Prophylactic Gastropexy Incorporating a Gastrotomy Incision in Dogs: A Retrospective Study of 21 Cases (2011–2013)
The objective of this retrospective study was to report any complications associated with incorporating a gastrotomy incision into a right-sided incisional prophylactic gastropexy. The medical records of dogs that underwent a gastrotomy for the removal of gastric foreign material and had a prophylactic right-sided incisional gastropexy performed at the gastrotomy site between April 2011 and February 2013 were reviewed. Two wk postoperative recheck examination and suture removal reports were reviewed and owners were contacted via phone and e-mail for long-term follow-up. In total, 21 cases were reviewed, 19 with long-term follow-up. No complications of the surgery were reported. We concluded that a prophylactic right-sided incisional gastropexy could successfully be performed incorporating the gastrotomy site without significant complications.
Introduction
Gastric-dilatation and volvulus (GDV) is an acute, life-threatening condition, classically affecting large, deep-chested adult dogs. Large and giant breed dogs have a 6% incidence of GDV.1 GDV affects about 60,000 dogs in the United States per year, with mortality rates between 10–60%.2 Past research has advocated that a gastropexy should be performed to prevent recurrence of GDV in dogs undergoing emergency surgery because of initial GDV.3–7 Without gastropexy, a recurrence rate has been reported as high as 55 to 85%.6,8,9 Furthermore, it has been suggested that a prophylactic gastropexy would prevent a first episode of GDV in genetically predisposed dogs and prevent a recurrence in dogs in which a first episode was treated medically.10 A recent retrospective study performed by Benitez et al. evaluated the long-term efficacy of an incisional gastropexy in preventing the occurrence of GDV when used prophylactically, as well as at the first episode of GDV.1Their reports support the incisional gastropexy as an effective method for preventing GDV.1
Gastropexy is described as a permanent fixation of the stomach to the abdominal wall by the surgical induction of adhesions. Previous literature reviewed the risk of GDV recurrence after different gastropexy techniques (incisional gastropexy, circumcostal gastropexy, tube gastrotomy, and belt loop gastropexy) and, although mortality rates differed with each technique, overall recurrence of GDV after gastropexy was uncommon, occurring in 3–5% of cases.3,5,6,11
Prior research evaluating the efficacy and strength of an incisional gastropexy has included cadaveric studies focusing on load to failure evaluation, histologic evaluation of adhesions, postoperative phone questionnaires, and ultrasound and contrast imagining studies.11–14 Ultrasonographic evaluation of gastric wall thickness, peristaltic contraction, simultaneous motion of stomach and abdominal wall during respiration, and appearance of the gastric wall have been used to determine efficacy of gastropexies.14
Due to the high incidence of GDV in large breed dogs, many veterinarians advocate prophylactic gastropexy be performed in at-risk dogs undergoing routine surgery, such as ovariohysterectomy or exploratory laparotomy for foreign body obstructions.11,15 Incisional gastropexies have previously been established as an effective technique that results in the permanent adhesion of the stomach to the body wall without added risks of rib fractures or pneumothorax and only transient complications of gastrointestinal disturbances (e.g., vomiting, regurgitation, diarrhea, inappetance).1
Possible additional complications associated with incorporating a gastrotomy incision into an incisional gastropexy include inflammation, abscessation, and dehiscence of the gastropexy site. The objective of this study was to describe a variation of the incisional gastropexy technique, which incorporates a gastrotomy site and could be readily performed in healthy at-risk dogs undergoing gastrotomies for foreign material without added complications.
