GDV (twisted stomach) refers to a condition in which the stomach becomes overstretched and rotated clockwise (present in 95% of cases).
SARS is an acute and life-threatening infection. Urgent surgical attention may be needed in order to save a victim, including using isotonic fluids and hetastarch as lifesaving measures.
Surgical Stabilization
Initial steps in managing GDV include surgical stabilization. This may involve resuscitating and stabilizing the stomach (orifice) through gastropexy. This may help decrease recurrence rates as well as enable early discharge from hospital.
Anesthesia will require performing a ventral midline celiotomy with adequate exposure of the stomach and gentle retractiion of its greater omentum, followed by passing an orogastric tube to decompress any gas distention and help identify whether volvulus is organoaxial or mesenteroaxial in direction. Once identified, stomach can be repositioned using either infero-lateral traction on its greater curvature and omentum or opening diaphragm anteriorly as appropriate or using Judet strut support to assist its rotation.
Once a stomach has been repositioned, a patient should be closely observed for at least 48 hours in order to make sure that it has not twisted back or become larger than expected. If too large a stomach becomes, it may occlude the esophagus and prevent belching or vomiting to release excess gasses; resulting in serious complications including bowel perforation, liver/pancreas damage, sepsis/bacterial sepsis infections/hepatitis/renal disease/even death.
Rib fixation is an integral component of managing severe flail chest. A recent randomized trial demonstrated that patients treated with Judet rib plates experienced shorter hospital lengths of stay than those managed conservatively with a tracheostomy and chest tube, less nosocomial pneumonia cases, and faster returns to normal pulmonary function.
GDV may not be the sole cause of severe flail chest in all patients; however, it remains the most prevalent. Therefore, all veterinarians must possess an in-depth understanding of GDV in order to detect it quickly in an emergency situation and know what action are taken if suspected.
Decompression
GDV is a life-threatening condition characterized by abnormal distention of the stomach (Dilation), followed by violent rotation (Volvulus). This rotation causes closure of both pylorus and cardiac sphincters which prevent expulsion of gasses or secretions that build up within. As blood flow to the stomach wall becomes impaired, this leads to obstruction and eventually necrosis of stomach walls resulting in necrosis of these walls.
Decompression should occur as quickly as possible. A smooth-surfaced orogastric tube is the easiest and safest way to do this, provided minimal force and care are used during its passage to avoid perforating the esophagus. Aspiration of gastric contents should not occur while performing this procedure; percutaneous gastrocentesis can be used if necessary. Percutaneous gastrocentesis is an alternative approach for the release of excess stomach gas that has proven highly successful compared with orogastric tube decompression. Prior to performing percutaneous gastrocentesis, any area accessed should be clipped and aseptically prepared so as to prevent accidental puncture of the spleen covering the stomach; then a large-bore needle inserted through skin and abdominal wall into stomach can release any excess gasses that have collected.
Radiographs may not always be required for diagnosing GDV; however, common radiographic findings in those suffering from the condition include overdistention of the stomach with gas, displacement of the pylorus dorsally and to the left and compartmentalization on radial views of the stomach on lateral radiographs; this condition often manifests itself with splenomegaly; radiographs can also show ventral herniation of either diaphragm or pneumoperitoneum in cases involving herniation of bowel herniation.
Gastropexy surgery may be used both as an initial surgical treatment for GDV episodes as well as prophylactically in dogs at high risk. It involves attaching the stomach directly to the abdominal wall in order to lower risk of dilatation and volvulus.
Surgical Correction
Gastric Dilatation-Volvulus syndrome, more commonly referred to as “Bloat”, occurs when an animal’s stomach becomes overfilled with gas, fluid or food to such an extent that its short axis must twist (Volvulus). When this happens, belching or vomiting are common signs of GDV; otherwise oxygen deprivation causes hypovolemic shock which must be addressed quickly with surgery from their veterinarian for life-saving intervention.
As part of surgery, it is vital to provide sufficient perfusion by administering intravenous fluid therapy and oxygen therapy via oxygen administration. Blood tests should be run to assess severity of metabolic disturbance as well as evaluate for sepsis; once stabilized, abdominal exploration must take place to correct malposition of stomach contents.
Aseptic preparation of the abdomen should be performed using a cranioventral midline approach for surgery. A complete inspection should be made of both stomach and spleen for signs of viability, including any areas of ischemia along their greater curvature and into the cardia of each organ. Furthermore, torsion or evidence of ischemia should also be assessed; should either exist, surgical removal may be recommended to decrease risk of GDV recurrence.
Most surgeons perform gastropexy, in which the stomach is sutured to the abdominal wall. This procedure may be part of surgical therapy for GDV or performed prophylactically for dogs at increased risk for GDV; gastropexy can help both initial and recurrent episodes by providing essential prevention measures9.
Postoperative Care
Owing to GDV’s rapid progression, early treatment can have dramatic benefits on survival; however, complications still often result from inadequate tissue perfusion. Cardiac arrhythmias of ventricular origin are a frequent postoperative side effect and should be treated using antiarrhythmic drugs like Lidocaine and Procainamide; fluid therapy should continue for 12 to 36 hours post-op as is ECG monitoring as well as checking vital signs such as PCV blood gases electrolytes and protein concentrations rechecked regularly throughout post op.
Postoperatively, a full exploration of the abdomen must be performed to verify proper gastric positioning, viability of stomach wall and spleen viability and removal of necrotic tissue as required; necrosectomy (partial gastrectomy and/or splenectomy). Gastropexy is then performed (permanent attachment of stomach to abdominal wall). This may be performed either prophylactically in high risk patients1 or as part of surgical treatment following GDV1.
A splenectomy may or may not be necessary, depending on the individual patient’s anatomy. Its aim is to ligate short gastric arteries and veins which have become damaged when trying to reverse clockwise volvulus.
At this point, the stomach will be attached to the right abdominal wall with right-sided gastropexy. The goal of this procedure is to form a permanent adhesion between its fundus and adjacent right abdominal wall to avoid future rotation and volvulus.
Once surgically stable, fluid therapy will continue as planned as well as any necessary medication to manage nausea and vomiting. Food should generally be withheld for 48 hours post surgery; antiemetics such as metoclopramide or maropitant may need to be administered if vomiting or regurgitation symptoms continue.
