Recurrence of Gastric Dilatation-Volvulus After Incisional Gastropexy in a Rottweiler

Introduction

Surgical goals of treatment for gastric dilatation-volvulus (GDV) include decompression and derotation of the stomach, assessment of gastric or splenic compromise, and permanent fixation of the stomach to prevent recurrence of the GDV.¹ One study reported a 92% reduction in the risk of recurrence of GDV following gastropexy when compared to dogs treated conservatively.¹ Other studies have documented a second episode of GDV in 42% to 75.8% of dogs treated without surgery.^2–7 Fixation methods for the stomach include right-sided tube gastropexy, belt-loop gastropexy, circumcostal gastropexy, incorporating gastropexy, and incisional gastropexy.^4,8–16

In retrospective reports that describe recurrence following surgical treatment of GDV, the distinction is seldom made between simple gastric dilatation following gastropexy versus true recurrence of volvulus.^{1,2–4,7–9,11} The purpose of this report is to document the recurrence of GDV following previous incisional gastropexy in a dog.

Case Report

An 8-year-old, castrated male rottweiler was examined at the University of Minnesota Veterinary Medical Center (UM-VMC) following a 6-hour history of depression, vomition of small amounts of foam, and abdominal distension. The dog had undergone surgical correction of GDV 4 months earlier at UM-VMC. The dog was otherwise healthy and was not taking any medications.

When treated for the initial GDV, abdominal exploratory surgery revealed a 180°-clockwise GDV, with necrosis of a 5 × 10-cm area of the greater curvature of the stomach. After derotation of the stomach, the devitalized area of the stomach was excised, and the gastric defect was apposed with 0 polydioxanone^a using a simple continuous suture pattern and then oversewn with a Cushing pattern. An incisional gastropexy was performed by suturing a longitudinal incision in the ventral gastric antrum (halfway between the greater and lesser curvatures of the stomach) to an incision (at the level of the 11th and 12th thoracic vertebrae) on the right ventral body wall with 0 polydioxanone, using two simple continuous patterns. The abdomen was closed routinely in three layers. The dog was hospitalized for 36 hours following surgery and was bright, alert, and eating well at the time of discharge.

Abnormal physical examination findings at the second presentation to the UM-VMC included tachycardia (145 beats per minute), ptyalism, abdominal distension and tympany, pain on palpation of the abdomen, and lethargy. Body weight was 42.5 kg, with a body condition score of 4/9. Based on the history and physical examination findings, gastric dilatation was suspected. The area of greatest abdominal tympany was located, and an 18-gauge intravenous (IV) catheter was used to trocharize the stomach for decompression. Cranial abdominal radiographs taken after trocharization demonstrated a gas-filled stomach, with a dorsally displaced pylorus [Figures 1A, 1B]. Electrocardiography demonstrated sinus tachycardia with occasional ventricular premature contractions. Abnormal findings detected on a complete blood count included mild eosinophilia (1.3 × 10³ cells/μL; reference range 0 to 1.2 × 10³ cells/μL) and mild anemia (37.7%; reference range 38.5% to 56.7%). Serum biochemical elevations were found in creatinine (1.8 mg/dL; reference range 0.5 to 1.5 mg/dL) and glucose (221 mg/dL; reference range 80 to 125 mg/dL). Decreased serum albumin (2.3 g/dL; reference range 2.5 to 3.7 g/dL) and potassium (3.3 mmol/L; reference range 3.6 to 5.6 mmol/L) were detected. A prothrombin time, activated partial thromboplastin time, and fibrin degradation products were within normal reference ranges.

The dog was premedicated with diazepam^b (0.5 mg/kg IV) and hydromorphone hydrochloride^c (0.1 mg/kg IV). Anesthesia was induced with fentanyl citrate^d (6 mg/kg IV) and maintained with sevoflurane^e in oxygen. An orogastric tube was inserted, and the stomach was decompressed of gas.

A midline cranial celiotomy was performed. The peritoneum was noted to be thickened upon entering the abdomen. A 180°-clockwise GDV was apparent. The stomach was gas-distended and covered by greater omentum [Figure 2]. The pylorus was located just to the left of midline. The fundus was dorsal and cranial to the prior gastropexy site at the right ventral body wall. A schematic of the stomach’s position at surgery is presented in Figure 3. The stomach was returned to the normal anatomical position. The original gastropexy adhesion was estimated to be 3.5 cm in length. The body wall adhesion to the seromuscular layer of the stomach was intact, although it had stretched to approximately 4 cm, allowing the stomach to be quite mobile. The area of previous gastric resection was hyperemic, but it appeared to be viable. The spleen was mildly engorged but was not malpositioned, and it had strong, palpable pulses. Examination of the remainder of the abdomen was normal. The stomach was lavaged with 8 liters of tepid water via the orogastric tube, until the stomach was emptied of all gastric contents. The original gastropexy site was left intact. A new 4-cm incision was made in the ventral pyloric antrum beginning 1 cm toward the greater curvature and orad to the original gastropexy site. A corresponding incision was made in the right ventral abdominal wall. The two incisions were apposed by two simple continuous suture patterns of 0 polypropylene.^f A gastropexy of the fundus was performed by suturing a 4-cm incision in the seromuscular layer of the gastric fundus (midway between the greater and lesser curvatures) to an incision along the left ventral abdominal wall. The two incisions were apposed with two simple continuous suture lines of 0 polypropylene. The fundic gastropexy was positioned as laterally as possible while minimizing tension so that the stomach would not pull the gastropexy sites abaxially after a meal. The linea alba was closed with 0 polydioxanone in a simple continuous suture pattern; the subcutaneous tissues were closed with 2-0 polydioxanone in a simple continuous suture pattern; and the skin was apposed with staples.^g Postoperative analgesia and fluid therapy were administered, and the dog recovered uneventfully. At telephone contact 3 months following the second surgery, the owner reported the dog had a normal appetite, attitude, and activity level.

