Topics in Compan An Med 29 (2014) 77–80
Topical Review
Gastropexy for Prevention of Gastric Dilatation-Volvulus in Dogs: History and Techniques Philip Allen, DVMa,1, April Paul, DVM, DACVECCb,n Keywords: surgery minimally invasive laparoscopic incisional gastropexy prophylactic gastropexy a
Tufts Cummings School of Veterinary, North Grafton, MA, USA
b
Tufts Veterinary Emergency Treatment and Specialties, Walpole, MA, USA
n
Address reprint requests to: April Paul, DVM, DACVECC, Tufts Veterinary Emergency Treatment and Specialties, 525 South Street, Walpole, MA 02081, USA. E-mail: [email protected] (A. Paul)
Gastric dilatation-volvulus (GDV) is a common and catastrophic disease of large and giant-breed dogs. Treatment of GDV includes medical stabilization followed by prompt surgical repositioning of the stomach in its normal anatomic position. To prevent reoccurrence, gastropexy is used to securely adhere the stomach to the body wall. Effective gastropexy decreases the recurrence of GDV from as high as 80% to less than 5%. The purpose of this article is to describe the history, indications, and techniques for gastropexy. Gastropexy was first reported in veterinary medicine in 1971 for the management of gastric reflux, and later in 1979 for treating and preventing the recurrence of GDV. Gastropexy is indicated in all dogs that undergo surgical correction of GDV. Additionally, prophylactic gastropexy should be strongly considered at the time of surgery in dogs undergoing splenectomy for splenic torsion and potentially other splenic pathology, and in dogs of at-risk breeds, such as Great Danes, that are undergoing exploratory celiotomy for any reason owing to evidence for increased risk of GDV in these patients. Although there are numerous techniques described, gastropexy is always performed on the right side of the abdomen, near the last rib. Ensuring an anatomically correct gastropexy location is vital to prevent postoperative complications such as partial pyloric outflow obstruction. Gastropexy can be performed as part of an open surgical approach to the abdomen or using a minimally invasive technique. When combined with surgical correction of GDV, gastropexy is almost always performed as an open procedure. The stomach is repositioned, the abdomen explored, and then a permanent gastropexy is performed. Techniques used for open gastropexy include incisional, belt-loop, circumcostal, and incorporating gastropexy, as well as gastrocolopexy. Each of these has been described later. Incisional gastropexy is currently the most commonly performed method of surgical gastropexy in dogs; it is quick, relatively easy, safe, and effective. Minimally invasive techniques for gastropexy are often used when gastropexy is performed as an elective, isolated procedure. Minimally invasive techniques include the grid approach, endoscopically guided miniapproach, and laparoscopic gastropexy. Laparoscopic gastropexy is the least invasive alternative; however, it requires special equipment and significant surgical expertise to perform. The authors consider it a veterinarian's responsibility to educate the owners of at-risk large and giant dog breeds about prophylactic gastropexy given such a favorable risk-benefit profile. & 2014 Elsevier Inc. All rights reserved.
Gastric dilatation-volvulus (GDV) is a common and catastrophic disease of large and giant-breed dogs.1-4 Treatment of GDV includes medical stabilization followed by prompt surgical repositioning of the stomach in its normal anatomic position. To prevent reoccurrence, gastropexy is used to securely adhere the stomach to the body wall. Without gastropexy the rate of recurrence of GDV may be as high as 80%; this is decreased to less than 5% with gastropexy.2-5 The purpose of this article is to describe the history, indications, and techniques for gastropexy.
History of Gastropexy The first gastropexy was reported in 1916 in the British Journal of Medicine, for 3 people with gastroptosis (downward displacement of the stomach), a condition that was common in workers who regularly lifted heavy weights.6 Gastropexy was first reported in veterinary medicine in 1971 for gastric reflux; it was not until 1979 that it was used for treating and preventing the recurrence of GDV.7,8 1 Current address: University of Minnesota, College of Veterinary Medicine, 1365 Gortner, St. Paul, MN 55108, USA.
http://dx.doi.org/10.1053/j.tcam.2014.09.001 1527-3369/& 2014 Topics in Companion Animal Medicine. Published by Elsevier Inc.
Indications for Gastropexy Gastropexy is indicated in all dogs that undergo surgical correction of GDV. Additionally, prophylactic gastropexy should be performed at the time of surgery (or at least strongly considered) in dogs undergoing splenectomy for splenic torsion and potentially other splenic pathology and dogs of at-risk breeds, such as Great Danes, that are undergoing exploratory celiotomy for any reason owing to evidence for increased risk of GDV in these patients.9-11 In recent years, there has been a growing interest in prophylactic gastropexy in at-risk dogs as an isolated procedure. Although a gastropexy does not eliminate the potential for gas bloat, when properly performed, it should eliminate the risk of volvulus. A challenge of deciding whether to perform a prophylactic gastropexy is that the lifetime risk of GDV is unknown in any dog. If a dog were to never develop a GDV, then the procedure would have been unneeded. However, if a GDV were to develop, the costs, morbidity, and risks of potential complications are much higher for treatment of GDV. In general, the risks of a properly performed prophylactic gastropexy are very low. However, the decision to perform a gastropexy requires discussion between the veterinarian and the client about the perceived risk of GDV for an
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P. Allen, A. Paul / Topics in Companion An Med 29 (2014) 77–80
individual dog and the risk vs. benefit of performing a prophylactic gastropexy. A decade-old study evaluated the probability of death due to GDV and the expected cost saved in veterinary services as outcome measures to determine the preferred course of action (i.e., to perform prophylactic gastropexy or not) in 5 at-risk breeds (Great Dane, Irish Setter, Rottweiler, Standard Poodle, and Weimaraner).12 This study determined that gastropexy is the preferred choice of action for all the at-risk breeds examined.12
Surgical Techniques for Gastropexy The goal of gastropexy in dogs with GDV is the formation of adhesions that permanently fix the stomach to the body wall. There is more literature focused on gastropexy techniques than any other aspect of GDV in dogs. Although there are numerous methods of performing a gastropexy, there is no clear “gold standard” gastropexy technique. Studies include both clinical data regarding dogs managed with different gastropexy techniques and reports of biochemical (e.g., tensile strength testing) and histologic assessment of the efficacy of different gastropexy techniques.13-21 Surgeon familiarity and comfort with specific procedures often influences which gastropexy technique is performed. In dogs already undergoing an exploratory celiotomy, the gastropexy is performed as part of an open approach to the abdomen; however, minimally invasive techniques can be considered for dogs undergoing prophylactic gastropexy as an isolated procedure. Regardless of the technique chosen, the gastropexy is always performed on the right side, near the last rib. The location of the gastropexy site is critical to avoiding complications as partial pyloric outflow obstruction may develop if an anatomic “kink” is inadvertently created.
