3. small Anim. Pract.
(1975) 16, 433-438.
Recurring gastric volvulus in a dog C. W. B E T T S , * S . K . K N E L L E R t
AND
E. R O S I N *
Departments of Small Animal Medicine and Surgery* and Anatomy and Radiologyt (Kneller), College of Veterinary Medicine, University of Georgia, Athens, Georgia 3060 1
ABSTRACT A successful prophylactic permanent gastropexy was performed on a dog that had previously experienced four gastric volvulus procedures, one prophylactic pyloroplasty, and two subsequent gastric volvulus repairs. Radiographic evaluation of the previous pyloroplasty and the final permanent gastropexy are illustrated.
INTRODUCTION Gastric dilation-volvulus is recognized as one of the few true surgical emergencies presented to the veterinary practitioner. I t has also been documented that dogs which survive an initial episode of gastric dilation-volvulus are prone to subsequent episodes (Betts et al., 1974; Wingfield et al., 1975). T h e surgical management of such cases is challenging and several methods have been advocated for initial repair and prophylaxis (DeHoff & Greene, 1972; Wingfield & Hoffer, 1974).
HISTORY In February 1973, a 9-year-old male German Shepherd was referred to the University of Georgia Small Animal Hospital to have prophylactic surgery for recurring gastric volvulus. The dog was a valuable show animal and was being used a t stud. The first gastric volvulus occurred in July 1971, several hours after the dog was fed. The dilation was slow in onset, with progressive signs of discomfort and distress. The stomach was repositioned surgically, a n engorged spleen was removed, and a gastropexy performed. After surgery, the dog recovered well and was started on a controlled diet. Small amounts of I/d combined with P/d (Riviana Foods Inc., 433
434
C . W . BETTS, S. K . K N E L L E R A N D 2. R O S I N
Hill’s Division, Topeka, Kansas) were fed at frequent intervals and water intake was supervised. The dog’s most strenuous exercise was service and at other times he was confined with restricted exercise. The second volvulus occurred in August 1971, with no known instigating factors, as did the third volvulus in November 1971, and the fourth volvulus in April 1972. I n the last three episodes the stomach was surgically repositioned only. I n May 1972, the dog was referred to the Animal Medical Center in New York City for prophylactic surgery. At this time, a Finney pyloroplasty (Schwartz & Storer, 1974) and gastropexy were done. Pyloric sphincter dysfunction has been reported as a cause of abnormal emptying of the stomach with subsequent gastric volvulus in the dog (Funkquist & Garmer, 1967) and pyloroplasty or pyloromyotomy is being advocated as a prophylactic measure to prevent recurrence (Betts et al., 1974; DeHoff & Greene, 1972). The fifth gastric volvulus occurred in August 1972 and the sixth in November 1972. As before, no significant influencing factors were known. PHYSICAL FINDINGS The results of the physical examination and screening laboratory tests were within normal limits. A radiographic evaluation of gastric motility and stomach emptying time was considered necessary before planning a surgical method of preventing future gastric volvulus recurrence. This would also demonstrate the efficacy of the previous pyloroplasty. PREOPERATIVE RADIOGRAPHIC INTERPRETATION An upper G I contrast study was performed after the ingesta had been cleared. Twelve ounces of micronized liquid barium mixture (Redi-Flow-Flow Pharmaceuticals Inc., Palo Alto, California) was administered by stomach tube. At 15 minutes after administration, approximately $ of the barium had entered the small intestine. At 1 hour after administration, only a mucosal coating of barium remained in the stomach. In our experience, this would indicate a slight decrease in gastric empyting time. The- pyloroduodenal area appeared to have a 10 cm diverticulum associated with the Finney pyloroplasty which filled with barium, but demonstrated good emptying and peristaltic activity (Fig. 1). OPERATIVE PROCEDURE O n 1 March 1973, the dog was positioned in right lateral recumbency, a linear paracostal incision was made into the abdominal cavity and a gastrostomy performed. The stomach was identified and what was thought to be the greater curvature was exteriorized. A sequentially layered closure of the abdominal wall
RECURRING GASTRIC VOLVULUS
FIG. 1. Lateral (a) and ventrodorsal (b) abdominal radiographs made 5 minutes after administration of 12 ounces of barium suspension. Barium fills the pyloroplasty site (arrow) and passes into the small bowel.
