Greg Anderson, DVM, Dipl. ACVS 格雷格 安德森, 美国兽医学院兽医学博士. University of Minnesota-Twin Cities St. Paul, Minnesota, U.S.A. 美国明尼苏达州圣保罗 明尼苏达大学双城分校

Transcription

1 Selected Cases of Gastrointestinal Surgery 胃肠外科案例精选 Greg Anderson, DVM, Dipl. ACVS 格雷格 安德森, 美国兽医学院兽医学博士 University of Minnesota-Twin Cities St. Paul, Minnesota, U.S.A. 美国明尼苏达州圣保罗 明尼苏达大学双城分校

2 Common Conditions Requiring Gastrointestinal Surgery 需要进行胃肠外科手术的常见病症 Dogs 犬 Foreign body ingestion causing obstruction 咽下异物造成梗阻 Gastric dilatation-volvulus (GDV) 胃扩张 - 扭转 Diagnostic biopsy procurement 诊断活检的采集 Gastrointestinal neoplasia 胃肠肿瘤 Prophylactic gastropexy 预防胃固定术 Cats 猫 Foreign body ingestion causing obstruction 咽下异物造成梗阻 Diagnostic biopsy procurement 诊断活检的采集 Gastrointestinal neoplasia 胃肠肿瘤 Idiopathic megacolon 特发性巨结肠

3 Foreign Body Ingestion 摄入异物 Dogs 犬 Toys, socks, underwear, hairbinders, rawhides, bones, carpet etc, etc, ect. 玩具, 袜子, 内衣, 发圈, 皮鞭, 骨头, 地毯, 等等. Cats 猫 String, hair, hairbinders, fabric, etc 毛线, 头发, 发圈, 纺织物, 等等

4 Foreign Body Ingestion 摄入异物 Dogs and Cats 犬和猫 Tend to be young 倾向于年龄小的动物 May have a history of dietary indiscretion 可能有随意进食的历史 Symptoms 症状 Vomiting or regurgitating 呕吐或反流 Painful posture 某些姿势造成疼痛 Restlessness and anxiety 躁动和焦虑 Diarrhea 腹泻 Decreased appetite 胃口不好

5 History 历史 Also consider 同时考虑 Vaccination/internal parasite history 免疫 / 内部寄生虫病史 Administration of medications (e.g. steroids/nsaids) 药物服用 ( 例如 : 类固醇 /NSAID) owners may not consider some items to be medications be specific 主人可能不考虑有些东西是药物 特定 Access to garbage/toys/food/toxins/recent trauma 接触垃圾 / 玩具 / 食物 / 毒素 / 近期外伤 Vomiting vs. regurgitation 呕吐与反胃

6 Foreign Body Ingestion 摄入异物 Physical Examination Findings 体检发现 Extremely variable 非常多变 Dehydration 脱水 Painful stance 疼痛状 Abdominal pain 腹痛 Panting 气喘 Abdominal distension 腹胀

7 Acute Abdomen Definition 急腹症 - 定义 A relatively nonspecific symptom complex, in which a patient complains of incapacitating abdominal pain, usually less than 24 hours duration, variably accompanied by fever, and leukocytosis that may require surgical intervention. 相对非特异性的复杂症状, 其中患者腹痛, 通常不超过 24 小时的持续时间, 伴有发热, 以及白细胞增多, 可能需要外科手术干预 Human termed applied to veterinary patients 人体术语用于兽医病患 Symptoms may be less severe 症状可能更轻 appendicitis is the most common cause of an acute abdomen in people 阑尾炎是人类最常见急腹症病因 nearly 100 other conditions may present in a similar fashion, in particular, ruptured ectopic pregnancy in a fallopian tube, ruptured acute diverticulitis and acute mesenteric lymphadenitis 接近 100 种其他病症可能有类似表现, 尤其是宫外孕导致的输卵管破裂, 急性破裂性憩室炎和急性肠系膜淋巴结炎

8 Plain Radiographs 简单 X 光片 Abdomen 腹部 Right AND Left lateral 右侧和左侧视角 Ventrodorsal or dorsoventral 腹背或背腹视角 Light sedation if necessary 如果需要, 轻度麻醉

9 Plain Radiographs 简单 X 光片 Radiographic signs associated with obstruction of the GI tract by foreign body X 光片与异物造成的胃肠道梗阻相关 Loss of abdominal detail 腹部细节缺失 Distended intestines 肠扩张 +/- foreign material +/- 异物