Open Gastropexy Techniques When combined with surgical repair of GDV, gastropexy is almost always performed as an open procedure. The stomach is repositioned, the abdomen explored, and then a permanent gastropexy is performed. Techniques used for open gastropexy include incisional, belt-loop, circumcostal, and incorporating gastropexy, as well as gastrocolopexy. Each of these has been described in the following sections.
Incisional Gastropexy Incisional gastropexy is currently the most commonly performed method of surgical gastropexy in dogs. It is performed by making an incision of 4-7 cm in the seromuscular layer of the gastric wall, parallel to the long axis of the stomach between the lesser and greater curvatures at the level of the pyloric antrum. The incision should only extend through the seromuscular layers and not enter the gastric lumen. An incision of equal length is then made through the peritoneum and right transversus abdominis muscle parallel to the muscle fiber direction. Finally, both incisions are sutured together in a simple continuous pattern with a 2-0 or 0 monofilament absorbable or nonabsorbable suture. The suture process is made simpler if started at the distal and cranial aspect of the incisions to avoid blindly trying to appose the tissues.22 In a retrospective study by Benitez et al.,23 the efficacy of incisional gastropexy for prevention of GDV in dogs was equivalent to reports of belt-loop gastropexy and superior to those of both circumcostal gastropexy and gastrocolopexy.
Belt-Loop Gastropexy The belt-loop gastropexy is a modification of the circumcostal gastropexy (described later). It is performed by incorporating a seromuscular flap from the pyloric antrum area into a tunnel in the right abdominal wall through the transversus abdominis muscle. Firstly, an approximately 3 5 cm2 seromuscular flap is generated at the level of the pyloric antrum along the greater curvature and is elevated with blunt dissection. Next, two 3 cm parallel incisions 2-3 cm apart are made through the peritoneum and right transversus abdominis muscle immediately caudal to the last rib. The free end of the gastric seromuscular flap is brought from cranial to caudal through the abdominal wall incisions and sutured back to the stomach in its original position using a 2-0 or 0 monofilament absorbable or nonabsorbable suture. It is recommended to incorporate at least 3 branches of the gastroepiploic artery in the base of the flap to ensure perfusion to the tissue.22 Although the gastric flap has the potential to undergo necrosis if a too narrow flap is created, this complication has not been recognized in clinical studies.15 In a study by Schulman et al.,1 there was no recurrence over a 33-month follow up period in 21 dogs that underwent belt-loop gastropexy. Circumcostal Gastropexy Circumcostal gastropexy was first described in 1982 but is now primarily of historical interest owing to its more invasive nature and the greater potential for complications. It was performed by creating a tunnel underneath the cartilaginous portion of the 10th or 11th rib by incising the overlying peritoneum and tranversus abdominis muscle. A seromuscular flap from the pyloric antrum was then passed cranial to caudal through the tunnel surrounding the rib with or without the assistance of stay sutures in the leading edge of the gastric flap. This flap was then sutured back to its origin on the stomach with 2-0 absorbable sutures in a simple interrupted or continuous pattern. Not only was this technique particularly technically demanding, but it was also associated with an increased risk of iatrogenic pneumothorax and rib fracture.4,20,24 GDV recurrence rates following this procedure have been documented to range from 3.3%20 to 4.3%.13,24 Tube Gastropexy The tube gastropexy was one of the first procedures developed for gastropexy in dogs. After correction of gastric volvulus, the procedure is performed by placing stay sutures at the ventral and dorsal borders of the pyloric antrum outline and a 24-F Foley catheter (or Pezzar urinary catheter) is introduced into the abdomen through the right ventral abdominal wall at the desired location (just caudal to the last rib). The Foley catheter is then passed through the center of the pyloric antrum tracing into the gastric lumen. The catheter balloon is inflated with sterile saline and secured to the stomach by tying a purse-string suture. Gentle traction on the catheter is used to bring the stomach into contact with the peritoneum and a sufficient number of seromuscular to parietal serosa simple interrupted sutures are placed. The Foley catheter is removed no less than 7 days after surgery; at which point, permanent adhesions should be formed.13 Although tube gastropexy is fairly fast and possibly technically easier than other gastropexy techniques, the postoperative lengthy hospitalization and a high complication rate limits it utility. The potential complications include premature dislodgement of the tube or removal by the animal, peritonitis or subcutaneous cellulitis associated with leakage of gastric contents around the tube, and persistent stoma drainage. A report
P. Allen, A. Paul / Topics in Companion An Med 29 (2014) 77–80
documented a 17% complication rate; this included the development of septic peritonitis in 2 of 24 dogs that was fatal.4 Possible additional benefits of a tube gastropexy are that it also allows for continued gastric decompression in the early postoperative period if necessary and provides access to the stomach for delivery of enteral nutrition and medications.25 Incorporating Gastropexy Incorporating gastropexy involves including approximately 4-7 cm of the gastric wall near the pyloric antrum with the cranial portion of the linea alba during closure of the celiotomy incision. Although this technique is effective, as well as rapid and easy to perform, it is not recommended, as future celiotomies risk incision into the gastric lumen and subsequent abdominal sepsis. Gastrocolopexy Gastrocolopexy was first described almost 40 years ago, making it one of the earliest techniques developed in attempts to prevent recurrence of GDV. The procedure is performed most commonly by scarifying the surface of the greater curvature of the stomach and the transverse colon and then suturing these tissues together using nonabsorbable suture. A study by Eggertsdóttir et al.26 documented a recurrence rate of 20% (4/20 dogs), which is higher than that reported with other gastropexy techniques.
