract CliniCal Cases

Omentum may be interposed between the jejunal loop and the abdominal wall to increase adherence. Once inside the abdominal cavity, the needle is passed through the wall of the selected jejunal loop, entering through its antimesenteric side and exiting distally a few centimetres further.

Since the catheter must always be inserted in an isoperistaltic direction (same direction of ingesta flow), the needle must enter the bowel loop in an antiperistaltic direction (opposite direction of ingesta flow).

The feeding tube/catheter must always be inserted following the direction of ingesta flow.

The tube/catheter is fed into the needle again and passed through the intestinal lumen. The needle is then removed while the catheter remains inside the jejunal lumen (Fig. 4).

a Distal

190

Proximal

b Distal

Proximal Fig. 4. Insertion of a 5-Fr feeding tube/catheter into

the intestinal lumen using a 10-G needle.

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The publishing strength of Grupo AsĂ­s Editorial Servet, a division of Grupo AsĂ­s, has become one of the reference publishing companies in the veterinary sector worldwide. More than 15 years of experience in the publishing of contents about veterinary medicine guarantees the quality of its work. With a wide national and international distribution, the books in its catalogue are present in many different countries and have been translated into nine languages to date: English, French, Portuguese, German, Italian, Turkish, Japanese, Russian and Chinese.

Its identifying characteristic is a large multidisciplinary team formed by doctors and graduates in Veterinary Medicine and Fine Arts, and specialised designers with a great knowledge of the sector in which they work. Every book is subject to thorough technical and linguistic reviews and analyses, which allow the creation of works with a unique design and excellent contents.

Servet works with the most renowned national and international authors to include the topics most demanded by veterinary surgeons in its catalogue. In addition to its own works, Servet also prepares books for companies and the main multinational companies in the sector are among its clients.

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