VSR 421: Regional Veterinary Surgery (2+1)

PYLORIC STENOSIS - TREATMENT

Medical management

• Dehydration, electrolyte & acid – base abnormalities should be corrected
• H 2 blockers.
• Antibiotics  is indicated for esophagitis due to  ulceration aspiration.

NOTE – Gastric prokinetics ( metoclopramide and cisapride ) should not be used if outflow obstruction is suspected.

Surgical management

presurgical preparation

• Withheld of the food for 24 hours before surgery.
• Presurgical endoscopy – – To define the extent of the lesion. – To confirm benign or malignant nature.
• Intravenous prophylactic antibiotics e.g., cefazolin ; 22 mg / kg i /v once or twice at 2-4 hrs interval.

Premedictaion

• Atropine (0.02-0.04 mg/kg s/c, I /m)
• Butorphanol (0.2-0.4 mg/kg s/c, i /m)

Induction

• Propofol (4-6 mg/kg i /v) or ketamine -diazepam
• Maintenance

Isoflurane

Site

• Dorsal recumbency
• Abdomen is prepared for a ventral midline incision – Extended from mid thorax to near the pubis.

Ventral midline celiotomy

• Surgical procedure include Pyloromyotomy, Pyloroplasty, Billroth I ( Gastroduodenostomy ) & Billroth II ( Gastrojejunostomy)
  • Pyloromyotomy – an incision is made through the serosa & muscularis layers of the pylorus only.
  • Pyloroplasty – a full thickness incision and tissue reorientation are performed to increase the diameter of the gastric outflow tract.
  • Billroth I – removal of the pylorus ( pylorectomy ) & attachment of the stomach to the duodenum ( gastroduodenostomy )
  • Billroth II – attachment of the jejunum to the stomach ( gastrojejunostomy ) after a partial gastrectomy ( including pylorectomy )

Fredet – Ramstedt pyloromyotomy

Procedure – It is simplest & easiest one. It probably provides only temporary benefit because healing may lessen the lumen size.

• Hold the pylorus between the index finger & thumb in the hand.
• Select a hypo vascular area of the ventral pylorus, & make a longitudinal incision through the serosa & muscularis, but not through the mucosa.
• Make sure that the mascularis layer is completely incised, to allow the mucosa to bulge into the incision site.
• If the mucosa is inadvertently penetrated, suture it with interrupted sutures of 2 – 0 or 3 – 0 absorbable suture material.

Heineke – Mikulicz pyloroplasty (transverse pyloroplasty)

• 3 - 5 cm longitudinal full thickness incision is made on the antimesenteric border, centered over the pylorus..
• Stay sutures are placed at mid – distance on either side of the longitudinal incision; traction is applied to convert the incision to a transverse orientation.
• The incision is closed in one layer with a simple interrupted or continuous appositional pattern.

Y – U Advancement Pyloroplasty

• Y shaped full thickness incision is centered over the pylorus ; the body of the Y extends along the antimesenteric border of the duodenum & the arms of the Y extended onto the pyloric antrum.
  •  The point of the U shaped flap is apposed to the end of the Y with a simple interrupted suture.
  •  The two sides of the resulting U shaped incision are sutured in a simple interrupted or continuous appositional pattern.