Minimally Invasive Gastropexy Techniques Although open surgical approaches via ventral midline incisions are safe and effective, minimally invasive techniques have the advantages of less postsurgical discomfort and more rapid recovery. Both of these are particularly appealing for elective procedures in young, typically active, large, and giant-breed dogs. Minimally invasive procedures are rarely reported for the treatment of dogs with GDV, as repositioning of the stomach and evaluation of the rest of the abdomen would be quite difficult. However, for surgeons experienced in minimally invasive procedures, this may be an option. Minimally invasive techniques include the grid approach, endoscopically guided miniapproach, and laparoscopic gastropexy. Grid Approach (Miniopen Approach) The grid approach, also known as the minilaparotomy involves making a small ( 6 cm) vertical skin incision just caudal to the 13th rib. The abdomen is approached by bluntly dissecting the external and internal abdominal oblique muscles and the transversus abdominis muscles along the muscle fibers. After entry into the peritoneal cavity, the gastric antrum can be reached. A 3-cm incision is made into the seromuscular layer of the gastric antrum, and this is sutured to the transversus abdominis fascia and muscle with a continuous suture pattern of absorbable monofilament. The rest of the superficial muscle layers are closed individually with a simple continuous pattern.27 Visualization of specific gastric landmarks including the pylorus, omental attachments, and gastric vasculature is essential to ensure that the correct portion of the gastrointestinal tract is being anchored. However, this technique is easy and requires no special equipment. Endoscopically Guided Miniapproach With the patient in left oblique recumbency, a gastroscope is advanced and the stomach is insufflated. Once the pyloric antrum is visualized, number 2 polypropylene suture on a cutting needle
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is passed through the right abdominal wall just caudal to the last rib and into the lumen of the stomach. The needle is viewed as it exits the stomach and is retrieved outside the dog. This stay suture is secured with a hemostat. An incision is made into the abdominal cavity through the body wall and the pyloric antrum is apposed similar to the grid gastropexy with a seromuscular incision.28,29 This technique has the advantage of improving placement of the gastropexy site, but it requires more equipment and skills to perform than the grid approach does. Laparoscopic Gastropexy Laparoscopic gastropexy is a popular minimally invasive technique, which allows for improved visualization as compared with the grid and endoscopic approaches. It involves inserting 3 portals along ventral midline; the first allows for insufflation and is made 1 cm caudal to the umbilicus, the second is the instrument port (3-4 cm caudal to the xyphoid), and the third is for the camera (placed midway between the first 2). A stay suture is introduced through the body wall into the abdomen over the pyloric antrum. The needle is grasped intracorporally, passed through the pyloric antrum, and exited the body wall. A similar procedure as the endoscopically guided technique is then performed; however, suturing the seromuscular layer to the transversus abdominis fascia and muscle can be performed by the surgeon either extracorporally or intracorporally with either a suture-assist device or laparoscopic needle holders. Staples may also be used, and recently barbed suture has been used, which negates the need to tie knots internally. Potential complications with laparoscopy gastropexy include perforation of the gastric lumen, splenic laceration, cardiovascular instability from decreased venous return (due to in abdominal insufflation), or air embolus during insufflation. In a case series of 25 dogs undergoing laparoscopic gastropexy (2 for GDV and 23 prophylactically), the recurrence rate was 0 at 1 year, and 20 dogs evaluated using ultrasonography were found to have intact gastropexy attachments.17 Although this is true with all gastropexy procedures, it is essential that the laparoscopic surgeon have training and experience to avoid intraoperative complications and minimize anesthesia time.
