GDV (commonly known as bloat, twisted stomach or Gastric Dilatation Volvulus) is a life-threatening condition requiring immediate surgical correction. [1]
Step one is decompression of the stomach in order to decrease esophageal perforation, either using an orogastric tube under sedation or gastrocentesis in awake patients.
Decompression
Decompression refers to a gradual reduction in atmospheric pressure experienced by divers and others who work in underwater environments, usually experienced as they descend to lower atmospheric pressure levels. Its opposite, compression, can lead to dangerous conditions like decompression sickness. Decompress can also refer to relieving stress or tension.
As part of emergency GDV management, it is critical to quickly reposition an abnormally positioned stomach. This will relieve occlusion of the caudal vena cava and allow blood from distended stomach to return towards heart (with improved preload), decompress stomach and spleen and decompress. Care should also be taken in evaluating for clockwise volvulus or rotation through rent in splenic mesentery which may contribute to gastric wall ischemia and should be ligated if present as they may contribute to gastric wall ischemia.
Before performing surgical correction of GDV, a stomach tube inserted through orotracheal intubation or trocharization should be inflated as far as possible to allow decompression and repositioning of the stomach. Palpation should also be performed to confirm proper stomach position in case there is clockwise volvulus or rotatation through rents in the splenic membrane.
Once the stomach has been repositioned, fluid therapy can resume. A continuous intravenous fluid drip with isotonic crystalloids and colloids may be administered, due to risk of endotoxemia and bacteria translocation into the gut; antibiotics will usually also be given.
GDV can be permanently treated through gastropexy, the surgical attachment of the stomach to the abdominal wall. This technique may be performed as part of GDV surgery treatment or prophylactically for dogs at increased risk for GDV9. Recurrence rates for GDV have been drastically reduced using this approach; many patients can return to normal activity levels within a day post surgery; strenuous activities should be avoided for 6 weeks in order to prevent complications caused by recurrent GDV episodes. Tube gastropexy may also be performed concurrently with other surgical techniques like incisional and circumcostal pexes so as to reduce recurrence risk further.
Incisional Pexy
There are various techniques for gastropexy, such as simple incisional pexy, circumcostal (belt-loop) pexy and tube gastropexy. Tube gastropexy involves placing a full-thickness pursestring suture made of monofilament delayed-absorbable or nonabsorbable monofilament from craniodorsal to ventral surface of stomach before tying off (MacCoy 1982). This is an efficient and quick method that has an outstanding recurrence rate (MacCoy 1982).
As with other abdominal viscera, the stomach must be completely de-rotated for thorough evaluation of its viability in relation to the peritoneum, stomach wall and spleen. Any areas of ischemia are evaluated, and partial gastric resection or splenectomy is performed as necessary to preserve these organs’ viability. Finally, using gastropexy, the stomach is permanently attached to its right lateral abdominal wall in order to reduce risk of volvulus in future episodes and thus avert GDV which compresses critical stomach vasculature causing hypovolemic shock, myocardial ischemia cardiac arrhythmias electrolyte imbalance and visceral necrosis.
Circumcostal Pexy
Surgical correction of GDV should be undertaken as soon as the patient has been stabilized. The goal of surgery is to lower the risk of gastric dilatation volvulus by anchoring (gastropexy) the stomach on the right side of the abdomen and anchoring it securely there – various techniques for gastropexy have been described, from incisional, circumcostal (belt loop), tube gastrotomy and pexy, to laparoscopic-assisted gastropexy are described here.
At the outset of an operation, abdominal viscera should be closely evaluated for signs of ischemia such as shock, hypovolemic shock, impaired venous return, cardiac arrhythmias or electrolyte imbalance. Decompression of the stomach occurs by using an orogastric tube with gastric cuff pressure of approximately 7 cm H20 and by moving its distal end away from its anatomic position; any areas of ischemic gastric wall tissue are then surgically removed by way of gastrointestinal resection/splenectomy before returning it back into its usual position.
Once permanent anchorages have been established, gastropexy is used to form them. Common open methods for gastropexy include an incisional, belt loop, or circumcostal pexy. A more recently developed technique called tube gastropexy may also be performed.
With this approach, a long tube is introduced into the abdominal cavity through a sero-muscular flap in the seromuscular layer and passed behind the pylorus before being secured to its right side using stay sutures, typically using simple interrupted 2-0 synthetic absorbable suture material. As no gastric lumen enters this route there is no risk of gastric perforation.
This gastropexy can be completed quickly and produces an effective result; however, one potential complication of this procedure is pneumothorax. To prevent this complication from arising, surgeons must use wide bites with stay sutures to avoid crossing ribs; in case pneumothorax arises anyway, respiratory support (e.g. bag and mask) will likely be necessary; alternatively a mushroom-tipped DePezzer catheter can provide decompression of stomach contents and nutrition support as needed.
Tube Pexy
One can employ several approaches when performing gastropexy on their pet, including incorporating, tube, circumcostal (belt-loop), and laparoscopic-assisted techniques.1 Unfortunately, no controlled studies have compared adhesion strength, clinical outcomes or physiological impacts between these different techniques; so ultimately it comes down to personal preference of veterinarian or factors such as surgeon experience or equipment availability that is used.
Tube gastropexy is the go-to treatment for long-term enteral feeding support in cases ranging from poor oral intake due to dysphagia or other medical conditions that interfere with chewing and swallowing (like pneumonia) to following extensive surgery such as total gastrectomy or esophagectomy.
During a surgical procedure, a small catheter is introduced through the mouth and into the stomach. Care should be taken when manipulating this tube to avoid perforating either pylorus or esophagus as forceful manipulation may cause distal obstruction. A mushroom tip catheter should be utilized in order to minimize absorption into gastrointestinal tract. After placement, rubber flinges should be attached at each end to secure placement and ensure optimal functionality of tube.
Care must be taken not to pass it beyond the lower esophageal sphincter (this could result in hernia), four jejunopexy sutures are placed evenly around each tube at each site and tied securely around their base with an abdominal wall purse-string made up of monofilament absorbable suture 3-0 monofilament absorbable suture (known as jejunostomy tubing).
Fluid diets are then administered through the tube into the stomach. Flushing it with large volumes of water 4 times a day helps avoid blockage; and caloric intake should gradually increase by 1/4 each day (this may be difficult with severely altered patients who may vomit or experience diarrhea). If ruptured gastropexy is diagnosed, immediate revision surgery must take place as quickly as possible to avoid complications like respiratory compromise and infection; open revision is more likely than endoscopic approaches as an approach that might produce success – this applies especially if large detachments have not caused pneumothorax formation or dysfunction of neoglottis dysfunction caused by large detachments that has yet caused pneumothorax formation or large detachments without yet having caused pneumothorax formation or large detachments have not caused pneumothorax formation or when large detachments have caused pneumothorax formation or caused the dysfunctional functioning neoglottis is likely than endoscopic approaches when dealing with large detachments without yet creating pneumothorax or dysfunction in cases where large detachment of pexy has occurred without creating pneumothorax or dysfunction in cases where large detachment of pexy. In such cases in which large detachment causes pneumothorax formation, or when large detachments caused neo thary neo thral – either pneumothorax formation caused neoglott causing dysfunction within.