Key gastrointestinal surgeries: Incisional gastropexy
THE PRIMARY INDICATION for gastropexy is to prevent the development or recurrence of gastric dilatation-volvulus (GDV).1-16 GDV most often affects large- and giant-breed dogs that have deep and narrow chests.2-8,13-15 Several other risk factors have been associated with the development of GDV, including increasing age, ingestion of large amounts of food or water, eating rapidly or from an elevated food dish, fearful temperament, and exercise after eating.3-5,15,17-19 Additionally, first-degree relatives of dogs with GDV appear to be at an increased risk; prophylactic gastropexy is recommended in these animals.2,4,15 Because dogs with GDV that do not undergo a gastropexy have recurrence rates of more than 70% and mortality rates of 80%, gastropexy should also be performed in all patients with GDV.1,11,20
TYPES OF GASTROPEXIES
The goal of a gastropexy is to create a permanent adhesion between the gastric wall and the abdominal wall.1-16 Ideally, a gastropexy should create a strong adherence, have minimal complications, not affect the stomach's natural orientation or markedly alter gastric outflow, and require minimal postoperative management.6,10 Gastropexy is usually performed by attaching the pyloric antrum to the right abdominal wall to prevent further gastric rotation.9,15There are several types of gastropexies, including incorporating, tube, circumcostal, belt-loop, laparoscopic-assisted, and incisional.1,3-16 No controlled studies have compared adhesion strength, clinical outcome, and physiologic impact of all the gastropexy techniques, so the choice of procedure is often based on the veterinarian's preference.
With incorporating gastropexy, the stomach wall is simply included in the linea alba closure.1,3,6,11 While this technique is rapid, it is not recommended because gastric perforation can occur if another midline celiotomy is performed without knowledge of the previous gastropexy and because the stomach may become abnormally positioned because of the procedure.1,3,6,11
Tube gastropexy, including percutaneous gastrostomy, involves placing a mushroom-tipped tube through the abdominal wall and into the gastric lumen. Tube gastropexy results in a permanent adhesion after 14 days and permits postoperative decompression and direct access to the gastrointestinal tract for feeding and for giving medications.1,5,11 Tubes are usually left in place for at least seven days to allow sufficient time for fibrous tissue formation. The disadvantages of tube gastropexy include more intensive postoperative management and decreased holding strength compared with circumcostal gastropexy, resulting in an increased risk of GDV recurrence.1,3-6,11,13 Additionally, tube leakage and subsequent peritonitis can occur.4,5,8,11,14
With circumcostal gastropexy, a seromuscular flap from the stomach is wrapped around the last rib and secured back to the stomach wall.1,11 This procedure does not penetrate the stomach lumen and creates a strong adhesion.1,4,6,7,11,13 Potential complications include iatrogenic rib fracture, pneumothorax, and increased surgical time.1,4,6-9,11 Modifications to the procedure have helped decrease surgical time and postoperative complications while maintaining the holding strength of the original technique.1,7,9
Belt-loop gastropexy involves tunneling a seromuscular flap through the abdominal wall.1,10,11 This procedure can be performed quickly and results in a strong adhesion without entering the gastric lumen.11 Minimal complications have been reported, although pneumothorax can still occur.1