Conclusions Gastropexy is a vital surgical technique for the prevention of the occurrence or recurrence of GDV in at-risk and affected dogs. Incisional gastropexy is the most commonly performed open gastropexy technique, while laparoscopic gastropexy is gaining in popularity for prophylactic gastropexy as an isolated procedure. When performed correctly by experienced surgeons, these gastropexy techniques are associated with extremely low complication rates and failure rates (i.e., recurrence of GDV). References 1. Schulman A, Lusk R, Ettinger S, Lippincott C. A new surgical technique to prevent recurrences of gastric dilatation-volvulus syndrome. J Am Anim Hosp Assoc 21:339–346, 1986 2. Wingfield WE, Betts CW, Greene RW. Operative techniques and recurrence rates associated with gastric volvulus in the dog. J Small Anim Pract 16: 427–432, 1975 3. Flanders JA, Harvey HJ. Results of tube gastrostomy as treatment for gastric volvulus in the dog. J Am Vet Med Assoc 185:74–77, 1984 4. Fox S. Gastric dilatation volvulus: results of 31 cases of circumcostal vs tube gastrostomy. Calif Vet 8:8–11, 1985 5. Glickman LT, Lantz GC, Schellenberg DB, Glickman NW. A prospective study of survival and recurrence following the acute gastric dilatation-volvulus syndrome in 136 dogs. J Am Anim Hosp Assoc 34:253–259, 1998 6. Connon M. Three cases of gastroptosis treated by gastropexy (Rovsing). Br Med J 2:250, 1916
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7. Castro VA, Nyhus LM, Gillison EW, Nakayoshi A, Bombeck CT. Posterior gastropexy (Hill) in the treatment of reflux esophagitis. An experimental study in the dog. Scand J Gastroenterol 6:49–55, 1971 8. Funkquist B. Gastric torsion in the dog. III. Fundic gastropexy as a relapsepreventing procedure. J Small Anim Pract 20:103–109, 1979 9. Marconato L. Gastric dilatation-volvulus as complication after surgical removal of a splenic haemangiosarcoma in a dog. J Vet Med A Physiol Pathol Clin Med 53:371–374, 2006 10. Millis DL, Nemzek J, Riggs C, Walshaw R. Gastric dilatation-volvulus after splenic torsion in two dogs. J Am Vet Med Assoc 207:314–315, 1995 11. Goldhammer MA, Haining H, Milne EM, Shaw DJ, Yool DA. Assessment of the incidence of GDV following splenectomy in dogs. J Small Anim Pract 51:23–28, 2010 12. Ward MP, Patronek GJ, Glickman LT. Benefits of prophylactic gastropexy for dogs at risk of gastric dilatation-volvulus. Prev Vet Med 60:319–329, 2003 13. Fox SM, Ellison G, Miller G. Observations on the mechanical failure of three gastropexy techniques. J Am Anim Hosp Assoc 21:729–734, 1985 14. Wilson ER, Henderson RA, Montgomery RD, Kincaid SA, Wright JC, Hanson RR. A comparison of laparoscopic and belt-loop gastropexy in dogs. Vet Surg 25:221–227, 1996 15. Whitney W, Scavelli T, Matthiesen D. Belt-loop gastropexy: technique and surgical results in 20 dogs. J Am Anim Hosp Assoc 25:75–83, 1989 16. Rawlings CA, Mahaffey MB, Bement S, Canalis C. Prospective evaluation of laparoscopic-assisted gastropexy in dogs susceptible to gastric dilatation. J Am Vet Med Assoc 221:1576–1581, 2002 17. Rawlings CA, Foutz TL, Mahaffey MB, Howerth EW, Bement S, Canalis C. A rapid and strong laparoscopic-assisted gastropexy in dogs. Am J Vet Res 62:871–875, 2001 18. Meyer-Lindenberg A, Harder A, Fehr M, Luerssen D, Brunnberg L. Treatment of gastric dilatation-volvulus and a rapid method for prevention of relapse in dogs: 134 cases (1988-1991). J Am Vet Med Assoc 203:1303–1307, 1993
19. MacCoy DM, Sykes GP, Hoffer RE. A permanent gastropexy technique for permanent fixation of the pyloric antrum. J Am Anim Hosp Assoc 18:736–768, 1982 20. Leib MS, Konde LJ, Wingfield WE, Twedt DC. Circumcostal gastropexy for preventing recurrence of gastric dilatation-volvulus in the dog: an evaluation of 30 cases. J Am Vet Med Assoc 187:245–248, 1985 21. Hardie RJ, Flanders JA, Schmidt P, Credille KM, Pedrick TP, Short CE. Biomechanical and histological evaluation of a laparoscopic stapled gastropexy technique in dogs. Vet Surg 25:127–133, 1996 22. Monnet E. Gastric dilatation-volvulus syndrome in dogs. Vet Clin North Am Small Anim Pract 33:987–1005, 2003(vi) 23. Benitez ME, Schmiedt CW, Radlinsky MG, Cornell KK. Efficacy of incisional gastropexy for prevention of GDV in dogs. J Am Anim Hosp Assoc 49:185–189, 2013 24. Woolfson J, Kostolich M. Circumcostal gastropexy; clinical use of the technique in 34 dogs with gastric dilatation-volvulus. J Am Anim Hosp Assoc 22:825–830, 1986 25. Ellison GW. Complications of gastrointestinal surgery in companion animals. Vet Clin North Am Small Anim Pract 41:915–934, 2011(vi) 26. Eggertsdóttir AV, Stigen y O, Lonaas L, et al. Comparison of the recurrence rate of gastric dilatation with or without volvulus in dogs after circumcostal gastropexy versus gastrocolopexy. Vet Surg 30:546–551, 2001 27. Steelman-Szymeczek SM, Stebbins ME, Hardie EM. Clinical evaluation of a right-sided prophylactic gastropexy via a grid approach. J Am Anim Hosp Assoc 39:397–402, 2003 28. Dujowich M, Keller ME, Reimer SB. Evaluation of short- and long-term complications after endoscopically assisted gastropexy in dogs. J Am Vet Med Assoc 236:177–182, 2010 29. Dujowich M, Reimer SB. Evaluation of an endoscopically assisted gastropexy technique in dogs. Am J Vet Res 69:537–541, 2008
Topical Review
Gastropexy for Prevention of Gastric Dilatation-Volvulus in Dogs: History and Techniques Philip Allen, DVMa,1, April Paul, DVM, DACVECCb,n Keywords: surgery minimally invasive laparoscopic incisional gastropexy prophylactic gastropexy a
Tufts Cummings School of Veterinary, North Grafton, MA, USA
b
Tufts Veterinary Emergency Treatment and Specialties, Walpole, MA, USA
n
Address reprint requests to: April Paul, DVM, DACVECC, Tufts Veterinary Emergency Treatment and Specialties, 525 South Street, Walpole, MA 02081, USA. E-mail: [email protected] (A. Paul)