10 Diameter of largest SI loop Height of L5 body 最大小肠袢直径 L5 椎体高度 If ratio is 1.6 or higher, good chance of obstruction 如果比值大于或等于 1.6, 很可能有梗阻 Bowel chosen must be small intestine 一定选择小肠 Can also use rib widths as upper end of normal SI diameter 也可使用 倍肋骨宽度作为正常小肠直径上限 0.40 cm 0.65 cm SI/L5 = 0.65/0.40 = 1.625

11 Don t Forget about the Esophagus 不要忘记食道 Vomiting vs. regurgitation 呕吐 vs 回流 Aspiration Pneumonia 吸入性肺炎 Pneumothorax 气胸 Diagnostics 诊断

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13 Radiographic Findings X 光片发现

14 Barium 钡 If concerned about perforation use iodinated contrast agent 如果担心有穿孔就用含碘造影剂 Contrast Radiographs 对照影像

15 Barium 钡 If concerned about perforation use iodinated contrast agent 如果担心有穿孔就用含碘造影剂 Contrast Radiographs 加强影像

16 CAUTION- Aspiration Pneumonia!!! 注意 - 吸入性肺炎!!!

17 Baylor 贝勒 Radiographs 射线光片 1 year-old neutered male Labrador retriever 1 岁公绝育拉布拉多寻回犬

18 Radiographs X 光片 Don t Forget about the Esophagus 不要忘记食道 Vomiting vs. regurgitation 呕吐 v 回流

19 Common F.B. Obstruction Sites 常见异物梗阻点 1. Cervical constriction 颈收缩 at level of cricopharyngeal sphincter 在环咽括约肌处 2. Thoracic inlet 胸部入口 soft tissues may impede esophageal dilatation at this site 此处软组织可能妨碍食管扩张 3. Base of heart 心底 bronchoaortic constriction 支气管动脉收缩 4. Diaphragmatic constriction 横膈膜收缩 at the hiatus 在裂孔处 bone foreign bodies most commonly lodge between the heart and diaphragm (65% - 79%) 骨头异物最常在心脏和隔膜处停驻 (65%-79%)

20 o Endoscopy 内窥镜 Allows retrieval of the object (63%) 可取出物体 )63%) oor advancement into the stomach (29%) 或延伸至胃 (29%) oonly 8% require esophageal surgery!!! 仅 8% 需要食道手术!!! Allows assessment of esophageal mucosa 可检查食道粘膜 oerosions / Ulcers 侵蚀 / 溃疡 operforations 穿孔 Endoscopy 内窥镜

21 Endoscopy 内窥镜 endoscopy to retrieve or push object into stomach 内窥镜取出或将异物推进胃部 bones will be digested and/or defecated within 7-10 days 骨头将在 7-10 日内排出或消化 Gastrotomy 胃切开术 after FB is pushed into stomach 异物被推进胃中以后

22 Gastric Foreign Body 胃中异物 May cause intermittent blockage resulting in vomiting 可能导致间歇性堵塞造成呕吐 May be chronic in nature 可能是慢性

23 Gastric Foreign Body 胃中异物 Sid Vicious 席德 维瑟斯

24 Gastric Foreign Body 胃中异物 Sid Vicious 席德 维瑟斯 3 month-old Neutered male domestic shorthair cat 3 月大绝育公本土短毛猫 Owner noticed gagging and crunchy skin 饲主发现反胃和皮肤 碎屑

25 Gastric Foreign Body 胃中异物 Sid Vicious 席德 维瑟斯 3 month-old Neutered male domestic shorthair cat 3 月大绝育公本土短毛猫 Owner noticed gagging and crunchy skin 饲主发现反胃和皮肤 碎屑

26 Gastric Foreign Body 胃中异物 Sid Vicious 席德 维瑟斯 Abdominal exploratory surgery 腹部勘察手术

27 Gastric Foreign Body 胃中异物 Sid Vicious 席德 维瑟斯 Two-layer appositional closure 两层同位合口 Mucosa-submucosa 粘膜层 - 粘膜下层 Seromuscularis 血清肌层 Interupted or continuous pattern 间断或连续 Absorbable monofilament 可吸收的单纤维 PDS, Maxon, etc PDS, Maxon 等 No need for inverting pattern 不需要反向模式

28 Intestinal Foreign Body 肠内异物 Pongo 彭哥 2 year-old neutered male Dalmation 2 岁绝育公斑点狗 Presented for vomiting 因呕吐赴诊 1 week duration 持续一周 Normal exam 正常检查