Materials and Methods
Medical records of dogs undergoing gastrotomy for the treatment of gastric foreign bodies that had a prophylactic right-sided gastropexy performed at the gastrotomy site between April 2011 and February 2013 were reviewed; data regarding breed, age, gender, surgical technique, suture material, hospitalization stay, postoperative complications, and use of postoperative antibiotics were collected. Postoperative abdominal ultrasound was performed in one case. Short-term follow-up was defined as 10–14 days post-surgery and long-term follow-up was defined as the time from the date of surgery until the date of either death or last date of contact. All recheck examinations and suture removals were performed within 10–14 days of surgery by either a board certified surgeon or surgery resident. Owners were contacted by telephone and e-mail for long-term follow up (median 13 months, range 5–18 months postoperatively) and asked about outcome with specific interest in occurrence of bloat, gastric disturbance, weight loss, and incidence of vomiting. Parametric data were described by mean +/- standard deviation. Nonparametric data were described by median (range).
Results
Signalment and Descriptive Data
Twenty-one cases met the inclusion criteria, which was a prophylactic gastropexy performed by incorporating the gastrotomy site. Seven purebred dogs were represented, including four golden retrievers (19%), two golden retriever mixed-breed dogs (9.5%), and four boxers (19%); these were the most common breeds. Other breeds included three German shepherd dogs (14.3%), two Labrador retrievers (9.5%), one Bouvier de Flandres (5%), one German shepherd dog mixed-breed (5%), one English mastiff mixed-breed (5%), one English bulldog (5%), one American pit bull terrier (5%), and one mixed-breed dog (5%). In total, 6 of the 10 male dogs were castrated. All 11 of the female dogs were spayed. The mean age at time of surgery was 3.84 years +/- 2.88 yr. The median weight for all patients at time of surgery was 30.6kg (range, 18.1–45.4kg).
Surgical Technique
All dogs were treated with a similar anesthetic protocol using an opioid and benzodiazepine premedication, induction agent, and inhalant anesthetic throughout the procedure. Intraoperative IV fluid rates were maintained at 10 mL/kg/hr with fluid boluses adjusted based on individual case requirements. All dogs had gastrointestinal foreign material confirmed at surgery with either all of the foreign material or a portion removed via a gastrotomy. In 10 cases (47.6%), a Diplomate of the American College of Veterinary Surgeons staff surgeon was involved in the surgery and the remaining 11 cases (52.4%) were performed by an unsupervised surgical resident.
All surgery reports clearly described the procedure of a right-sided incisional gastropexy being performed at the gastrotomy site. The incisional gastropexy was performed by creating a full thickness incision through the gastric wall, serosa, muscularis, submucosa, and mucosa at the level of the pyloric antrum. The incision length varied between surgeries depending on the foreign material being removed; however, based on a review of surgical reports, all incisions were less than or equal to 4 cm in length. In all cases, the mucosal and submucosal layers of the stomach were closed in a simple continuous pattern with either 3-0 PDS IIa (71.4%, n=15) or 2-0 PDS IIa (28.6%, n=6). After closure of the mucosal and submucosal layers, the incision was locally lavaged. A corresponding incision was made through the peritoneum and transversus abdominus muscle on the right abdominal wall approximately 2–3 cm caudal and parallel to the last rib. The gastric (serosal and muscularis layers) and abdominal incisions were apposed with either 0-PDS II a (90.5%, n =19) or 2-0 PDS IIa (9.5%, n=2) in a simple continuous pattern. In 7 of the 21 cases, additional procedures were performed and these included an enterotomy (14.2%), intestinal resection and anastamosis (5%), splenectomy (5%), ovariohysterectomy (5%), and castration (5%).
Postoperative Care
The average hospitalization stay postoperatively was 1.76 days +/- 0.61 day. Two dogs were hospitalized for 3 days postoperative. Both of those cases had an enterotomy in addition to the gastrotomy and gastropexy performed. In accordance with hospital protocol, all cases received preoperative, intraoperative, and 24 hr postoperative IV antibiotics (ampicillinb 20 mg/kg IV q 8 hr or cefazolinc 22 mg/kg IV q 8 hr). However, 62% of the cases (n=13) were discharged with 10–14 days of oral antibiotics (cephalexind 22 mg/kg PO q 12 hr, amoxicilline 20 mg/kg PO q 12 hr, Amoxicillin trihydrate/clavulanate potassiumf 12–16 mg/kg PO q 12 hr, or marbofloxacing 5 mg/kg PO q 24 hr). Thirty-eight percent of cases (n=8) were not dispensed antibiotics at discharge. The decision to dispense antibiotics at discharge was based on surgeon preference. No gross contamination was documented in any of the surgery reports.