Gastric dilatation-volvulus (GDV) is a common and catastrophic disease of large and giant-breed dogs. Treatment of GDV includes medical stabilization followed by prompt surgical repositioning of the stomach in its normal anatomic position. To prevent reoccurrence, gastropexy is used to securely adhere the stomach to the body wall. Effective gastropexy decreases the recurrence of GDV from as high as 80% to less than 5%. The purpose of this article is to describe the history, indications, and techniques for gastropexy. Gastropexy was first reported in veterinary medicine in 1971 for the management of gastric reflux, and later in 1979 for treating and preventing the recurrence of GDV. Gastropexy is indicated in all dogs that undergo surgical correction of GDV. Additionally, prophylactic gastropexy should be strongly considered at the time of surgery in dogs undergoing splenectomy for splenic torsion and potentially other splenic pathology, and in dogs of at-risk breeds, such as Great Danes, that are undergoing exploratory celiotomy for any reason owing to evidence for increased risk of GDV in these patients. Although there are numerous techniques described, gastropexy is always performed on the right side of the abdomen, near the last rib. Ensuring an anatomically correct gastropexy location is vital to prevent postoperative complications such as partial pyloric outflow obstruction. Gastropexy can be performed as part of an open surgical approach to the abdomen or using a minimally invasive technique. When combined with surgical correction of GDV, gastropexy is almost always performed as an open procedure. The stomach is repositioned, the abdomen explored, and then a permanent gastropexy is performed. Techniques used for open gastropexy include incisional, belt-loop, circumcostal, and incorporating gastropexy, as well as gastrocolopexy. Each of these has been described later. Incisional gastropexy is currently the most commonly performed method of surgical gastropexy in dogs; it is quick, relatively easy, safe, and effective. Minimally invasive techniques for gastropexy are often used when gastropexy is performed as an elective, isolated procedure. Minimally invasive techniques include the grid approach, endoscopically guided miniapproach, and laparoscopic gastropexy. Laparoscopic gastropexy is the least invasive alternative; however, it requires special equipment and significant surgical expertise to perform. The authors consider it a veterinarian's responsibility to educate the owners of at-risk large and giant dog breeds about prophylactic gastropexy given such a favorable risk-benefit profile. & 2014 Elsevier Inc. All rights reserved.
Gastric dilatation-volvulus (GDV) is a common and catastrophic disease of large and giant-breed dogs.1-4 Treatment of GDV includes medical stabilization followed by prompt surgical repositioning of the stomach in its normal anatomic position. To prevent reoccurrence, gastropexy is used to securely adhere the stomach to the body wall. Without gastropexy the rate of recurrence of GDV may be as high as 80%; this is decreased to less than 5% with gastropexy.2-5 The purpose of this article is to describe the history, indications, and techniques for gastropexy.
History of Gastropexy The first gastropexy was reported in 1916 in the British Journal of Medicine, for 3 people with gastroptosis (downward displacement of the stomach), a condition that was common in workers who regularly lifted heavy weights.6 Gastropexy was first reported in veterinary medicine in 1971 for gastric reflux; it was not until 1979 that it was used for treating and preventing the recurrence of GDV.7,8 1 Current address: University of Minnesota, College of Veterinary Medicine, 1365 Gortner, St. Paul, MN 55108, USA.
http://dx.doi.org/10.1053/j.tcam.2014.09.001 1527-3369/& 2014 Topics in Companion Animal Medicine. Published by Elsevier Inc.
Indications for Gastropexy Gastropexy is indicated in all dogs that undergo surgical correction of GDV. Additionally, prophylactic gastropexy should be performed at the time of surgery (or at least strongly considered) in dogs undergoing splenectomy for splenic torsion and potentially other splenic pathology and dogs of at-risk breeds, such as Great Danes, that are undergoing exploratory celiotomy for any reason owing to evidence for increased risk of GDV in these patients.9-11 In recent years, there has been a growing interest in prophylactic gastropexy in at-risk dogs as an isolated procedure. Although a gastropexy does not eliminate the potential for gas bloat, when properly performed, it should eliminate the risk of volvulus. A challenge of deciding whether to perform a prophylactic gastropexy is that the lifetime risk of GDV is unknown in any dog. If a dog were to never develop a GDV, then the procedure would have been unneeded. However, if a GDV were to develop, the costs, morbidity, and risks of potential complications are much higher for treatment of GDV. In general, the risks of a properly performed prophylactic gastropexy are very low. However, the decision to perform a gastropexy requires discussion between the veterinarian and the client about the perceived risk of GDV for an
78
P. Allen, A. Paul / Topics in Companion An Med 29 (2014) 77–80
individual dog and the risk vs. benefit of performing a prophylactic gastropexy. A decade-old study evaluated the probability of death due to GDV and the expected cost saved in veterinary services as outcome measures to determine the preferred course of action (i.e., to perform prophylactic gastropexy or not) in 5 at-risk breeds (Great Dane, Irish Setter, Rottweiler, Standard Poodle, and Weimaraner).12 This study determined that gastropexy is the preferred choice of action for all the at-risk breeds examined.12
Surgical Techniques for Gastropexy The goal of gastropexy in dogs with GDV is the formation of adhesions that permanently fix the stomach to the body wall. There is more literature focused on gastropexy techniques than any other aspect of GDV in dogs. Although there are numerous methods of performing a gastropexy, there is no clear “gold standard” gastropexy technique. Studies include both clinical data regarding dogs managed with different gastropexy techniques and reports of biochemical (e.g., tensile strength testing) and histologic assessment of the efficacy of different gastropexy techniques.13-21 Surgeon familiarity and comfort with specific procedures often influences which gastropexy technique is performed. In dogs already undergoing an exploratory celiotomy, the gastropexy is performed as part of an open approach to the abdomen; however, minimally invasive techniques can be considered for dogs undergoing prophylactic gastropexy as an isolated procedure. Regardless of the technique chosen, the gastropexy is always performed on the right side, near the last rib. The location of the gastropexy site is critical to avoiding complications as partial pyloric outflow obstruction may develop if an anatomic “kink” is inadvertently created.
