Key gastrointestinal surgeries: Incisional gastropexy

THE PRIMARY INDICATION for gastropexy is to prevent the development or recurrence of gastric dilatation-volvulus (GDV).1-16 GDV most often affects large- and giant-breed dogs that have deep and narrow chests.2-8,13-15 Several other risk factors have been associated with the development of GDV, including increasing age, ingestion of large amounts of food or water, eating rapidly or from an elevated food dish, fearful temperament, and exercise after eating.3-5,15,17-19 Additionally, first-degree relatives of dogs with GDV appear to be at an increased risk; prophylactic gastropexy is recommended in these animals.2,4,15 Because dogs with GDV that do not undergo a gastropexy have recurrence rates of more than 70% and mortality rates of 80%, gastropexy should also be performed in all patients with GDV.1,11,20

TYPES OF GASTROPEXIES

The goal of a gastropexy is to create a permanent adhesion between the gastric wall and the abdominal wall.1-16 Ideally, a gastropexy should create a strong adherence, have minimal complications, not affect the stomach's natural orientation or markedly alter gastric outflow, and require minimal postoperative management.6,10 Gastropexy is usually performed by attaching the pyloric antrum to the right abdominal wall to prevent further gastric rotation.9,15

There are several types of gastropexies, including incorporating, tube, circumcostal, belt-loop, laparoscopic-assisted, and incisional.1,3-16 No controlled studies have compared adhesion strength, clinical outcome, and physiologic impact of all the gastropexy techniques, so the choice of procedure is often based on the veterinarian's preference.

Incorporating gastropexy

With incorporating gastropexy, the stomach wall is simply included in the linea alba closure.1,3,6,11 While this technique is rapid, it is not recommended because gastric perforation can occur if another midline celiotomy is performed without knowledge of the previous gastropexy and because the stomach may become abnormally positioned because of the procedure.1,3,6,11

Tube gastropexy

Tube gastropexy, including percutaneous gastrostomy, involves placing a mushroom-tipped tube through the abdominal wall and into the gastric lumen. Tube gastropexy results in a permanent adhesion after 14 days and permits postoperative decompression and direct access to the gastrointestinal tract for feeding and for giving medications.1,5,11 Tubes are usually left in place for at least seven days to allow sufficient time for fibrous tissue formation. The disadvantages of tube gastropexy include more intensive postoperative management and decreased holding strength compared with circumcostal gastropexy, resulting in an increased risk of GDV recurrence.1,3-6,11,13 Additionally, tube leakage and subsequent peritonitis can occur.4,5,8,11,14

Circumcostal gastropexy

With circumcostal gastropexy, a seromuscular flap from the stomach is wrapped around the last rib and secured back to the stomach wall.1,11 This procedure does not penetrate the stomach lumen and creates a strong adhesion.1,4,6,7,11,13 Potential complications include iatrogenic rib fracture, pneumothorax, and increased surgical time.1,4,6-9,11 Modifications to the procedure have helped decrease surgical time and postoperative complications while maintaining the holding strength of the original technique.1,7,9

Belt-loop gastropexy

Belt-loop gastropexy involves tunneling a seromuscular flap through the abdominal wall.1,10,11 This procedure can be performed quickly and results in a strong adhesion without entering the gastric lumen.11 Minimal complications have been reported, although pneumothorax can still occur.1

Laparoscopic-assisted gastropexy

Recently, veterinary surgeons have proposed using laparoscopic techniques to perform gastropexy with staples or sutures.1,4,6,10,12 Laparoscopic techniques result in less tissue trauma, decreased postoperative pain, and a faster return to normal function.10,12 Complications can be related to trocar placement (e.g. perforation of abdominal viscera or subcutaneous emphysema) or to increased abdominal pressure during abdominal insufflation.12 In addition, expensive laparoscopic equipment and advanced training are required.4,6,10,12

Incisional gastropexy

Incisional gastropexy is a fast, simple procedure that involves apposing the muscular layer of the gastric wall and the right transverse abdominis muscle.1,3,5,8,11-14,16 This technique forms strong, long-term adhesions and results in few postoperative complications.1,5,8,12-14,16

TECHNIQUE FOR INCISIONAL GASTROPEXY

For general perioperative considerations when performing this procedure, including diagnostic testing, patient monitoring, and postoperative support, please see the symposium introduction .

