Small Animal Surgical Emergencies. Группа авторов

8.11a). The tip of the tube is passed through the stab incision into the abdominal cavity with the aid of forceps (Figure 8.11b).

      3 The pyloric antrum is identified.

      4 A purse‐string suture of an appropriate synthetic absorbable suture material (e.g., 2–0 polydioxanone) is preplaced in the pyloric antrum.

      5 A stab incision is made into the stomach through the purse‐string suture and the catheter tip is placed into the lumen (Figure 8.11c).

      6 The purse‐string suture is tied tightly around the catheter and. if using a Foley, the bulb is inflated with saline.

      7 Four pexy sutures of an appropriate synthetic absorbable suture material (e.g. 2–0 polydioxanone) are preplaced around the gastric and abdominal wall incisions (a box suture; Figure 8.11d). Care is taken to avoid including the end of the catheter in these sutures.

      8 The sutures are then tied tightly (Figure 8.11e) and the pexy site is omentalized.

      9 The balloon or mushroom tip is drawn up to the stomach wall and the tube secured on the outside of the skin with a Roman sandal suture.

      10 An abdominal bandage is placed postoperatively to protect the tube.

      11 The gastropexy tube should remain in place for 7–10 days. The tube is removed by traction and the stoma is left to heal by secondary intention.

A tube gastropexy is similar to a standard tube gastrostomy but, importantly, the tube is placed through the right body wall and into the pyloric antrum. This technique has some advantages in certain circumstances, as it allows postoperative decompression if recurrent gastric distension occurs and can be used for enteral feeding. This may be particularly useful in dogs undergoing significant gastric resection or those with chronic gastric dilatation. The main disadvantage is that the tube needs to be maintained for at least seven days and the technique involves a full‐thickness incision into the stomach, with a theoretical risk of peritonitis. The recurrence rate for tube gastropexy is reported as 5–11% [58, 59, 66]. One study reported tube gastropexy with a mushroom tipped catheter in 31 dogs [76]. Three dogs had a major complication including two with premature tube removal due to interference from the dog. One dog died due to septic peritonitis as a result; 30 dogs survived to discharge and there was no recurrence of GDV in 21 dogs with follow‐up at a median of 2.5 years (range 3 months to 5 years).

Figure 8.10 Series of intraoperative images showing the technique for belt‐loop gastropexy. (a) Seromuscular incision (yellow arrow) in the pyloric region to create a flap based on the serosal blood vessels. (b) The flap is undermined, taking care not to penetrate the submucosa (S). A stay suture has been placed in the tip of the flap (yellow arrow). (c) Parallel incisions in the body wall through the peritoneum and transverse abdominal muscle. The tissue between the incisions is undermined to create a tunnel, the “loop.” (d) The flap has been passed caudal to cranial through the loop and sutured back in place with absorbable suture material.

      Source: Courtesy of Dan Brockman.

      Circumcostal Gastropexy

      A circumcostal gastropexy is similar to a belt‐loop gastropexy but the seromuscular flap is passed around the last rib, although there are several variations of the technique [60, 67, 77]. Studies have reported a recurrence rate of 0–6.9% for circumcostal gastropexy [60, 63, 66, 77, 78]. This technique has been associated with complications including pneumothorax and rib fracture [60, 77]. Although greater tensile strength compared with other techniques has been identified [66], the importance of this strength is questionable; the authors of this chapter do not believe that it offers any significant advantage over incisional or belt‐loop gastropexy.

Figure 8.11 Series of intraoperative images showing the technique for tube gastropexy. (a) Stab incision in right abdominal wall, caudal to the last rib. (b) The stomach tube (a mushroom‐tipped catheter) is passed through the stab incision with the aid of forceps. (c) The tip of the catheter is being placed into the gastric lumen through a stab incision in the center of a preplaced purse‐string suture. (d) The first of four “box” sutures has been placed between the abdominal wall and stomach. (e) The four sutures have been placed, completing the tube gastropexy. The tube is anchored to the skin with a Roman sandal suture.

      Other Techniques

      Two additional techniques, gastrocolopexy and incorporating gastropexy, have been described. The proposed benefit of these techniques is that they are simpler and quicker to perform than other methods. However, it has not been shown that anesthesia or surgical time is associated with outcome in dogs with GDV and the authors do not believe that these techniques provide an advantage over other methods in most circumstances [7, 23]. Both have potential drawbacks [45, 78, 79]. However, one study reported the long‐term results of incorporating gastropexy in 203 dogs with GDV [80]. Recurrence of clinical signs of gastric dilatation or GDV occurred in 13 dogs (6.4%) at a median follow‐up of 20 months (range 3–50 months). In addition, 13 dogs (6.4%) subsequently underwent exploratory celiotomy without apparent issues due to the gastropexy. Nevertheless, the authors would not recommend the routine use of incorporating gastropexy or gastrocolopexy.

      Following gastric repositioning and gastropexy, the abdomen is lavaged and closed in a routine fashion. Provided that all aspects of preoperative stabilization and anesthesia are appropriate, anesthesia and surgical time have not been associated with mortality [7, 23].

Postoperative Care

      Postoperative care can be intensive and particular attention should be given to fluid therapy to ensure adequate hydration, the administration of appropriate pain relief, and maintaining adequate nutrition. Hypovolaemia, if still present, should be treated aggressively and may occur from continued fluid loss from the gastrointestinal tract as well as into the peritoneal cavity. Parameters that should be monitored closely include mucous membrane color and capillary refill time, PCV and total solids, acid–base balance, and urine output. A continuous electrocardiogram is useful to evaluate for the presence of arrhythmias. Blood pressure monitoring (invasive or non‐invasive) is also useful, although non‐invasive blood pressure monitoring can be challenging in the presence of arrhythmias. Placing an indwelling urinary catheter will allow measurement of urine output to help monitor perfusion status and as many of these dogs are recumbent for a period following surgery, can help to keep them comfortable. Mobilization as soon as possible after surgery should be encouraged. As long as there are no contraindications to feeding, water should be offered as soon as the dog is awake and food shortly afterwards. Intravenous fluid therapy can then be weaned gradually, over the next 48–72 hours. Because of the concern regarding compromise to the gastric mucosa, histamine‐2 receptor antagonists (famotidine), proton‐pump inhibitors (omeprazole, pantoprazole) and coating agents (sucralfate) should be considered.

Complications

      Complications are common following GDV surgery and include arrhythmias, gastric necrosis or dehiscence, ileus/inappetence, acute kidney injury, DIC and sepsis. Postoperative complications such as acute kidney injury, DIC and sepsis