Open Gastropexy Techniques When combined with surgical repair of GDV, gastropexy is almost always performed as an open procedure. The stomach is repositioned, the abdomen explored, and then a permanent gastropexy is performed. Techniques used for open gastropexy include incisional, belt-loop, circumcostal, and incorporating gastropexy, as well as gastrocolopexy. Each of these has been described in the following sections.
Incisional Gastropexy Incisional gastropexy is currently the most commonly performed method of surgical gastropexy in dogs. It is performed by making an incision of 4-7 cm in the seromuscular layer of the gastric wall, parallel to the long axis of the stomach between the lesser and greater curvatures at the level of the pyloric antrum. The incision should only extend through the seromuscular layers and not enter the gastric lumen. An incision of equal length is then made through the peritoneum and right transversus abdominis muscle parallel to the muscle fiber direction. Finally, both incisions are sutured together in a simple continuous pattern with a 2-0 or 0 monofilament absorbable or nonabsorbable suture. The suture process is made simpler if started at the distal and cranial aspect of the incisions to avoid blindly trying to appose the tissues.22 In a retrospective study by Benitez et al.,23 the efficacy of incisional gastropexy for prevention of GDV in dogs was equivalent to reports of belt-loop gastropexy and superior to those of both circumcostal gastropexy and gastrocolopexy.
Belt-Loop Gastropexy The belt-loop gastropexy is a modification of the circumcostal gastropexy (described later). It is performed by incorporating a seromuscular flap from the pyloric antrum area into a tunnel in the right abdominal wall through the transversus abdominis muscle. Firstly, an approximately 3 5 cm2 seromuscular flap is generated at the level of the pyloric antrum along the greater curvature and is elevated with blunt dissection. Next, two 3 cm parallel incisions 2-3 cm apart are made through the peritoneum and right transversus abdominis muscle immediately caudal to the last rib. The free end of the gastric seromuscular flap is brought from cranial to caudal through the abdominal wall incisions and sutured back to the stomach in its original position using a 2-0 or 0 monofilament absorbable or nonabsorbable suture. It is recommended to incorporate at least 3 branches of the gastroepiploic artery in the base of the flap to ensure perfusion to the tissue.22 Although the gastric flap has the potential to undergo necrosis if a too narrow flap is created, this complication has not been recognized in clinical studies.15 In a study by Schulman et al.,1 there was no recurrence over a 33-month follow up period in 21 dogs that underwent belt-loop gastropexy. Circumcostal Gastropexy Circumcostal gastropexy was first described in 1982 but is now primarily of historical interest owing to its more invasive nature and the greater potential for complications. It was performed by creating a tunnel underneath the cartilaginous portion of the 10th or 11th rib by incising the overlying peritoneum and tranversus abdominis muscle. A seromuscular flap from the pyloric antrum was then passed cranial to caudal through the tunnel surrounding the rib with or without the assistance of stay sutures in the leading edge of the gastric flap. This flap was then sutured back to its origin on the stomach with 2-0 absorbable sutures in a simple interrupted or continuous pattern. Not only was this technique particularly technically demanding, but it was also associated with an increased risk of iatrogenic pneumothorax and rib fracture.4,20,24 GDV recurrence rates following this procedure have been documented to range from 3.3%20 to 4.3%.13,24 Tube Gastropexy The tube gastropexy was one of the first procedures developed for gastropexy in dogs. After correction of gastric volvulus, the procedure is performed by placing stay sutures at the ventral and dorsal borders of the pyloric antrum outline and a 24-F Foley catheter (or Pezzar urinary catheter) is introduced into the abdomen through the right ventral abdominal wall at the desired location (just caudal to the last rib). The Foley catheter is then passed through the center of the pyloric antrum tracing into the gastric lumen. The catheter balloon is inflated with sterile saline and secured to the stomach by tying a purse-string suture. Gentle traction on the catheter is used to bring the stomach into contact with the peritoneum and a sufficient number of seromuscular to parietal serosa simple interrupted sutures are placed. The Foley catheter is removed no less than 7 days after surgery; at which point, permanent adhesions should be formed.13 Although tube gastropexy is fairly fast and possibly technically easier than other gastropexy techniques, the postoperative lengthy hospitalization and a high complication rate limits it utility. The potential complications include premature dislodgement of the tube or removal by the animal, peritonitis or subcutaneous cellulitis associated with leakage of gastric contents around the tube, and persistent stoma drainage. A report
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documented a 17% complication rate; this included the development of septic peritonitis in 2 of 24 dogs that was fatal.4 Possible additional benefits of a tube gastropexy are that it also allows for continued gastric decompression in the early postoperative period if necessary and provides access to the stomach for delivery of enteral nutrition and medications.25 Incorporating Gastropexy Incorporating gastropexy involves including approximately 4-7 cm of the gastric wall near the pyloric antrum with the cranial portion of the linea alba during closure of the celiotomy incision. Although this technique is effective, as well as rapid and easy to perform, it is not recommended, as future celiotomies risk incision into the gastric lumen and subsequent abdominal sepsis. Gastrocolopexy Gastrocolopexy was first described almost 40 years ago, making it one of the earliest techniques developed in attempts to prevent recurrence of GDV. The procedure is performed most commonly by scarifying the surface of the greater curvature of the stomach and the transverse colon and then suturing these tissues together using nonabsorbable suture. A study by Eggertsdóttir et al.26 documented a recurrence rate of 20% (4/20 dogs), which is higher than that reported with other gastropexy techniques.