Prepare the patient from the xiphoid to the pubis, and perform a midline celiotomy. A nonsterile assistant can pass an orogastric tube to facilitate gastric decompression in dogs with GDV. The surgeon can help guide the tube into the stomach by manipulating it through the cardia and fundus as it is advanced. Once the stomach is decompressed, reduction of the volvulus is achieved by pulling the pylorus ventrally and to the dog's right.

With the stomach in normal position, make a 4- to 5-cm incision through the seromuscular layer of the pyloric antrum, which is located between the pylorus and the incisure (Figure 1). The incision should be parallel to the longitudinal axis of the stomach and midway between the greater and lesser curvatures (Figure 2). The mucosa can usually be slipped away from the serosa and muscularis layers with digital pressure to avoid penetrating the lumen during gastric incision (Figure 3).

Figures 1,2,3

Towel clamps can be placed full thickness through the right abdominal wall to evert the body wall and expose the peritoneum (Figure 4). Make a 4- to 5-cm incision (equal to the length of the gastric incision), angling from craniodorsal to caudoventral, through the peritoneum and superficial musculature of the right ventrolateral body wall, caudal to the last rib and 6 to 8 cm to the right of midline (Figure 5). Appose the gastric and abdominal wall incisions with 2-0 or 0 monofilament suture in a simple continuous suture pattern. Absorbable suture is recommended since fistula formation has been reported with the use of nonabsorbable sutures.4 Take bites in the craniodorsal portion of the abdominal wall and gastric incisions, and tie the initial knot, leaving the knot end long. A hemostat can be attached to this end so it can be found easily as the closure is finished. Suture the dorsal portions of both incisions together; when the caudal extent of the incision is reached, continue the suture pattern cranially to appose the ventral portion of the incision (Figure 6). Tie the suture back to the long end of the cranial knot to finish the pattern (Figures 7 & 8).1,11

Figures 4,5,6,7,8

COMPLICATIONS

Complications from incisional gastropexy are minimal as long as the abdominal and gastric wall incision location, length, and depth are appropriate.1,5,11,12,14 Direct apposition of gastric and body wall muscle is critical in forming a strong adhesion.14 The effects of gastropexy on motility may depend on the severity of the disease; normal dogs that undergo circumcostal gastropexy have normal gastric emptying (90% emptying at 5.5 hours), but dogs with GDV that undergo circumcostal gastropexy will have increased gastric emptying time (90% emptying at 13 hours) after surgery.21 Gastric motility may be temporarily decreased after surgery in dogs with GDV because of gastric muscle overstretching or damage and subsequent atony.8,16,21 Fortunately, this appears to be subclinical.8,16 Inappropriate placement of a gastropexy may also result in outflow obstruction if the angle between the pyloric antrum and duodenum is too acute.22

Kara Watson, BS

Karen M. Tobias, DVM, MS, DACVS

Department of Small Animal Clinical Sciences

College of Veterinary Medicine

The University of Tennessee

Knoxville, TN 37996-4544

REFERENCES

1. Rasmusen L. Stomach. In: Slatter D, ed. Textbook of small animal surgery. 3rd ed. Philadelphia, Pa: WB Saunders Co, 2003;610-614.

2. Ward MP, Patronek GJ, Glickman LT. Benefits of prophylactic gastropexy for dogs at risk of gastric dilatation-volvulus. Prev Vet Med 2003;60:319-329.

