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WSV18-0298
SVA SOFT TISSUE SURGERY
SURGICAL MANAGEMENT OF GASTRIC DILATION- VOLVULUS
H.B. Seim1
1Colorado State University
If you would like a copy of this surgical procedure on DVD go to www.videovet.org.
Key Points
• Survival is generally determined by early and appropriate presurgical management
• Patients referred for surgery should be decompressed prior to referral with continued decompression provided during transport
• Incisional gastropexy results in a fast, easy, permanent adhesion
• Ventricular tachycardia is a common postoperative complication
• Gastric necrosis signals an unfavourable prognosis
Introduction: Patients with GDV are considered critical care cases; every minute of presurgical treatment is vital to a successful outcome. Survival is generally determined by early and appropriate presurgical management; not surgery. Efficient presurgical treatment usually involves
a minimum of two people. Gastric decompression and shock therapy should be done simultaneously. If this is not possible; decompression should be performed first.
It is stated that gastric decompression is the single most important factor in reversing cardiovascular deficits in patients with GDV.
Decompression: Generally, orogastric intubation can successfully be performed in 80 - 90% of GDV patients. Decompression via flank needle puncture should be attempted in cases difficult to intubate or severely depressed metabolically deranged patients.
Technique: The stomach tube is measured to the
last rib and marked with a piece of tape. A stiff foal or mare stomach tube with a smooth beveled tip works best (having several diameter and stiffness tubes is ideal). Apply adequate lubrication to the tube. Place a functional mouth speculum; generally a roll of 2” tape secured in the mouth with tape encircling the muzzle. As the stomach tube is passed, you will generally meet resistance at the esophageal-stomach junction. Pass the tube firmly in a twisting manner to pass the lower esophageal sphincter.
If unsuccessful, place the patient in various positions and attempt to pass the tube (i.e., elevate animal at 45 degree angle with rear feet on floor and forefeet on table, right lateral recumbancy, and left lateral
recumbancy). This movement may encourage the stomach to rotate enough to allow tube passage. Be careful not to position the patient in dorsal recumbancy as this will increase abdominal visceral pressure on the caudal vena cava and may exacerbate signs of shock.
If still unsuccessful, try different diameter tubes; try a smaller diameter, more flexible tube and proceed as described above.
If still unsuccessful, attempt to remove some of the air
in the stomach by placing an l8 gauge needle at the point of distention in the right flank region. Ping the
area to make sure the spleen is not under the proposed trocarization site. After trocar decompression, attempt to pass the stomach tube as described above.
If still unsuccessful, sedate the dog with a narcotic (e.g., Oxymorphone) and try to pass the tube again. Mild sedation is recommended if the patient strongly resists physical restraint.
Success in passing a stomach tube depends on the skill of the operator and available assistants.
If you are successful at passing a stomach tube, but
plan to refer the patient to a referral surgical center for gastropexy, transport the patient with the tube remaining in the stomach (i.e., taped to the mouth) or bring the tube out through a pharyngostomy incision or place a nasogastric tube.
If a stomach tube was successfully passed, stomach contents should be evaluated for color and presence or absence of necrotic looking gastric mucosa. This may give an impression of gastric viability.
Fluids: Shock dosage of polyionic isotonic fluid
is carefully administered to expand the vascular compartment. Patients are frequently monitored during fluid administration to help determine ultimate fluid rate and amount. One or two indwelling cephalic catheters are placed.
Referral: If you are successful at passing a stomach tube, but plan to refer the patient to a referral surgical center for gastropexy, transport the patient with the tube remaining in the stomach (i.e., taped to the mouth) or bring the tube out through a pharyngostomy as described below.
Pharyangostomy placement:
a. Orally palpate the fossa lateral to the hyoid apparatus until a lateral bulge is seen
b. Make a small skin incision over the bulge and press a curved forceps (substitute for finger) through the soft tissues and skin incision.
c. Pull the stomach tube through the incision with curved forceps; then pass the tube over the arytenoid cartilages, down the esophagus, and into the stomach (measure to
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