Follow-Up
Nineteen cases returned within 10–14 days for a recheck examination and suture removal. Two cases did not return for a 2 wk recheck examination. Either a board certified staff surgeon or a surgery resident examined all 19 cases. None of the rechecked patients had signs of an incisional infection or complications at time of recheck examination and suture removal. One case was diagnosed with an unrelated skin infection at suture removal and was treated with antibiotics. One incision was bruised with a 0.5 cm2 area of poor apposition, but there were no signs of infection and the patient was afebrile. One case developed elevations in serum creatinine 8 mo post-surgery, and on ultrasound, the stomach, gastrotomy, and gastropexy site were all within normal limits. Eighteen cases were not seen at the referral hospital after their 2 wk surgery recheck and suture removal. Eighteen cases were available for long-term follow-up (median 13 mo, range 5–18 mo postoperatively). Owners were contacted by telephone and/or e-mail 5–18 mo after surgery and asked about outcome with specific interest in occurrence of bloat, gastric disturbance, weight loss, and incidence of vomiting. All 18 cases that were available for long-term follow-up had no owner-reported complications; had not been treated for gastric dilatation or GDV; and had no vomiting, gastric disturbances, or weight loss. Owners reported excellent medical health and no concurrent medial problems in 17 of the 18 cases. One case was euthanized due to progressive neurologic disease, unrelated to the gastric surgery.
Discussion
This case series demonstrates that a right-sided incisional gastropexy incorporating the gastrotomy site can successfully be performed in dogs undergoing a gastrotomy for removal of foreign material without any expected complication. GDV is a devastating condition that affects many large breed dogs and, despite rapid diagnosis and early surgical intervention, it can still have devastating outcomes. The benefits of performing a prophylactic gastropexy in high-risk dogs have been previously established. To our knowledge, this case series demonstrates that performing this procedure together in one incision rather than two is an alternative technique that does not increase morbidity.
The limitations of this study are the retrospective nature, small population, and subjective/limited follow-up. The first 72–96 hr postoperatively are the most critical period of gastrointestinal healing and when most dehiscence occurs.3 While this study does not objectively evaluate the gastropexy incision, except in one case in which an abdominal ultrasound confirmed permanent adhesion formation at the gastropexy site, it was conjectured that if dehiscence or abscessation had occurred at the gastropexy site, it would have been detected during the first 72–96 hr. Therefore, the fact that 19 of the 21 cases returned for the routine 2 wk post-surgery visit without complications supported a successful surgery. Furthermore, while subclincial abscessation or dehiscence could have occurred, no clinical signs were documented. Long-term follow-up in the form of an owner questionnaire was obtained in 18 of the 21 cases with no owner reported complications or incidence of gastric dilatation, GDV, or other gastrointestinal disturbances.
Additional benefits to this technique may be attributed to surgical time. The surgical time for a routine right-sided incisional gastropexy and separate gastrotomy compared to the described technique in this case series was not calculated or compared. The authors speculate that there would be a decrease in surgical time when comparing this technique to completing a traditional gastrotomy and performing a right-sided incisional gastropexy at a separate location. In order to confirm this, additional controlled studies are needed.
Conclusion
In summary, the authors conclude that incorporating a right-sided incisional gastropexy in a gastrotomy site is a valid prophylactic technique that can be performed in dogs at high risk of developing a GDV while they are already undergoing anesthesia for removal of gastric foreign material without causing added complications.
Contributor Notes