Discussion

Recurrence of GDV has been reported in three dogs following a tube gastropexy using the Dragstedt modification of the Stamm tube gastrostomy.^8,9 All dogs were reportedly treated with a second tube gastropexy; however, surgical details of the second volvulus episode were not described in any of these cases. A recent prospective study of survival and recurrence rates after GDV found three recurrences out of 74 dogs that had undergone gastropexy for GDV.² Methods of the original gastropexies, diagnostics used to confirm the recurrences, and specifics of subsequent therapy for the dogs were not mentioned.

To the authors’ knowledge, recurrence of GDV following incisional gastropexy has not been previously reported. Possible factors in the origin of GDV include the stomach’s loose anatomical fixation and longer or more elastic attachments.^5,6,17–19 Gastropexy adds an additional point of fixation to prevent displacement of the pylorus ventrally and to the left, as is commonly seen in GDV.¹ It is possible that similar anatomical processes also predispose dogs to a recurrence of gastric volvulus.

The normal canine stomach does not directly contact the body wall. It is loosely held in place by its attachments to the esophagus and diaphragm (at the esophageal hiatus) and to the duodenum.²⁰ Portions of the lesser omentum that normally assist in maintaining the position of the stomach include the hepatoduodenal ligament and the hepatogastric ligament.²⁰ The greater omentum attaches loosely to the greater curvature of the stomach and provides no positional support. It has been suggested that repeated episodes of gastric dilatation, especially when associated with splenic involvement, may cause stretching of the gastrosplenic ligament and hepatoduodenal and hepatogastric ligaments, thereby predisposing dogs to GDV.^17,18 Hall et al. showed that the hepatogastric ligaments of similarly sized dogs treated for GDV were significantly longer than the ligaments of control dogs.¹⁹ Histologically, ligaments of dogs in the two groups did not differ. It was not known whether dogs with prior GDV had longer ligaments because of their disease process or if the longer ligaments had predisposed them to GDV.

In the case reported here, the original gastropexy was intact but appeared stretched. The reason for the stretching of the gastropexy adhesion was unknown. It is possible that multiple, subclinical episodes of gastric dilatation occurred in this dog as it healed, thereby stretching the gastropexy and preventing tight adhesions between the ventral surface of the gastric antrum and the right body wall. Early studies on the biomechanics of incisional gastropexy identified a period of decreased tensile strength during the maturation phase of wound healing.^21,22 Mechanical stress on the gastropexy site from further unrecognized episodes of gastric dilatation may have been sufficient to stretch the adhesions during collagen reorganization in this dog. Full-thickness biopsies of the original gastropexy and associated stomach wall would have been helpful, but they were not obtained at surgery. Hardie et al. evaluated load-to-failure and histological properties of incisional gastropexy sites at 7 versus 30 days following surgery in normal dogs.²³ At both times, nearly all developing fibrovascular tissue and mature connective tissue remained adhered to the gastric incision rather than to the body wall in those dogs with failure of the adhesion. The diffuse, smooth appearance of the fibrous attachment at the second surgery in the dog reported here suggested chronic stress on the site after some healing had taken place, rather than an acute failure where hemorrhage and evidence of tearing might be expected.

At the second surgery in this dog, two additional gastropexies were performed—one in the pyloric region and one in the fundic region. At closure, the stomach was nearly flush with the ventral body wall, revealing a possible complication of these procedures. Any further celiotomies that might be required in this dog must take into consideration the current position of the dog’s stomach. Additionally, the multiple attachments made to the body wall might interfere with normal distension and collapse of the stomach after a meal. Bilateral incisional gastropexy has been reported to eliminate gastric migration after intermittent gastroesophageal intussusception in an 8-week-old Siberian husky, with good results.²⁴ Using this concept in the case presented here, additional gastropexies were performed in an attempt to achieve two-point fixation of the stomach, as the prior gastropexy was deemed nonfunctional.

Fundic gastropexy has been previously reported for prevention of torsion following GDV in dogs, but it has not been previously implemented for the treatment of recurrence after routine gastropexy.²⁵ In that study, of the 144 dogs undergoing gastropexy of the fundus alone and for which long-term follow-up information was available, two had a recurrence of gastric dilatation, but none had a recurrence of volvulus.

Conclusion

Gastric dilatation-volvulus recurred 4 months after incisional gastropexy in an 8-year-old rottweiler. At a second surgery, multiple incisional gastropexies were performed in the dog in an attempt to prevent further recurrence. The true incidence of recurrence of GDV remains unknown. Further prospective studies with large numbers of cases and long-term follow-up may help identify the recurrence rate of GDV after gastropexy.