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Compendium April 2013 (Vol 35, No 4)

Surgical Views: Incisional Gastropexy to Prevent and Treat Canine Gastric Dilatation-Volvulus

by Clarence Rawlings, DVM, PhD, DACVS

    Abstract

    Gastric dilatation-volvulus (GDV) is a life-threatening emergency in large-breed and deep-chested dogs. This article describes a technique for incisional gastropexy that can be used during emergency surgical treatment or, preferably, as a preventive procedure in a healthy, GDV-susceptible dog. Gastropexy can be done during a traditional laparotomy, as described here, or as a laparoscopically assisted procedure, as described elsewhere.

    Gastric dilatation-volvulus (GDV) is a life-threatening emergency in large-breed and deep-chested dogs.1–7 Signs of GDV include abdominal distention, retching without vomiting, excessive salivation, and abdominal discomfort. The dog may become weak and recumbent and develop signs of shock. Signs are often reported as developing soon after eating a large meal, drinking a large amount of water, eating from an elevated bowl, and being active or excited.1 Whether life-threatening bloat develops depends on whether the stomach is only distended or is distended and rotated (volvulus). When the stomach rotates, venous return from the abdomen is obstructed, and hypovolemic and toxic shock develop.7 Bloat signs are usually reversible if the stomach is only distended and excess gas and fluid are expelled. Although a wide variety of management procedures are touted as preventing gastric distention, only a gastropexy can prevent GDV once distention develops.

    Any GDV-susceptible dog with acute abdominal distention or pain after eating should be considered an emergency. Emergent care focuses on diagnosis and initial treatment of shock or dyspnea, when present. Treatment for shock requires rapid administration of intravenous fluids. Sedatives and narcotics are administered to facilitate passing a large and relatively rigid stomach tube. If the tube cannot be passed, gastrocentesis may be required. For some bloated dogs, gastric intubation during heavy sedation can be achieved by suspending them from their front legs and holding them erect with their head up. If decompression using a stomach tube is successful, radiography should be performed. If volvulus is present, emergency surgery is indicated.

    Successful surgery requires continued shock treatment, general anesthesia, and abdominal surgery to reposition and evaluate the stomach and abdominal organs, followed by a gastropexy, which secures the gastric antrum to the right side just caudal to the last rib. I have also performed laparoscopic correction of GDV in carefully selected dogs. Some dogs require additional surgery, such as partial gastrectomy, removal of gastrointestinal foreign bodies, biopsy of masses, or even splenectomy. Even with surgical treatment, mortality from GDV has been reported as 16%,8 18%,8and 24%3 in large, retrospective studies. Without a gastropexy, >80% of affected dogs experience recurrence and die within a year; recurrence is less than 5% in dogs receiving a gastropexy.4 Medical treatment carries a guarded prognosis, which provides an indication for emergent surgical exploration and gastropexy in patients with GDV. Even dogs treated successfully without surgery should have a gastropexy in the near future.

    Gastropexy can be done electively to prevent GDV, using the same techniques as those developed for emergency surgery.6,9,10 A secure gastropexy can help prevent gastric volvulus when gastric dilatation occurs. Gastropexy techniques that have proven to be strong, can be quickly performed by experienced surgeons, and have minimal complications include incisional, circumcostal, and belt-loop gastropexies.7 Gastropexy can be done during a traditional laparotomy, as described here, or as a laparoscopically assisted procedure, as described elsewhere.11–13 Other less invasive gastropexy techniques include a minilaparotomy by a right-side grid approach,14 gastroscopic-assisted gastropexy,15 and laparoscopically sutured gastropexy.16 Many technical variations of these procedures have been developed according to the surgeon’s experience. My preferred technique is described below.