435
436
C . W . B E T T S , S. K . K N E L L E R A N D E . R O S I N
FIG. 2. Ventrodorsal radiographs made at 3 minutes (a) and 60 minutes (b) after administration of barium suspension. In Fig. 2a, barium coated mucosa is visualized at the surgery site (arrow). The gas filled gastric lumen is seen in Fig. 2b. The stomach lies entirely along the left abdominal wall. Barium is seen in the jejunum.
RECURRING GASTRIC VOLVULUS
43 7
in an elliptical fashion was done u p through the subcutaneous tissue. An opening was made into the stomach, tissue taken for histological examination, and a mucocutaneous closure performed. Finally a mucosa-to-mucosa closure with 00 chromic catgut was done to eliminate leakage of gastric contents. I t was hoped that a permanent gastropexy sufficiently strong to prevent further volvulus would form.
POST-OPERATIVE COURSE The dog recovered well from surgery and was discharged to the care of the owner and the referring veterinarian on 3 March 1973. O n 5 March 1973 the mucosal closure had opened and was leaking gastric juice. Several unsuccessful attempts were made to close the mucosal layer. O n 2 April 1973 the dog was again admitted to the University of Georgia Small Animal Hospital. A very strong gastrostomy had formed by this time. O n 3 April 1973 the edges of the wound were dtbrided and deep horizontal mattress sutures of 24 gauge stainless steel monofilament wire were placed through rubber tubing stints. A second more superficial layer, using 28 gauge stainless steel monofilament wire, was then placed through rubber tubing stints. An upper GI contrast study was performed on 12 April 1973 in the same manner as that described above. There was equal gastric emptying in both studies. The entire stomach was visualized along the left abdominal wall (Fig. 2). The surgery site was also well visualized, with barium coated mucosa extending to the abdominal wall. No leakage of barium was noted from the operation site. The sutures were removed 2 weeks after surgery at which time the wound had healed. The dog was euthanatized for reasons not pertaining to the gastrointestinal tract 16 months after closure of the gastrostomy. The dog had resumed a normal diet and was successfully utilized in a breeding programme.
DISCUSSION Before the permanent gastropexy, the longest period of time between volvuli in the German Shepherd was 5 months. During the 18 month interval from the first volvulus to being referred to the University of Georgia, the dog survived six gastric volvuli and operative repairs, plus a major abdominal procedure. I n each volvulus episode, prompt recognition of signs and early professional management contributed greatly to the animal’s survival. One additional case, a 7-year-old Great Dane with recurring gastric dilations, has been handled this way. A pyloromyotomy and a permanent gastropexy were performed. In this case, a gastrostomy opening was not performed. T h e last layer, incorporating the stomach, was to the dermal fascia, followed by routine closure of the skin. Unfortunately, this dog was euthanatized 2 weeks after surgery
438
C . W . BETTS, S . K . KNELLER A N D E . ROSIN
because of the animal’s vicious temperament. At post-mortem examination the gastropexy was intact and healing. Gastropexy, splenectomy, and pyloroplasty or pyloromyotomy have all been advocated in correction and prevention of gastric volvulus (DeHoff & Green, 1972; Wingfield & Hoffer, 1974; Betts et al., 1974). However, gastric volvulus has been shown to recur after these procedures alone or in combination (Betts et al., 1974). A tube gastrostomy at the time of volvulus correction has also been suggested to prevent recurrence (Berg, 1968). CONCLUSIONS Routine gastropexy is not permanent and does not prevent recurrence of gastric volvulus. A permanent gastropexy as in the method described is suggested by the authors to prevent recurrence. This method should be modified to conclude as a gastric muscularis-serosa to dermal fascia closure with routine closure of the skin. REFERENCES BERG,P. Gastric Torsion. (1968) In Kirk, R.W. (Ed.). Current Veterinary Therapy ZZI. W. B. Saunden Co. Philadelphia, BETTS,C.W., WINGFIELD, W.E. & GREENE, R.W. (1974) 3. small Anim. Pract. 15, 727. DEHOFF,W.D. & GREENE, R.W. (1972) Vet. Clin. N. Amer., 2, 141. SCHWARTZ, S.I. & STORER, E.H. (1974) Principles of Surgery, 2nd Edn. 2, 1065. FUNKQUIST, B. & GARNER, L. (1967). 3. small Anim. Pract., 8, 523. WINGFIELD, W.E. & HOFFER, R.E. (1974) Current Sm. An. Surg. Ed. by M. J. Bojrah. Lea and Febiger, Philadelphia. WINGFIELD, W.E., BETTS,C.W. & GREENE, R.W. (1975) 3,small Anim. Pract., 16, 427.