3. Monnet E. Gastric dilatation-volvulus syndrome in dogs. Vet Clin North Am Small Anim Pract 2003;33:987-1005.

4. Rawlings CA, Mahaffey MB, Bement S, et al. Prospective evaluation of laparoscopic-assisted gastropexy in dogs susceptible to gastric dilatation. J Am Vet Med Assoc 2002;221:1576-1581.

5. Waschak MJ, Payne JT, Pope ER, et al. Evaluation of percutaneous gastrostomy as a technique for permanent gastropexy. Vet Surg 1997;26:235-241.

6. Rawlings CA, Foutz TL, Mahaffey MB, et al. A rapid and strong laparoscopic-assisted gastropexy in dogs. Am J Vet Res 2001;62:871-875.

7. Degna MT, Formaggini L, Fondati A, et al. Using a modified gastropexy technique to prevent recurrence of gastric dilatation-volvulus in dogs. Vet Med 2001;96:39-50.

8. Wacker CA, Weber UT, Tanno F, et al. Ultrasonographic evaluation of adhesions induced by incisional gastropexy in 16 dogs. J Small Anim Pract 1998;39:379-384.

9. Pope ER, Jones BD. Clinical evaluation of a modified circumcostal gastropexy in dogs. J Am Vet Med Assoc 1999;215:952-955.

10. Wilson ER, Henderson RA, Montgomery RD, et al. A comparison of laparoscopic and belt-loop gastropexy in dogs. Vet Surg 1996;25:221-227.

11. Fossum TW. Surgery of the digestive system. In: Small animal surgery. 2nd ed. St. Louis, Mo: Mosby, 2002;346-350.

12. Hardie RJ, Flanders JA, Schmidt P, et al. Biomechanical and histological evaluation of a laparoscopic stapled gastropexy technique in dogs. Vet Surg 1996;25:127-133.

13. Fox SM, Ellison GW, Miller GF, et al. Observations of the mechanical failure of three gastropexy techniques. J Am Anim Hosp Assoc 1985;21:729-734.

14. MacCoy DM, Sykes GP, Hoffer RE, et al. A gastropexy technique for permanent fixation of the pyloric antrum. J Am Anim Hosp Assoc 1982;18:763-768.

15. Glickman LT, Lantz GC, Schellenberg DB, et al. A prospective study of the survival and recurrence following the acute gastric dilatation-volvulus syndrome in 136 dogs. J Am Anim Hosp Assoc 1998;34:253-259.

16. Tanno F, Weber U, Wacker C, et al. Ultrasonographic comparison of adhesions induced by two different methods of gastropexy in the dog. J Small Anim Pract 1998;39:432-436.

17. Raghavan M, Glickman N, McCabe G, et al. Diet-related risk factors for gastric dilatation-volvulus in dogs of high-risk breeds. J Am Anim Hosp Assoc 2004;40:192-203.

18. Glickman LT, Glickman NW, Schellenberg DB, et al. Non-dietary risk factors for gastric dilatation-volvulus in large and giant breed dogs. J Am Vet Med Assoc 2000;217:1492-1499.

19. Glickman LT, Glickman NW, Schellenberg DB, et al. Multiple risk factors for the gastric dilatation-volvulus syndrome in dogs: a practitioner/owner case-control study. J Am Anim Hosp Assoc 1997;33:197-204.

20. Eggertsdottir AV, Moe L. A retrospective study of conservative treatment of gastric dilatation-volvulus in the dog. Acta Vet Scand 1995;36:175-184.

21. Hall JA, Willer RL, Seim HB III, et al. Gastric emptying of nondigestible radiopaque markers after circumcostal gastropexy in clinically normal dogs and dogs with gastric dilatation-volvulus. Am J Vet Res 1992;53:1961-1965.

22. Jennings PB Jr, Mathey WS, Ehler WJ. Intermittent gastric dilatation after gastropexy in a dog. J Am Vet Med Assoc 1992;200:1707-1708.