    Patient Selection for Elective Gastropexy

    A prophylactic gastropexy should be discussed with the client at the first examination of a breed-susceptible puppy or at the initial visit for a new pet or new client. This topic should be integrated into discussions involving nutrition, training, immunization, parasite control, and sterilization. One study found that large-breed (Akita, bloodhound, collie, Irish setter, rottweiler, standard poodle, and Weimaraner) and giant-breed (Great Dane, Irish wolfhound, greater Swiss mountain, Newfoundland, and Saint Bernard) dogs had a 6% cumulative incidence of GDV, with GDV accounting for 16% of all deaths in these breeds.17 The lifetime risk for bloating (95% confidence interval) ranged from 3.9% (0% to 11.2%) for rottweilers to 36.7% (25.2% to 44.6%) for Great Danes.6 Mixed-breed dogs with a body size and shape similar to those of GDV-susceptible breeds are also susceptible. Some dogs inherit a risk for GDV; dogs that have a first-order relative (parent or sibling) with GDV have a marked increased likelihood of developing GDV.18 Most affected dogs are middle-aged, with dogs older than 7 years being at least twice as likely to develop GDV as 2- to 4-year-old dogs.1 Because middle-aged and older dogs are more frequently affected, and because the incidence increases with age, older dogs remain candidates for prophylactic gastropexy. Other candidates include dogs with behaviors linked to gastric dilatation, including gulping large amounts of dry food, drinking copious amounts of water right after eating, and exercising vigorously soon after meals.

    During discussions with owners of GDV-susceptible dogs, clinicians should reference the statistics of lifetime risk factors for GDV and the mortality rate in affected dogs, based on studies such as those mentioned above.17,18 Clients who search for information about GDV on the Internet should be cautioned to look for evidence-based rather than anecdotal reports. A December 2011 Google search produced more than 60 pages of Web sites and blogs about GDV and gastropexies. While some sites were evidence based, many stressed that GDV-susceptible dogs will not bloat if they are fed non-cereal dry diets in combination with recommended feeding and exercise guidelines, which is not always true. Even when some evidence-based guidelines are practiced, many dogs still experience GDV. Owners need to further appreciate that even with aggressive treatment, many dogs with GDV die, and emergency surgery for GDV is costly. Another concern is the idea that, because the risk for GDV may be inherited, GDV-susceptible breeding dogs should be given the opportunity to develop GDV to help determine whether they should be bred. This approach is not practical because most dogs that experience GDV are past their prime reproductive age. I encourage clinicians to discuss the rationale for a preventive gastropexy with owners of GDV-susceptible dogs, even if a dog is middle-aged.

    Preoperative Patient Management

    Most patients that undergo a prophylactic gastropexy are healthy or have only mild systemic disease, thus permitting the general anesthesia technique favored by the practice. As with any gastrointestinal surgery, appropriate management should reduce the likelihood and complications associated with vomiting. The patient should be fasted in an effort to avoid reflux during anesthesia. Additional treatment to reduce the effects of reflux may be attempted using products such as famotidine, pantoprazole, or omeprazole. In emergency and bloated patients, drugs such as prokinetics (e.g., metoclopramide) and histamine-2 receptor antagonists are used in an attempt to reduce the risk of aspiration pneumonia. Because a prophylactic gastropexy is a quick, noncontaminated procedure, antibiotics are usually not appropriate. If the gastric lumen is entered during dissection or suturing, antibiotics may be administered. Perioperative analgesia should be provided.

    Operating Technique for Incisional Gastropexy

    The dog is placed in dorsal recumbency, and the primary surgeon stands on the patient’s left side. The technique described here is markedly enhanced when an assistant stands on the right side of the patient to retract and position viscera.

    For a prophylactic gastropexy, the abdominal incision is made on the cranial midline and should be long enough to permit the surgeon to easily insert a hand into the abdomen for identification and retraction of the antrum. A longer incision and self-retaining retractor are required to do a complete abdominal exploration. Tissues are periodically moistened, but I rarely use laparotomy sponges and retractors for elective gastropexies.