(1975) 16, 433-438.
Recurring gastric volvulus in a dog C. W. B E T T S , * S . K . K N E L L E R t
AND
E. R O S I N *
Departments of Small Animal Medicine and Surgery* and Anatomy and Radiologyt (Kneller), College of Veterinary Medicine, University of Georgia, Athens, Georgia 3060 1
ABSTRACT A successful prophylactic permanent gastropexy was performed on a dog that had previously experienced four gastric volvulus procedures, one prophylactic pyloroplasty, and two subsequent gastric volvulus repairs. Radiographic evaluation of the previous pyloroplasty and the final permanent gastropexy are illustrated.
INTRODUCTION Gastric dilation-volvulus is recognized as one of the few true surgical emergencies presented to the veterinary practitioner. I t has also been documented that dogs which survive an initial episode of gastric dilation-volvulus are prone to subsequent episodes (Betts et al., 1974; Wingfield et al., 1975). T h e surgical management of such cases is challenging and several methods have been advocated for initial repair and prophylaxis (DeHoff & Greene, 1972; Wingfield & Hoffer, 1974).
HISTORY In February 1973, a 9-year-old male German Shepherd was referred to the University of Georgia Small Animal Hospital to have prophylactic surgery for recurring gastric volvulus. The dog was a valuable show animal and was being used a t stud. The first gastric volvulus occurred in July 1971, several hours after the dog was fed. The dilation was slow in onset, with progressive signs of discomfort and distress. The stomach was repositioned surgically, a n engorged spleen was removed, and a gastropexy performed. After surgery, the dog recovered well and was started on a controlled diet. Small amounts of I/d combined with P/d (Riviana Foods Inc., 433
434
C . W . BETTS, S. K . K N E L L E R A N D 2. R O S I N
Hill’s Division, Topeka, Kansas) were fed at frequent intervals and water intake was supervised. The dog’s most strenuous exercise was service and at other times he was confined with restricted exercise. The second volvulus occurred in August 1971, with no known instigating factors, as did the third volvulus in November 1971, and the fourth volvulus in April 1972. I n the last three episodes the stomach was surgically repositioned only. I n May 1972, the dog was referred to the Animal Medical Center in New York City for prophylactic surgery. At this time, a Finney pyloroplasty (Schwartz & Storer, 1974) and gastropexy were done. Pyloric sphincter dysfunction has been reported as a cause of abnormal emptying of the stomach with subsequent gastric volvulus in the dog (Funkquist & Garmer, 1967) and pyloroplasty or pyloromyotomy is being advocated as a prophylactic measure to prevent recurrence (Betts et al., 1974; DeHoff & Greene, 1972). The fifth gastric volvulus occurred in August 1972 and the sixth in November 1972. As before, no significant influencing factors were known. PHYSICAL FINDINGS The results of the physical examination and screening laboratory tests were within normal limits. A radiographic evaluation of gastric motility and stomach emptying time was considered necessary before planning a surgical method of preventing future gastric volvulus recurrence. This would also demonstrate the efficacy of the previous pyloroplasty. PREOPERATIVE RADIOGRAPHIC INTERPRETATION An upper G I contrast study was performed after the ingesta had been cleared. Twelve ounces of micronized liquid barium mixture (Redi-Flow-Flow Pharmaceuticals Inc., Palo Alto, California) was administered by stomach tube. At 15 minutes after administration, approximately $ of the barium had entered the small intestine. At 1 hour after administration, only a mucosal coating of barium remained in the stomach. In our experience, this would indicate a slight decrease in gastric empyting time. The- pyloroduodenal area appeared to have a 10 cm diverticulum associated with the Finney pyloroplasty which filled with barium, but demonstrated good emptying and peristaltic activity (Fig. 1). OPERATIVE PROCEDURE O n 1 March 1973, the dog was positioned in right lateral recumbency, a linear paracostal incision was made into the abdominal cavity and a gastrostomy performed. The stomach was identified and what was thought to be the greater curvature was exteriorized. A sequentially layered closure of the abdominal wall
RECURRING GASTRIC VOLVULUS
FIG. 1. Lateral (a) and ventrodorsal (b) abdominal radiographs made 5 minutes after administration of 12 ounces of barium suspension. Barium fills the pyloroplasty site (arrow) and passes into the small bowel.
