Department of Small Animal Medicine and Clinical Biology, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
Gastric dilatation volvulus (GDV) typically occurs in male, middle-aged to older, large and giant breed dogs. Other predisposing factors include body conformation (large thoracic depth-to-width ratio), behavior (rapid and gulping eating style), eating from a raised food dish, stress (grooming, dog shows, boarding), food particles less than 3 cm in size, once daily feeding, underlying inflammatory bowel disease, gastric foreign body, splenectomy and increased hepatogastric ligament length. The lifetime risk for a large or giant breed dog developing GDV is 24% and 21% respectively and their risk of dying of GDV is 7%. In spite of appropriate medical and surgical intervention, case fatality rates between 10% and 33% have been reported.
When gastropexy is performed after repositioning of the stomach in a dog with GDV, a permanent adhesion between the stomach and the right abdominal wall decreases the recurrence rate from 55% to 4%. Consequently, the median survival time for dogs after emergency surgery for GDV increases from 188 days to 547 days when gastropexy is performed. Because gastropexy is performed at the same time as the surgical GDV treatment (repositioning of the stomach) the different techniques to perform gastropexy use the same midline celiotomy approach.
Circumcostal gastropexy relies on a gastric seromuscular tissue flap which is passed through a tunnel created behind the last full rib and sutured back to the stomach. Circumcostal gastropexy results in a very strong connection. Tensile tests performed at day 21 after surgery revealed a breaking strength of 109 N. After circumcostal gastropexy gastric dilatation can still occur, but confirmed recurrences of GDV have not been published.
Belt-loop gastropexy differs from single-pedicle circumcostal gastropexy since the seromuscular flap is passed through a soft tissue tunnel in the abdominal wall instead of around the last rib. Maximum tensile strength 50 days after surgery is reported to be 109 N. None of three retrospective studies (cumulative patient number 60) with follow-up times up to 33 months could detect any occurrence of GDV.
Both techniques, however, can be associated with major complications such as hemorrhage, iatrogenic pneumothorax, iatrogenic rib fracture and peritonitis. In an attempt to decrease morbidity and surgical time a technically easier procedure was developed.
Incisional gastropexy relies on the healing and fusion of the edges of a gastric seromuscular incision to the edges of a vertical transverse abdominal muscle incision. Mean tensile load to failure is 85 N. This mechanically slightly weaker adhesion still results in a dramatically decreased GDV recurrence (0–4%). Because this technique is faster and has fewer complications it is considered the technique of choice.
Considering the high incidence of GDV (the Great Dane is reported to have a 40% lifetime risk for the development of GDV) and because not all of the predisposing factors can be eliminated, elective surgery in selected patients is justified. In Rottweilers and Great Danes, a prophylactic gastropexy resulted in a 2 to 30-fold reduction in mortality due to GDV, respectively. Prophylactic gastropexy can be performed by conventional (midline) celiotomy or by more recently introduced minimally invasive surgical techniques.
Laparoscopic-assisted gastropexy uses an umbilical portal for the endoscope and a flank portal for a grasping instrument to pull the stomach against the abdominal wall. The flank portal is then converted to a mini-laparotomy to perform what basically is an incisional gastropexy. The mean ultimate load of the adhesion in tension is reported to be 106 N. No occurrence of GDV within 1 year after gastropexy was reported in 23 dogs. Only minor complications or described: a temporary skin fold at the side of the gastropexy immediately after the surgery (47%), seroma formation at the site of gastropexy (6%) and iatrogenic perforation of the splenic capsule during trocar placement (12%).
Endoscopic-assisted gastropexy uses an endoscope to dilate the stomach and visually guide placement of two percutaneous stay sutures in the pyloric region. A mini-laparotomy is then created to perform the gastropexy. A possible difficulty during the procedure is to achieve appropriate contact between the stomach and the abdominal wall caudal to the 13th rib to enable gastropexy. The patient may need to be repositioned several times before gravity induces stomach-to-abdominal wall contact and this will contribute to the duration of the procedure. No occurrence of GDV was reported in a study on 23 dogs.
Laparoscopic gastropexy is performed using three ventral midline portals to manipulate the stomach, make a longitudinal gastric seromuscular incision and intracorporeally suture this to the edges of a horizontal transverse abdominal muscle incision. Mean tensile load to failure of a stapled variation at 30 days was 72 N. No major complications were reported during the procedure nor postoperatively.
Overall, minimal invasive techniques can be considered as a good alternative to conventional celiotomy gastropexies. Since prophylactic procedures should always be performed using the technique associated with the least morbidity, minimally invasive techniques must preferentially be used. They create a comparatively strong gastropexy and are associated with a decrease in incisional complications and a significant decrease in time required to regain normal activity postoperatively. Furthermore, the laparoscopic approach offers the possibility to evaluate most abdominal cavity organs without the necessity of enlarging the incision as in classical celiotomy and concurrently, the possibility to take biopsies in case of pathological findings. Intracorporeal suturing is technically challenging. The use of training simulators and further specialized training is recommended to enhance a surgeon's skills and reduce the time needed for a prophylactic laparoscopic gastropexy.
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