Selected Cases of Gastrointestinal Surgery 胃肠外科案例精选 · 2017-07-27 · Common...

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

Selected Cases of Gastrointestinal Surgery胃肠外科案例精选

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

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…


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

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


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

“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. ” http://medical-dictionary.thefreedictionary.com/acute+abdomen

“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

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

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

Diameter of largest SI loopHeight 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 2.5-3 rib widths as upper end of normal SI diameter

也可使用2.5-3倍肋骨宽度作为正常小肠直径上限

0.65 cm

0.40 cm

SI/L5 = 0.65/0.40 = 1.625

Diagnostics 诊断

• 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

Radiographic FindingsX光片发现

Contrast Radiographs 对照影像

• 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

• Barium 钡• If concerned about

perforation use iodinated contrast agent

如果担心有穿孔就用含碘造影剂

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

Radiographs射线光片

• Baylor 贝勒

– 1 year-old neutered male Labrador retriever 1岁公绝育拉布拉多寻回犬

RadiographsX光片

• Don’t Forget about the Esophagus 不要忘记食道

– Vomiting vs. regurgitation 呕吐v回流

Common F.B. Obstruction Sites常见异物梗阻点

1. Cervical constriction 颈收缩

n at level of cricopharyngeal sphincter 在环咽括约肌处

2. Thoracic inlet 胸部入口

n 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

n bronchoaortic constriction 支气管动脉收缩

4. Diaphragmatic constriction 横膈膜收缩

n at the hiatus 在裂孔处

n 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%）

Endoscopy内窥镜

oEndoscopy内窥镜 n 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！！！

n 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

• 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

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


• 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”



– Abdominal exploratory surgery

腹部勘察手术


• 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

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


• Pongo– 2 year-old neutered

male Dalmation2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


• 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


• 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


• 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. 102.8体温102.8


• Pongo彭哥

– Abdominal ultrasound performed

进行腹部超声


• Pongo彭哥

– Exploratory Surgery Performed

进行勘察手术


• 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


• Rudy鲁迪

– Abdominal radiographs

腹部X光片


• Rudy鲁迪

– Abdominal exploratory surgery

腹部勘察手术

– Jejunal obstruction

空肠梗阻


• 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


Ingestion of a porcupine

吞食箭猪

• 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

Gastric Dilatation and Volvulus (GDV)胃扩张和扭转（GDV）

http://puppyer.com/img/articles/1/gastric-dilatation-volvulus-bloat_3_118.jpg

GDV 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

n Fat or oil in first 4前4个脂肪或油

Familial history家族病史n GDV in 1st degree relative1级亲属患GDV

Gastric dilatation and Volvulus胃扩张和扭转

• 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


• 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


• 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 arrhythmias50%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）

Diagnostics诊断

• Physical exam 体检

• History 病史

• MDB, if time allows若时间允许，MDB• Radiographs-most useful

diagnostic toolX光-最有用的诊断工具

– Right lateral 右侧视角

– Diagnostic for GDVGDV诊断

Food bloat (GD)食物膨胀

RadiographsX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

Biochemical analyses (not on DPL fluid)生化分析（不是DPL液体）

• Glucose (septic) 葡萄糖（败血症）

– 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）

Bonczynski JJ, et al. Vet Surg 2003;32:161–6.

Resuscitation复苏

• 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

Decompression减压

• Stomach tube胃管

– Sedation镇静

– Larger volume大量

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

Gastric necrosis胃坏死• CBC changes are nonspecificCBC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

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 (2002–2008). 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

Surgery for GDVGDV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已采用其他所有方法

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


– 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


– 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



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 GDVGDV手术


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



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


– Resection of nonviable tissue

切除不能存活的组织• Cut and suture切除并缝合


• 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）


• 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


• Gastropexy胃固定术– 2-0 monofilament

absorbable suture2-0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

Post operative complications术后并发症

• Arrhythmias心律失常

• 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

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%

Post operative complications术后并发症

• Arrhythmias心律失常

• 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

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

Selected Cases of Gastrointestinal Surgery 胃肠外科案例精选 · 2017-07-27 · Common...

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