435
436
C . W . B E T T S , S. K . K N E L L E R A N D E . R O S I N
FIG. 2. Ventrodorsal radiographs made at 3 minutes (a) and 60 minutes (b) after administration of barium suspension. In Fig. 2a, barium coated mucosa is visualized at the surgery site (arrow). The gas filled gastric lumen is seen in Fig. 2b. The stomach lies entirely along the left abdominal wall. Barium is seen in the jejunum.
RECURRING GASTRIC VOLVULUS
43 7
in an elliptical fashion was done u p through the subcutaneous tissue. An opening was made into the stomach, tissue taken for histological examination, and a mucocutaneous closure performed. Finally a mucosa-to-mucosa closure with 00 chromic catgut was done to eliminate leakage of gastric contents. I t was hoped that a permanent gastropexy sufficiently strong to prevent further volvulus would form.
POST-OPERATIVE COURSE The dog recovered well from surgery and was discharged to the care of the owner and the referring veterinarian on 3 March 1973. O n 5 March 1973 the mucosal closure had opened and was leaking gastric juice. Several unsuccessful attempts were made to close the mucosal layer. O n 2 April 1973 the dog was again admitted to the University of Georgia Small Animal Hospital. A very strong gastrostomy had formed by this time. O n 3 April 1973 the edges of the wound were dtbrided and deep horizontal mattress sutures of 24 gauge stainless steel monofilament wire were placed through rubber tubing stints. A second more superficial layer, using 28 gauge stainless steel monofilament wire, was then placed through rubber tubing stints. An upper GI contrast study was performed on 12 April 1973 in the same manner as that described above. There was equal gastric emptying in both studies. The entire stomach was visualized along the left abdominal wall (Fig. 2). The surgery site was also well visualized, with barium coated mucosa extending to the abdominal wall. No leakage of barium was noted from the operation site. The sutures were removed 2 weeks after surgery at which time the wound had healed. The dog was euthanatized for reasons not pertaining to the gastrointestinal tract 16 months after closure of the gastrostomy. The dog had resumed a normal diet and was successfully utilized in a breeding programme.
DISCUSSION Before the permanent gastropexy, the longest period of time between volvuli in the German Shepherd was 5 months. During the 18 month interval from the first volvulus to being referred to the University of Georgia, the dog survived six gastric volvuli and operative repairs, plus a major abdominal procedure. I n each volvulus episode, prompt recognition of signs and early professional management contributed greatly to the animal’s survival. One additional case, a 7-year-old Great Dane with recurring gastric dilations, has been handled this way. A pyloromyotomy and a permanent gastropexy were performed. In this case, a gastrostomy opening was not performed. T h e last layer, incorporating the stomach, was to the dermal fascia, followed by routine closure of the skin. Unfortunately, this dog was euthanatized 2 weeks after surgery
438
C . W . BETTS, S . K . KNELLER A N D E . ROSIN
because of the animal’s vicious temperament. At post-mortem examination the gastropexy was intact and healing. Gastropexy, splenectomy, and pyloroplasty or pyloromyotomy have all been advocated in correction and prevention of gastric volvulus (DeHoff & Green, 1972; Wingfield & Hoffer, 1974; Betts et al., 1974). However, gastric volvulus has been shown to recur after these procedures alone or in combination (Betts et al., 1974). A tube gastrostomy at the time of volvulus correction has also been suggested to prevent recurrence (Berg, 1968). CONCLUSIONS Routine gastropexy is not permanent and does not prevent recurrence of gastric volvulus. A permanent gastropexy as in the method described is suggested by the authors to prevent recurrence. This method should be modified to conclude as a gastric muscularis-serosa to dermal fascia closure with routine closure of the skin. REFERENCES BERG,P. Gastric Torsion. (1968) In Kirk, R.W. (Ed.). Current Veterinary Therapy ZZI. W. B. Saunden Co. Philadelphia, BETTS,C.W., WINGFIELD, W.E. & GREENE, R.W. (1974) 3. small Anim. Pract. 15, 727. DEHOFF,W.D. & GREENE, R.W. (1972) Vet. Clin. N. Amer., 2, 141. SCHWARTZ, S.I. & STORER, E.H. (1974) Principles of Surgery, 2nd Edn. 2, 1065. FUNKQUIST, B. & GARNER, L. (1967). 3. small Anim. Pract., 8, 523. WINGFIELD, W.E. & HOFFER, R.E. (1974) Current Sm. An. Surg. Ed. by M. J. Bojrah. Lea and Febiger, Philadelphia. WINGFIELD, W.E., BETTS,C.W. & GREENE, R.W. (1975) 3,small Anim. Pract., 16, 427.
