Assessment of Gastric Health. Approach to Partial Gastrectomy. Splenectomy. Gastric Dilatation/Over-Distension

Transcription

1 Questins n Gastric Dilatatin-Vlvulus Syndrme Assessment f Gastric Health Apprach t Partial Gastrectmy Splenectmy Gastric Dilatatin/Over-Distensin

2 Hw d I evaluate gastric wall health? Clur: Nrmal gastric wall clur is pink Hyperaemic gastric sersal surface indicates the stmach wall is likely viable Black areas f gastric sersa is nn-viable and is an indicatin fr partial gastrectmy White areas f gastric sersa is nn-viable, and is an indicatin fr partial gastrectmy Bld supply Viable gastric wall will bleed freely if the sersal surface is cut Nn-viable gastric wall will either nt bleed, r will ze dark bld if the sersal surface is cut Flurescein injected int gastrepiplic arteries Flurescein dye may be injected int arteriles supplying areas f questinable viability in the gastric wall. Failure f flurescein t enter any regin f the stmach wall indicates pr gastric viability and will indicate partial gastrectmy shuld be perfrmed

3 When shuld I remve the spleen? Splenectmy shuld be cnsidered in the fllwing situatins Splenic trsin. The stmach shuld be de-rtated prir t splenectmy even if the spleen is trsed, but be sure t avid inadvertently un-twisting the spleen during this maneuvre. Grss splenic engrgement. Splenic engrgement ccurs as a result f splenic venus cmpressin. Grssly engrged spleens cntain many inflammatry mediatrs released frm dead and dying splenic cells. Remval f a grssly engrged spleen reduces systemic inflammatin in the pst-perative perid. Partial splenic avulsin. Avulsin f the splenic vasculature shuld prmpt splenectmy.

4 What abut simple gastric dilatatin? Is surgery warranted? Gastric ver-distensin will result in many f the same pathphysilgical events as gastric dilatatin-vlvulus syndrme, including gastric vein cmpressin, gastric wall damage, and altered gastric mtility in the ensuing perid fllwing distensin. As such, severe gastric ver-distensin shuld be cnsidered a medical emergency requiring decmpressin. A number f patients will develp GDV sme hurs t weeks fllwing gastric verdistensin in fact gastric ver-distensin ften precedes the develpment f GDV, and fr this reasn, many authrs recmmend prphylactic gastrpexy at the time f gastric ver-distensin r shrtly fllwing this event.

5 Hw D I Perfrm Partial Gastrectmy? Partial gastrectmy is indicated in patients with devitalised stmach wall. Several techniques have been described, including invaginatin f the devitalised gastric submucsa/mucsa, and full-thickness partial gastrectmy. The fllwing diagrams illustrate the preferred technique, which is a cmbinatin f full-thickness partical gastrectmy and invaginatin. Step 1: Identify the gastric regin t be resected Step 2: Evert the regin t be resected and clamp at the base with Dyen intestinal frceps Step 3: Suture the gastric wall at the base f the Dyen intestinal frceps.

6 Step 4: Remve the devitalised gastric segment, leaving a small amunt f everted gastric wall Step 5: Incise the sersa and muscularis layers f the stmach just lateral t the everted gastric wall Step 6: Perfrm and inverting simple cntinuus suture t clse the stmach wall. This results in sersa-t-sersa appsitin, and mucsa-t-mucsa appsitin in a tw-layer gastric wall clsure