Gastric dilatation-volvulus: Controlling the crisis - Veterinary Medicine
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Gastric dilatation-volvulus: Controlling the crisis
Although widely recognized, gastric dilatation-volvulus is still not fully understood. This overview provides up-to-date information on the possible causes, risk factors, diagnosis, and treatment of this life-threatening syndrome.


VETERINARY MEDICINE


SURGICAL TREATMENT

Surgical intervention is required after the patient is medically stabilized and is recommended as soon as possible.15 Delayed surgery increases the potential for gastric wall edema and necrosis and venous stasis, especially if the stomach is rotated 360 degrees. If the surgery is delayed, cardiac arrhythmias can develop. Most dogs that have arrhythmias develop them within 36 hours after the gastric dilatation episode.

The purpose of this surgery is to derotate the stomach, evaluate the stomach wall and spleen for ischemic injury, and perform a gastropexy.

Derotation

To begin the surgery, place the dog in dorsal recumbency, and perform a midline celiotomy. The surgeon should stay on the dog's right side. Upon opening the abdominal cavity, omentum will be covering the stomach, which confirms the GDV diagnosis. The stomach can be decompressed again before derotation with a large orogastric tube. After identifying the pylorus and the fundus, grasp the pylorus with your right hand and pull it ventrally toward the abdominal incision while pushing the fundus dorsally into the abdominal cavity with your left hand.

The spleen follows the motion of the stomach. If splenic torsion is present, perform a splenectomy without untwisting the vascular pedicle.

After derotation, evaluate the stomach and spleen for ischemic injuries. Usually, the spleen shows signs of venous congestion that resorbs quickly after derotation of the stomach. Splenectomy is indicated if thrombosis of the splenic artery is present.


3. Necrosis of the body of the stomach along the greater curvature. The dark color and absence of peristalsis are two criteria used to evaluate the stomach wall’s viability. The absence of the slipping of the mucosa and submucosa is another criterion.
Evaluating gastric wall perfusion is difficult. About 20% of dogs with GDV have a devitalized gastric wall requiring gastrectomy.15 Ischemic injury occurs most commonly in the fundic area along the greater curvature. No objective criteria exist to evaluate the gastric wall. The absence of a peristaltic wave, a pale greenish-to-gray serosal color, a thin gastric wall, the absence of the slipping of the mucosa and submucosa when tested, and lack of bleeding after a partial thickness incision are signs of gastric wall devitalization (Figure 3).

Gastrectomy

If the body of the stomach along the greater curvature of the stomach wall is necrotic, a gastrectomy is required. Two options are available: gastrectomy with either traditional suture technique or stapling suture.

Pack the stomach off from the abdominal cavity with moistened laparotomy sponges. Retract the healthy stomach with stay sutures to prevent gastric spillage.


4A. Gastric necrosis occurs along the greater curvature of the stomach in the body and the fundus. Automatic stapling equipment assists in removing the necrotic section.
If a suture technique is used, ligation of the branches of the short gastric arteries and left gastroepiploic artery supplying the area is required. Resect the necrotic gastric wall with Metzenbaum scissors to the level of healthy gastric tissue. A two-layer closure with a continuous inverting suture pattern using 3-0 absorbable monofilament suture is necessary to close the stomach. This technique has been associated with a 60% mortality.22


4B. A partial gastrectomy being performed by using automatic stapling equipment.
If autostapling equipment is available, a gastrointestinal anastomosis device (GIA 50—Covidien) or a thoracoabdominal device (TA 90—Covidien) can be used to perform the gastrectomy (Figures 4A & 4B). Advantages of this technique include decreased risk of abdominal contamination from gastric spillage and decreased surgical time. Mortality rate with the autostapling equipment is close to 10%.23 Stomach rupture is associated with severe peritonitis that would require appropriate treatment.

Gastropexy

After gastrectomy, a gastropexy is required to stabilize the pyloric antrum on the right side of the abdominal cavity. Gastropexy substantially decreases the chance of recurrence—after a gastropexy, dogs can still dilate their stomachs but not rotate them.

A belt-loop gastropexy and an incisional gastropexy are the two techniques most commonly performed (see Skills Laboratory: Performing a belt-loop gastropexy). The modified incisional gastropexy with incorporation of the body of the stomach in the midline closure is not appropriate since it does not stabilize the pyloric antrum in the right side of the abdomen.

If needed, a splenectomy is performed in a routine fashion. The abdominal cavity is then flushed with warm sterile saline solution and closed in a routine fashion.


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Source: VETERINARY MEDICINE,
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