29 Intestinal Foreign Body 肠内异物 Pongo 2 year-old neutered male Dalmation 2 岁绝育公斑点狗 Presented for vomiting 因呕吐赴诊 1 week duration 持续一周 Normal exam 正常检查

30 Intestinal Foreign Body 肠内异物 Pongo 彭哥 Possible partial intestinal obstruction 可能是局部肠梗阻 Some material seen in stomach 胃中可见某些物质

31 Intestinal Foreign Body 肠内异物 Pongo 彭哥 Possible partial intestinal obstruction 可能是局部肠梗阻 Some material seen in stomach 胃中可见某些物质 Sent home on maropitant and omeparazole 开 maropitant 和奥美拉锉后回家

32 Intestinal Foreign Body 肠内异物 Pongo 彭哥 Represented 1 month later with same symptoms 1 月后因同样症状赴诊 Lost 3.8 kg 体重减轻 3.8kg Pain on abdominal palpation 腹部触诊疼痛 Temp 体温 102.8

33 Intestinal Foreign Body 肠内异物 Pongo 彭哥 Abdominal ultrasound performed 进行腹部超声

34 Intestinal Foreign Body 肠内异物 Pongo 彭哥 Exploratory Surgery Performed 进行勘察手术

35 Intestinal Foreign Body 肠内异物 Pongo 彭哥 Exploratory Surgery Performed 进行勘察手术

36 Intestinal Foreign Body 肠内异物 Rudy 鲁迪 3 year-old intact male springer spaniel dog 3 岁史宾格犬 3 day history of vomiting 呕吐 3 天 Equivocal pain of abdominal papation 腹部触诊可疑疼痛

37 Intestinal Foreign Body 肠内异物 Rudy 鲁迪 Abdominal radiographs 腹部 X 光片

38 Intestinal Foreign Body 肠内异物 Rudy 鲁迪 Abdominal exploratory surgery 腹部勘察手术 Jejunal obstruction 空肠梗阻

39 Intestinal Foreign Body 肠内异物 Rudy 鲁迪 Enterotomy closed with single, appositional layer of suture 单层同位缝合关闭肠切开处 Absorbable monofilament suture 可吸收单纤维缝线

40 Intestinal Foreign Body 肠内异物 Ingestion of a porcupine 吞食箭猪

41 Intestinal Foreign Body 肠内异物 Ingestion of a porcupine 吞食箭猪

42 Intestinal Foreign Body 肠内异物 Ingestion of a porcupine 吞食箭猪

43 Gastric Dilatation and Volvulus (GDV) 胃扩张和扭转 (GDV) Gastric dilatation 胃扩张 Distension with fluid, air and froth 因液体, 空气和泡沫扩张 Volvulus 扭转 Rotation on the mesenteric axis 眼肠系膜轴旋转

44 Etiology 病因 Unknown 未知 Predisposing factors 发病诱因 Deep chested 胸腔深 Male 雄性 Underweight 体重不足 Rapid eater, SID feeding, elevated feeding 进食快,SID 喂养, 过度喂养 Food ingredients 食物成分 Fat or oil in first 4 前 4 个脂肪或油 Familial history 家族病史 GDV in 1 st degree relative 1 级亲属患 GDV GDV

45 Gastric dilatation and Volvulus Gastric distention compresses caudal vena cava causing decreased venous return to heart 胃扩张压迫尾端体腔静脉导致静脉回心血量下降 Decreased tissue perfusion 组织灌输降低 Redistributive shock 再分配休克 胃扩张和扭转

46 Gastric dilatation and Volvulus Tachycardia 心动过速 Poor pulse quality 脉搏质量差 Non-productive retching 非生产性恶心 Abdominal distention 腹胀 Pale mucuous membranes 粘膜颜色浅 胃扩张和扭转

47 Gastric dilatation and Volvulus 胃扩张和扭转 Mortality rate between 15-55% 死亡率 15-55% Risk factors for mortality low body temp, time (>6 hours prior to presentation), gastric necrosis, acute renal failure, hypotension at any time, concurrent gastrectomy/splenectomy, pre-op cardiac arrythmia, sepsis, peritonitis 死亡风险因素 - 低体温, 时间 ( 发作超过 6 小时 ), 胃部坏死, 急性肾衰竭, 随时高血压, 同时胃切开术 / 脾切除术, 术前心律失常, 败血症, 腹膜炎 50% will develop cardiac arrhythmias 50% 发生心律失常 (hypoperfusion, lactic acidosis, electrolyte imbalance, ischemic reperfusion injury, oxygen free radicals, pancreatic production of MDF) ( 灌注不足, 酸中毒, 电解质紊乱, 缺血性再灌损伤, 氧自由基, 胰腺生成 MDF)