Minimally Invasive Gastropexy Techniques Although open surgical approaches via ventral midline incisions are safe and effective, minimally invasive techniques have the advantages of less postsurgical discomfort and more rapid recovery. Both of these are particularly appealing for elective procedures in young, typically active, large, and giant-breed dogs. Minimally invasive procedures are rarely reported for the treatment of dogs with GDV, as repositioning of the stomach and evaluation of the rest of the abdomen would be quite difficult. However, for surgeons experienced in minimally invasive procedures, this may be an option. Minimally invasive techniques include the grid approach, endoscopically guided miniapproach, and laparoscopic gastropexy. Grid Approach (Miniopen Approach) The grid approach, also known as the minilaparotomy involves making a small ( 6 cm) vertical skin incision just caudal to the 13th rib. The abdomen is approached by bluntly dissecting the external and internal abdominal oblique muscles and the transversus abdominis muscles along the muscle fibers. After entry into the peritoneal cavity, the gastric antrum can be reached. A 3-cm incision is made into the seromuscular layer of the gastric antrum, and this is sutured to the transversus abdominis fascia and muscle with a continuous suture pattern of absorbable monofilament. The rest of the superficial muscle layers are closed individually with a simple continuous pattern.27 Visualization of specific gastric landmarks including the pylorus, omental attachments, and gastric vasculature is essential to ensure that the correct portion of the gastrointestinal tract is being anchored. However, this technique is easy and requires no special equipment. Endoscopically Guided Miniapproach With the patient in left oblique recumbency, a gastroscope is advanced and the stomach is insufflated. Once the pyloric antrum is visualized, number 2 polypropylene suture on a cutting needle
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is passed through the right abdominal wall just caudal to the last rib and into the lumen of the stomach. The needle is viewed as it exits the stomach and is retrieved outside the dog. This stay suture is secured with a hemostat. An incision is made into the abdominal cavity through the body wall and the pyloric antrum is apposed similar to the grid gastropexy with a seromuscular incision.28,29 This technique has the advantage of improving placement of the gastropexy site, but it requires more equipment and skills to perform than the grid approach does. Laparoscopic Gastropexy Laparoscopic gastropexy is a popular minimally invasive technique, which allows for improved visualization as compared with the grid and endoscopic approaches. It involves inserting 3 portals along ventral midline; the first allows for insufflation and is made 1 cm caudal to the umbilicus, the second is the instrument port (3-4 cm caudal to the xyphoid), and the third is for the camera (placed midway between the first 2). A stay suture is introduced through the body wall into the abdomen over the pyloric antrum. The needle is grasped intracorporally, passed through the pyloric antrum, and exited the body wall. A similar procedure as the endoscopically guided technique is then performed; however, suturing the seromuscular layer to the transversus abdominis fascia and muscle can be performed by the surgeon either extracorporally or intracorporally with either a suture-assist device or laparoscopic needle holders. Staples may also be used, and recently barbed suture has been used, which negates the need to tie knots internally. Potential complications with laparoscopy gastropexy include perforation of the gastric lumen, splenic laceration, cardiovascular instability from decreased venous return (due to in abdominal insufflation), or air embolus during insufflation. In a case series of 25 dogs undergoing laparoscopic gastropexy (2 for GDV and 23 prophylactically), the recurrence rate was 0 at 1 year, and 20 dogs evaluated using ultrasonography were found to have intact gastropexy attachments.17 Although this is true with all gastropexy procedures, it is essential that the laparoscopic surgeon have training and experience to avoid intraoperative complications and minimize anesthesia time.