    The oral and aboral ends of the gastropexy are determined so that the gastropexy aboral commissure is approximately 6 cm from the pylorus and the gastric antral incision is 4 to 5 cm long. Traction sutures should be placed at each end of the antral incision. Traction sutures can be secured with a figure-of-eight pattern to provide greater anchoring. The incision into the antrum can be preceded by rolling the antral wall to “slip” the membranes, developing a plane between the seromuscular and the submucosal layers. A #10 blade is used to make the initial incision through the seromuscular layer to nearly the gastric mucosa. A Metzenbaum scissors is then used to dissect the submucosa from the seromuscular layer and to extend the seromuscular incision. The submucosa and mucosa should “bulge” without any restriction from submucosal fibers. Two towel clamps are used to retract the right abdominal wall, which requires one hand of the assistant surgeon. Exposure can be improved by using the fingertips to apply pressure to the abdominal wall while pulling laterally on the towel clamps. A mirror image of the antral incision is made through the transversus abdominis muscle, running parallel and 4 to 5 cm caudal to the caudal rib (FIGURE 1A, FIGURE 1BFIGURE 1C , and VIDEO 1).a

    I prefer to place a continuous reenforcing suture line to appose the abdominal wall to the antrum, approximately 2 cm distal to the incisions. This line is started in the deepest part of the site before the primary closure is started. This reenforcing suture maintains the antrum in the appropriate position near the transversus abdominis incision and relieves tension on the primary gastropexy sutures. Some surgeons prefer not to use this second suture line, but at least a few interrupted sutures aid in maintaining position while the primary closure is completed. Both patterns are continuous, using a 2-0 synthetic slowly absorbable suture, such as polydioxanone, and a taper-point needle. I prefer to do the cranial suturing first, starting with the reenforcing layer and then the primary closure (FIGURE 2AFIGURE 2BFIGURE 2C , and VIDEO 2). The sutures are each tied at the medial commissure, and the cranial side of the primary gastropexy suture line is then continued around the caudal side. It will be tied to the tag left from the knot that started the cranial side (FIGURE 3AFIGURE 3B , and VIDEO 3). The reenforcing suture is then continued around the caudal side (FIGURE 4AFIGURE 4B , and VIDEO 4). Extreme care should be taken to ensure a wide bite of the seromuscular layer without entering the gastric lumen. Avoiding needle and suture penetration of the gastric lumen is facilitated by dissection with the Metzenbaum scissors when making the initial incision, consistent needle entry from the gastric incision side, and good exposure of the seromuscular layer while suturing.

    Before the abdomen is closed, the gastropexy site is examined and lavaged. There should be no evidence of twisting or extraluminal obstruction. The abdomen is closed in a standard three-layer fashion.

    Patient Management After Surgery

    Injectable analgesia is routinely administered for the first few hours after surgery, and an NSAID is provided after discharge. Most elective patients are discharged the morning after surgery with instructions to feed small meals on that day. Management of emergency patients after surgery frequently requires extended critical care based on clinical signs. Abdominal ultrasonography performed 6 to 12 months after surgery is recommended to identify adhesions typical of a gastropexy.12,19

    Dogs with a gastropexy can still develop gastric dilatation, but an effective gastropexy should prevent volvulus. When these dogs develop gastric dilatation, medical treatment should be adequate for resolution. If a gastropexy is known to be present, the emergency clinician should start medical treatment and examine the patient for radiographic signs of volvulus before making a decision to operate.

    Downloadable PDF

    Dr. Rawlings discloses that he has received financial benefits from Covidien, Ethicon, and Karl Storz Veterinary Endoscopy.
    aAll photographs and videos are as viewed by the primary surgeon standing on the left side of the patient, and the patient’s head is to the right.

    References

    1. Glickman LT, Glickman NW, Perez CM, et al. Analysis of risk factors for gastric dilatation and dilatation-volvulus in dogs. J Am Vet Med Assoc 1994;204:1465-1471.