48 Physical exam 体检 History 病史 MDB, if time allows 若时间允许,MDB Radiographs-most useful diagnostic tool X 光 - 最有用的诊断工具 Right lateral 右侧视角 Diagnostic for GDV GDV 诊断 Diagnostics 诊断

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50 Food bloat (GD) 食物膨胀

51 Radiographs X 光 Free gas 自由气体 Between stomach and liver and diaphragm on lateral radiograph X 光侧视时在胃, 肝脏和隔膜之间 Horizontal beam with animal in left lateral recumbency 动物左侧斜躺时水平光柱 Standing lateral x-ray can help reveal free air due to a ruptured stomach or colon 站姿侧视 X 光可帮助显示有胃或结肠破裂造成的自由气体

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53 Biochemical analyses (not on DPL fluid) 生化分析 ( 不是 DPL 液体 ) Glucose (septic) 葡萄糖 ( 败血症 ) Bonczynski JJ, et al. Vet Surg 2003;32: gradient of >20mg/dL between blood and abdominal glucose (100% sensitivity and specificity in dogs) 血液和腹腔葡萄糖浓度 >20mg/dL( 犬类 100% 敏感性和特异性 )

54 Large bore venous catheters in front limbs 前肢大口径静脉导管 Fluid resuscitation with crystalloids 晶体液体复苏 Decompression (stomach tube, trochar) not a benign procedure 降压 ( 胃管, 套针 )- 不是很好做的手术 Resuscitation 复苏

55 Decompression 减压 Stomach tube 胃管 Sedation 镇静 Larger volume 大量

56 Decompression 减压 Trocharization Simple 简单 Lower volume evacuated 排出体积较少 No difference in effectiveness or survival 效果和存活率上无差别

57 Gastric necrosis 胃坏死 CBC changes are nonspecific CBC 变化不明确 Chemistry reveals a metabolic acidosis 化学显示代谢性酸中毒 Fluid resuscitation will reverse acidosis 液体复苏可逆酸中毒 Blood Lactate > 6.0 mmol/l indicates likely gastric wall necrosis 血液乳酸 >6.0mmol/L 预示很有可能胃壁坏死 Specificity 88% 特异性 88% Sensitivity 61% 敏感型 61% Can be helpful prognostic indicator 可以作为有用的预后指标 34% mortality with gastric necrosis 患胃坏死 34% 死亡率 2% mortality without gastric necrosis 未患胃坏死 2% 死亡率

58 Zacher, LA, Berg, J, Shaw, SP, et al.: Association between outcome and changes in plasma lactate concentration during presurgical treatment in dogs with gastric dilatation-volvulus: 64 cases ( ). J Am Vet Med Assoc. 236, 2010, 892. Survival rates, using optimal cutoff values, were significantly lower for dogs with: 使用最理想分界值, 以下情况下犬存活率较低 : Post treatment lactate concentrations above 6.4 mmol/l (23%), 治疗后乳酸盐浓度超过 6.4mmol/L(23%) Absolute changes in lactate concentration of 4 mmol/l or less (10%), 乳酸浓度绝对变化小于 4mmol/L(10%) Percentage change in lactate concentrations of 42.5% or less (15%) than in those that responded to fluids and gastric decompression. 乳酸浓度变化百分比为 42.5%(15%) 或小于液体和胃部减压起疗效的犬

59 Surgery once.. 以下情况进行手术.. Surgery for GDV GDV 的手术 Patient has stabilized, or 病患情况稳定或 All efforts have been made to stabilize patient 已采用其他所有方法

60 Surgery for GDV GDV 的手术 Surgery once.. 以下情况进行手术.. Patient has stabilized, or 病患情况稳定或 All efforts have been made to stabilize patient 已采用其他所用方法 Goals 目标 Derotate stomach 胃部扭转回复 Finish gastric decompression 完成胃部减压 Assess tissue for viability 检查组织活力 Perform gastropexy 进行胃固定术

