Abstract: Background and Objective: Gastric dilatation-volvulus (GDV) is an acute medical and surgical condition caused by several pathophysiologic effects that occur secondary to gastric distention and malpositioning. Materials and Methods: Surgical procedures utilized in the treatment of gastric dilatation-volvulus can be divided into 2 categories, (1) Immediate decompression and (2) Therapeutic gastropexy. Immediate decompression is performed with a successfully passed stomach tube secured to the patient or temporary gastrostomy as described. Therapeutic or prophylactic gastropexy techniques are described. As anatomic repositioning of the stomach is necessary to perform prior to permanent gastropexy. Repositioning occasionally occurs spontaneously at the time of gastric decompression. Knowledge of normal anatomy is necessary to understand how repositioning is performed. A specific ‘Surgical Plan’ should be in mind before entering the operating room theatre. This will improve the efficiency of surgery and thus decrease overall surgery time. Conclusion: Gastric dilatation volvulus (GDV) is characterized by accumulation of gas within the stomach, rotation of the stomach, failure of eructation and pyloric emptying, increased gastric pressure and shock. It can be acute or, more rarely, can be chronic, acute cases can be rapidly fatal. It is common in deep-chested dogs and the risk of a large or giant breed dog developing. Rapid diagnosis, stabilization and surgical management can lead to a good prognosis for these dogs. The treatment of gastric dilatation-volvulus with two principal surgical techniques.
INTRODUCTION
The gastric dilatation-volvulus (GDV) is a medical emergency and surgical procedure, which occurs almost exclusively on large dogs. It usually characterizes by an accumulation of air and liquid in the stomach which causes dilation, followed or not by its twisting. The consequences are on the one hand local, with ischemia at the gastric level and on the other, systemic, by decreased venous return. A treatment, corrective surgery and close postoperative necessary to minimize the gastric but also cardiac consequences of ischemia. Despite intensive care, this condition is fatal in 15-40% of cases1,2.
EMERGENCY CARE IN GDV
Decompression: Generally, orogastric intubation can successfully be performed in 80-90% of GDV patients. Decompression via flank needle puncture should be attempted in cases difficult to intubate or severely depressed metabolically deranged patients3,4,1.
Technique: The stomach tube is measured to the last rib and marked with a piece of tape. A stiff foal or mare stomach tube with a smooth beveled tip works best (having several diameter and stiffness tubes is ideal). Apply adequate lubrication to the tube. Place a functional mouth speculum, generally a roll of 2" tape secured in the mouth with tape encircling the muzzle. As the stomach tube is passed, it will generally meet resistance at the esophageal stomach junction. Pass the tube firmly in a twisting manner to pass the lower esophageal sphincter5-7.
If unsuccessful, place the patient in various positions and attempt to pass the tube (i.e., elevate animal at 45 degree angle with rear feet on floor and forefeet on table, right lateral recumbancy and left lateral recumbancy). This movement may encourage the stomach to rotate enough to allow tube passage. Be careful not to position the patient in dorsal recumbancy as this will increase abdominal visceral pressure on the caudal vena cava and may exacerbate signs of shock8. If a stomach tube was successfully passed, stomach contents should be evaluated for color and presence or absence of necrotic looking gastric mucosa. This may give an impression of gastric viability9,10.
Fluids: Shock dosage of polyionic isotonic fluid is carefully administered to expand the vascular compartment. Patients are frequently monitored during fluid administration to determine ultimate fluid rate and amount. One or two indwelling cephalic catheters are placed10,11.
SURGICAL TREATMENT
Surgical procedures utilized in the treatment of gastric dilatation-volvulus can be divided into two categories, (1) Immediate decompression and (2) Therapeutic gastropexy. Immediate decompression is performed with a successfully passed stomach tube secured to the patient or temporary gastrostomy as described above. Therapeutic or prophylactic gastropexy techniques are described.
Gastric repositioning: Anatomic repositioning of the stomach is necessary to perform prior to permanent gastropexy. Repositioning occasionally occurs spontaneously at the time of gastric decompression. Knowledge of normal anatomy is necessary to understand how repositioning is performed. A specific ‘Surgical Plan’ should be in mind before entering the operating room theatre. This will improve the efficiency of surgery and thus decrease overall surgery time7,11,12.
The treatment of gastric dilatation-volvulus is done with two principal surgical techniques.
Incisional gastropexy: This technique is based on the construction of a seromuscular antral flap attached to a incised segment of transversus abdominus muscle. Prior to selecting the location on the transversus abdominal wall for gastropexy, visualize the diaphragmatic muscle fibers as they radiate into the abdominal cavity and attach near the costal arch Fig. 1a, b. It is important that the gastropexy site be distant from the diaphragm muscle insertion. In addition, it is important to locate the ideal position for the gastric antral incision. The incision is located equidistant between the pylorus and gastric incisure and equidistant between the greater curvature and lesser curvature. A 3-4 cm incision is made in the antral portion of the stomach. Once the antral incision has been made, the bleeding surface of the antrum is brought to the right body wall. With the stomach in a normal position, the bleeding antral surface is touched to the peritoneal wall approximately 2-3 cm deep to the abdominal wall incision and caudal to the insertion of the diaphragm. A blood mark is created on the peritoneum at this proposed location. This will be the site for the permanent gastropexy Fig. 1c, d. The peritoneum and transversus abdominus muscle are then incised creating a mirror image defect of the stomach incision. The incisional defect in the stomach is then sutured to the incisional defect in the abdominal wall. The defects are sutured in two layers using a simple continuous pattern with 2-0 or 3-0 monofilament or multifilament synthetic absorbable suture7,13.