    2. Glickman LT, Glickman NW, Schellenberg DB, et al. Multiple risk factors for the gastric dilatation-volvulus syndrome in dogs: a practitioner/owner case-control study. J Am Anim Hosp Assoc 1997;33:197-204.

    3. Glickman LT, Lantz GC, Schellenberg, Glickman NW. A prospective study of survival and recurrence following the acute gastric dilatation-volvulus syndrome in 136 dogs. J Am Anim Hosp Assoc 1998;34:253-259.

    4. Eggertsdóttir AV, Moe L. A retrospective study of conservative treatment of gastric dilatation-volvulus in the dog. Acta Vet Scand 1995;36:175-184.

    5. Moore GE, Burkman KD, Carer MN, et al. Causes of death or reasons for euthanasia in military working dogs: 927 cases (1993-1996). J Am Vet Med Assoc 2001;219:209-214.

    6. Ward MP, Patronek GJ, Glickman LT. Benefits of prophylactic gastropexy for dogs at risk of gastric dilatation-volvulus. Prev Vet Med 2003;60:319-329.

    7. Fossum TW. Surgery of the stomach. In: Fossum TW, ed. Small Animal Surgery. 3rd ed. St Louis, MO: Mosby Elsevier; 2007:409-443.

    8. Beck JJ, Staatz AJ, Pelsure DH, et al. Rick factors associated with short-term outcome and development of perioperative complications in dogs undergoing surgery because of gastric dilatation-volvulus: 166 cases (1991-2003). J Am Vet Med Assoc 2006;229:1934-1939.

    9. Belandria GA, Pavletic MM, Boulay JP, et al. Gastropexy with an automatic stapling instrument for the treatment of gastric dilatation and volvulus in 20 dogs. Can Vet J 2009;50:733-740.

    10. Eggertsdóttir AV, Stigen y Ø, Lønaas L, et al. Comparison of the recurrence rate of gastric dilatation with and without volvulus in dogs after circumcostal gastropexy versus gastrocolopexy. Vet Surg 2001;30:546-551.

    11. Rawlings CA, Foutz TL, Mahaffey MB, et al. A rapid and strong laparoscopic-assisted gastropexy in dogs. Am J Vet Res 2001;62:871-875.

    12. Rawlings CA, Mahaffey MB, Bement S, et al. Prospective evaluation of laparoscopic-assisted gastropexy in dogs susceptible to gastric dilatation. J Am Vet Med Assoc 2002;221:1576-1581.

    13. Rawlings CA. Laparoscopy. In: Tams TR, Rawlings CA, eds. Small Animal Endoscopy. St Louis, MO: Elsevier Saunders; 2010:431-435.

    14. Steelman-Szymeczek SM, Stebbins ME, Hardie EM. Clinical evaluation of a right-sided prophylactic gastropexy via a grid approach. J Am Anim Hosp Assoc 2003;39:397-402.

    15. Dujowich M, Keller ME, Beimer SB. Evaluation of short- and long-term complications after endoscopically assisted gastropexy in dogs. J Am Vet Med Assoc 2012;236:177-182.

    16. Mayhew PD, Brown DC. Prospective evaluation of two intra-corporeally sutured prophylactic laparoscopic gastropexy techniques compared to laparoscopic-assisted gastropexy in dogs. Vet Surg 2009;38:738-746.

    17. Glickman LT, Glickman NW, Schellenberg DB, et al. Non-dietary risk factors for gastric dilatation-volvulus in large and giant breed dogs. J Am Vet Med Assoc 2000;217:1492-1499.

    18. Glickman LT, Glickman NW, Schellenberg DB, et al. Incidence of breed-related factors for gastric dilatation-volvulus in dogs. J Am Vet Med Assoc 2000;216:40-45.

    19. Wacker CA, Weber UT, Tanno F, et al. Ultrasonographic examination of adhesions induced by incisional gastropexy in 16 dogs. J Small Anim Pract 1998;39:379-384.

    References »

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