61 Midline celiotomy 中线剖腹 Make a long incision to reduce tension 用长切口降低张力 Derotate stomach 胃部扭转回复 Grip pylorus with right hand and pull ventrally and towards you 右手抓住幽门向前 靠近自己牵拉 Push fundus with left dorsally and away from you 左边向后 远离自己的方向推胃底 Surgery for GDV GDV 的手术

62 Assess stomach tissue viability 检查胃组织活力 Cardia, fundus and along greater curvature are typical locations for tissue comprimise 组织损害通常位于胃前, 胃底和胃大弯 Surgery for GDV GDV 的手术

63 Assess stomach tissue viability 检查胃组织活力 Nonviable colors 不能存活的颜色 Gray 灰色 Black 黑色 Dark purple 深紫色 Surgery for GDV GDV 的手术

64 Assess stomach tissue viability 检查胃组织存活能力 Nonviable colors 不能存活的颜色 Gray 灰色 Black 黑色 Dark purple 深紫色 Comprimised but viable colors 受损但可存活的颜色 Light purple 浅紫色 Red 红色 Surgery for GDV GDV 手术

65 Assess stomach tissue viability 检查胃组织存活能力 Texture 质地 Two layer slip-normal 两层片 - 正常 This layer comprimised 这一层 - 受损 Surgery for GDV GDV 的手术

66 Resection of nonviable tissue 切除不能存活的组织 Cut and suture 切除并缝合 Surgery for GDV GDV 手术

67 Surgery for GDV GDV 手术 Splenic comprimise 脾脏受损 Tearing of short gastrics associated with volvulus (often blood in abdomen) 胃部微小撕裂与肠扭转关联 ( 腹腔常有血液 ) Thrombosis of vessels 血管血栓 Inspect 检查 Splenectomy if compromised (rare) 如果受损切除脾脏 ( 很少见 )

68 Gastropexy 胃固定术 Prevents recurrence 防止复发 5% with pexy vs 80% without 固定后 5% 复发 vs 未固定 80% 复发 Many techniques 很多技巧 Incisional is the most simple 切开固定最简单 Surgery for GDV GDV 手术

69 Gastropexy 胃固定术 2-0 monofilament absorbable suture 2-0 单纤维可吸收缝线 Suture furthest edges together first in simple continuous 用简易连续方法先缝合最远边缘 Suture nearest edges together last in simple continuous 用简易连续方法最后缝合最近边缘 Surgery for GDV GDV 手术

70 Post operative complications Arrhythmias 心律失常 术后并发症 DIC 弥散性血管内凝血 Sepsis/ARDS/MODS/SIRS 败血症 / 急性呼吸窘迫综合症 / 多器官功能障碍综合症 / 全身炎症反应综合症 Gastric ulceration 胃溃疡 Reflux esophagitis 反流性食管炎 Aspiration pneumonia 吸入性肺炎

71 Prognosis 预后 Good to guarded 良好到正常 Aspiration pneumonia 吸入性肺炎 Gastric necrosis 胃坏死 DIC 弥散性血管内凝血 MODS 多器官功能障碍综合症 Sepsis 败血症 Mortality 死亡率 Dilatation 扩张 : 0.9% Volvulus 肠扭转 : ~15-55% Recurrence 复发 Pexy 固定 : <5% No Pexy 未固定 : 80%

72 Post operative complications Arrhythmias 心律失常 术后并发症 DIC 弥散性血管内凝血 Sepsis/ARDS/MODS/SIRS 败血症 / 急性呼吸窘迫综合症 / 多器官功能障碍综合症 / 全身炎症反应综合症 Gastric ulceration 胃溃疡 Reflux esophagitis 反流性食管炎 Aspiration pneumonia 吸入性肺炎

73 Take home notes 学习记忆要点 High suspicion most likely warrants surgical exploration 高度怀疑时大多数情况采取勘察手术 When, and if, to explore can be a very challenging decision and is influenced by many factors 是否进行 何时进行勘察是很具挑战的问题并受多种因素影响 Severe abdominal pain highest consideration to surgical intervention 严重腹痛 - 着重考虑手术 Hemodynamic stability prior to anesthesia maximizes long term outcome (may or may not be possible) 麻醉前血液动力稳定使长期结果最优化 ( 也许可能, 也许不可能 ) Early surgical intervention (when indicated) minimizes anesthetic risk and maximizes post-operative outcome in the stable patient 尽快手术 ( 决定后 ) 将麻醉风险最低化并使稳定病患术后结果最优化 Don t forget about the rest of the patient 不要忘记病患其他情况