Conclusions Gastropexy is a vital surgical technique for the prevention of the occurrence or recurrence of GDV in at-risk and affected dogs. Incisional gastropexy is the most commonly performed open gastropexy technique, while laparoscopic gastropexy is gaining in popularity for prophylactic gastropexy as an isolated procedure. When performed correctly by experienced surgeons, these gastropexy techniques are associated with extremely low complication rates and failure rates (i.e., recurrence of GDV). References 1. Schulman A, Lusk R, Ettinger S, Lippincott C. A new surgical technique to prevent recurrences of gastric dilatation-volvulus syndrome. J Am Anim Hosp Assoc 21:339–346, 1986 2. Wingfield WE, Betts CW, Greene RW. Operative techniques and recurrence rates associated with gastric volvulus in the dog. J Small Anim Pract 16: 427–432, 1975 3. Flanders JA, Harvey HJ. Results of tube gastrostomy as treatment for gastric volvulus in the dog. J Am Vet Med Assoc 185:74–77, 1984 4. Fox S. Gastric dilatation volvulus: results of 31 cases of circumcostal vs tube gastrostomy. Calif Vet 8:8–11, 1985 5. Glickman LT, Lantz GC, Schellenberg DB, Glickman NW. A prospective study of survival and recurrence following the acute gastric dilatation-volvulus syndrome in 136 dogs. J Am Anim Hosp Assoc 34:253–259, 1998 6. Connon M. Three cases of gastroptosis treated by gastropexy (Rovsing). Br Med J 2:250, 1916
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7. Castro VA, Nyhus LM, Gillison EW, Nakayoshi A, Bombeck CT. Posterior gastropexy (Hill) in the treatment of reflux esophagitis. An experimental study in the dog. Scand J Gastroenterol 6:49–55, 1971 8. Funkquist B. Gastric torsion in the dog. III. Fundic gastropexy as a relapsepreventing procedure. J Small Anim Pract 20:103–109, 1979 9. Marconato L. Gastric dilatation-volvulus as complication after surgical removal of a splenic haemangiosarcoma in a dog. J Vet Med A Physiol Pathol Clin Med 53:371–374, 2006 10. Millis DL, Nemzek J, Riggs C, Walshaw R. Gastric dilatation-volvulus after splenic torsion in two dogs. J Am Vet Med Assoc 207:314–315, 1995 11. Goldhammer MA, Haining H, Milne EM, Shaw DJ, Yool DA. Assessment of the incidence of GDV following splenectomy in dogs. J Small Anim Pract 51:23–28, 2010 12. Ward MP, Patronek GJ, Glickman LT. Benefits of prophylactic gastropexy for dogs at risk of gastric dilatation-volvulus. Prev Vet Med 60:319–329, 2003 13. Fox SM, Ellison G, Miller G. Observations on the mechanical failure of three gastropexy techniques. J Am Anim Hosp Assoc 21:729–734, 1985 14. Wilson ER, Henderson RA, Montgomery RD, Kincaid SA, Wright JC, Hanson RR. A comparison of laparoscopic and belt-loop gastropexy in dogs. Vet Surg 25:221–227, 1996 15. Whitney W, Scavelli T, Matthiesen D. Belt-loop gastropexy: technique and surgical results in 20 dogs. J Am Anim Hosp Assoc 25:75–83, 1989 16. Rawlings CA, Mahaffey MB, Bement S, Canalis C. Prospective evaluation of laparoscopic-assisted gastropexy in dogs susceptible to gastric dilatation. J Am Vet Med Assoc 221:1576–1581, 2002 17. Rawlings CA, Foutz TL, Mahaffey MB, Howerth EW, Bement S, Canalis C. A rapid and strong laparoscopic-assisted gastropexy in dogs. Am J Vet Res 62:871–875, 2001 18. Meyer-Lindenberg A, Harder A, Fehr M, Luerssen D, Brunnberg L. Treatment of gastric dilatation-volvulus and a rapid method for prevention of relapse in dogs: 134 cases (1988-1991). J Am Vet Med Assoc 203:1303–1307, 1993
19. MacCoy DM, Sykes GP, Hoffer RE. A permanent gastropexy technique for permanent fixation of the pyloric antrum. J Am Anim Hosp Assoc 18:736–768, 1982 20. Leib MS, Konde LJ, Wingfield WE, Twedt DC. Circumcostal gastropexy for preventing recurrence of gastric dilatation-volvulus in the dog: an evaluation of 30 cases. J Am Vet Med Assoc 187:245–248, 1985 21. Hardie RJ, Flanders JA, Schmidt P, Credille KM, Pedrick TP, Short CE. Biomechanical and histological evaluation of a laparoscopic stapled gastropexy technique in dogs. Vet Surg 25:127–133, 1996 22. Monnet E. Gastric dilatation-volvulus syndrome in dogs. Vet Clin North Am Small Anim Pract 33:987–1005, 2003(vi) 23. Benitez ME, Schmiedt CW, Radlinsky MG, Cornell KK. Efficacy of incisional gastropexy for prevention of GDV in dogs. J Am Anim Hosp Assoc 49:185–189, 2013 24. Woolfson J, Kostolich M. Circumcostal gastropexy; clinical use of the technique in 34 dogs with gastric dilatation-volvulus. J Am Anim Hosp Assoc 22:825–830, 1986 25. Ellison GW. Complications of gastrointestinal surgery in companion animals. Vet Clin North Am Small Anim Pract 41:915–934, 2011(vi) 26. Eggertsdóttir AV, Stigen y O, Lonaas L, et al. Comparison of the recurrence rate of gastric dilatation with or without volvulus in dogs after circumcostal gastropexy versus gastrocolopexy. Vet Surg 30:546–551, 2001 27. Steelman-Szymeczek SM, Stebbins ME, Hardie EM. Clinical evaluation of a right-sided prophylactic gastropexy via a grid approach. J Am Anim Hosp Assoc 39:397–402, 2003 28. Dujowich M, Keller ME, Reimer SB. Evaluation of short- and long-term complications after endoscopically assisted gastropexy in dogs. J Am Vet Med Assoc 236:177–182, 2010 29. Dujowich M, Reimer SB. Evaluation of an endoscopically assisted gastropexy technique in dogs. Am J Vet Res 69:537–541, 2008