| Fig. 1(a-d): | (a) Abdominal draping, make a ventral midline abdominal incision extending from the xyphoid to 2-3 cm caudal to the umbilicus, (b) Incise only the seromuscular layer of the stomach without entering the gastric lumen and (c-d) Suture the more ventral and medial incisions in apposition using the caudal suture line to complete the gastropexy |
Laparoscopy surgery: The animal is placed in dorsal decubitus, the abdomen is classically disinfected with Chlorohexidine (soap and solution, Hibitane® laboratory Astra Zenaca) alternating with a 70% alcoholic solution, before the insertion of the surgical drapes. The pneumoperitoneum is created by a needle of Verrès introduced on the white line caudally to the umbilicus in the caudal direction and to the right of the animal to minimize the risks of splenic lacerations. It is then connected to the insufflator (Lapflow 40®, Smith Nephew Dyonics after checking the correct position of the Verrès needle at By means of a glass syringe Fig. 2a, b. The pneumoperitoneum is conventionally created by insufflation Of CO2 and the insufflation pressure is set to 12 mm of mercury10,11,14.
An 11 mm optical channel (Storz) is then placed at the umbilicus (diameter of 11 mm, length of 10.5 cm, with valve). It is introduced into the abdominal cavity at By means of a Klemm mandrel with an eccentric end "Zerocart". Inspection Of the peritoneal cavity is performed, in order to diagnose as quickly as possible iatrogenic organic lesions, such as splenic lacerations. Two 6 mm (Storz) operator channels are then placed (10.5 cm long, with Valve, Klemm mandrel with eccentric end "Zerocart", the first to the left of the Median plane through the right muscle of the abdomen, about 2-3 cm cranial to the umbilicus and the second to the right of the median plane, more laterally than the first and at the height of the umbilicus 8,2,15.
A new inspection of the peritoneal cavity is carried out before proceeding to the actual operating time. The falciform ligament of the liver is reclined dorsally and laterally to the left by means of an atraumatic forceps inserted in the operator channel located to the left of the animal.
| Fig. 2(a-b): | (a) Laparoscopy surgery equipment (surgery and imaging service, Batna University) and (b) Optical channel (Storz) is then placed at the umbilicus |
Indeed, this one tends to stick to the end of the optic and to hamper the visualization of the peritoneal cavity. The pyloric antrum is then seized by means of an atraumatic forceps inserted into the operator channel located to the right of the animal and brought cranially to its pexy10,11.
Postoperative management: In most cases 3-4 days of intensive monitoring is necessary for the successful management of GDV patients. Postoperative considerations are listed below:
| • | Shock is a postoperative possibility and the patient should be monitored and treated accordingly. |
| • | Patients are generally held off food and water for 24 h following surgery. During this time maintenance fluids should be supplied using polyionic isotonic crystalloid fluid. Vomiting may occur following surgery, the NPO period should be extended accordingly. Gastritis and gastric motility disorder may be seen in postoperative GDV patients |
| • | After 24 h of no vomiting, oral alimentation should begin gradually with a sequence of ice cubes, water and finally canned dog food. This should occur over a 2-3 days period |
| • | Antibiotics should be continued for 7-10 days |
| • | Routine surgical complications such as infection, dehiscence, seroma, etc. should be watched for and treated accordingly |
| • | ECG monitoring: The most common severe postoperative complication is cardiac arrhythmia. Approximately 75% of GDV patients will develop arrhythmia’s in the immediate postoperative period. Arrhythmia’s can be present at the initial time of presentation but most often occur within 24-72 h after surgery. Ventricular premature contractions, progressing to ventricular tachycardia is most common. Etiology is unknown but shock, hypoxia, acid base alterations, endotoxins, myocardial depressant factor (MDF), reperfusion injury, release of free radicals and hypokalemia have been identified. Occurrence of a total body potassium deficit has been proposed. Etiology of the hypokalemia includes anorexia, vomiting, tremendous outpouring of potassium rich fluids into a dilated stomach and use of potassium poor fluids in treatment of shock. For this reason, adding 20-30 mEq of potassium chloride per liter of maintenance fluids during and after surgery are recommended1,11,16 |
| • | Gastric motility: Occasionally GDV patients will develop postoperative gastric motility abnormalities. Patients with gastric hypomotility or gastric stasis should be treated with a motility modifier (i.e., metaclopramide, erythromycin, etc) |
CONCLUSION
Gastric dilatation volvulus (GDV) is characterized by accumulation of gas within the stomach, rotation of the stomach, failure of eructation and pyloric emptying, increased gastric pressure and shock. It can be acute or more rarely, can be chronic, acute cases can be rapidly fatal. It is common in deep-chested dogs and the risk of a large or giant breed dog developing. Rapid diagnosis, stabilization and surgical management can lead to a good prognosis for these dogs. The treatment of gastric dilatation-volvulus with two principal surgical technic.