Acute GDV Surgery: What you need to know
October 23, 2012
Acute GDV refers to a sudden gastric dilatation volvulus (bloated and twisted stomach) – a life-threatening condition that can appear very suddenly, and requires a prompt surgery to save the dog’s life. It can be a worrisome situation, because it comes on so suddenly. It is good to know about this condition and about the surgery if you have a dog in your life, since it is not something you can wait to fix.
What happens to cause GDV?
Large, deep-chested dogs are most prone; to some degree the smaller barrel-chested dogs get GDV. Vigorous exercise, height of feeding dishes, eating large sized dry kibble meals, exercising right after mealtime, and other factors have been considered possible risk factors, but it is often unclear what triggers GDV, according to studies. Apparently abnormal stomach contractions are a factor, leading to bloating with gas initially. The twisting then can occur, and if sufficiently twisted, blockage of the stomach outflow, and blockage or reduction of the circulation supplying the area occurs.
What signs should I look for?
Repeat retching (efforts of vomiting), weakness, collapse, loss of appetite or thirst and less commonly, stomach fluid coming from the nostrils are some of the signs caregivers may see. The abdomen may become quite distended.
What does the surgery involve?
There are different techniques used to repair the problem. A common technique is an incisional gastropexy. Your vet will explain the best plan of action based on the initial evaluation of the dog, as the steps taken may vary according to the status of the patient.
Here are some considerations for a typical GDV dog:
Your vet will attempt to stabilize the patient immediately. Some steps include:
Relieve pressure by stomach tube or a trocar (large bore needle) through abdomen wall (The trocar needle will enter the stomach and allow the gas to escape outside the body, much like deflating a balloon, while a stomach tube goes down the esophagus through the mouth and so releasing gas via the mouth.) At the same time the technician will place an IV catheter and the vet will begin shock management including fast administration of intravenous fluids, and pain medications will be started.
Blood work is done to assess internal status, and a detailed treatment plan will be developed. Frequently the electrolytes and the metabolic balance are abnormal, and fluid therapy will be used to correct these problems. Antibiotics given via the IV catheter will be started. A lactate test may be done, as well as an ECG, blood count and chemistry screen. Urinalysis and other testing may be recommended.
X-rays of the abdomen will be done to see how rotated the stomach is – it can be more or less twisted, and sometimes the spleen is involved with the twist, so the spleen can appear enlarged and out of place.
Once the dog is assessed, the vet will discuss potential complications of the surgery and anesthetic, which can include death, because the twist has effects on the whole body, including the heart, which can complicate the operation and the post-op period. One concern is that the circulation has been cut off to the stomach wall. This can lead to dead sections, sometimes necessitating removal of a portion of the stomach. If the spleen has lost circulation and cell death has occurred, spleen removal (splenectomy) may be required. The heart may generate arrhythmias, so irregular heartbeats may occur at any time at surgery or post-op for a few days. These “VPCs” can be treated with medications, but sometimes these rhythm disturbances are fatal.
The surgery itself lasts a variable time, depending on whether there is a need to remove the spleen and damaged stomach tissue.
The dog is given potent pain medicine throughout the hospital stay. Comfort is a high priority. Newer drug combinations with constant rate infusions provide nice steady blood levels of analgesics.
Let us follow along, and watch the time clock as our team gets to work on an uncomplicated GDV surgery!
A pre-op sedative is given to calm the dog. Next another injection into the catheter relaxes the dog, and enough is given so the dog loses consciousness. A sterile tube is placed down into the windpipe and gas anesthesia begins. These gas anesthetics are the same ones used for people. Monitoring of temperature, blood pressure, oxygenation, and residual carbon dioxide measurements, along with a constant ECG is begun. The whole abdomen is shaved down to the skin, and sterilizing solutions are scrubbed on using a three-stage “prep”. The area is then covered and nothing touches it until surgery.
Once the animal is anesthetized and prepped, the dog is taken into a sterile surgery suite. Attending team members wear caps and masks and clean covers to help prevent introduction of germs. All of the highly trained personnel on the team have their own jobs to do. A certified veterinary technician manages the anesthetic. A scavenger removes waste anesthetic gas from the room. Emergency drugs are close by. The anesthetist watches breathing, heart, pulses, and colour of the mucous membranes closely, and keeps the anesthetic depth at a precise level – not too deep, but deep enough so the dog cannot feel anything at all, and is not aware (is unconscious). Sometimes a breathing machine (ventilator) is used to help keep adequate oxygen pumping into the lungs.
The surgeon and any assistants do a long and thorough scrub of hands and arms, using antibacterial soap, and carefully dry up and put on gloves, while wearing a sterile gown, surgery mask and cap, and frequently, surgery booties to cover their shoes.
The surgeon and surgical assistant are ready to enter the surgery suite. The dog is positioned with the back cushioned on a warm water blanket on the surgery table. A final sterile skin prep is done just before the drapes are put on. Two levels of drapes are clamped around the incision site closely to maintain a clean area, and sterilized instruments in a surgical pack are opened and sorted for the procedure.
The operation incision is made along the tummy midline, all the way up to near where the chest cavity starts and down enough to allow for a good view of the abdomen. The stomach is decompressed (emptied), de-rotated back into position, and spleen and stomach checked for damage. A scan of other structures in the abdomen is done to confirm that no other abnormalities exist. The stomach is flushed of any gas and fluid by placing a tube down the esophagus via the mouth and rinsing the stomach out thoroughly. If the stomach is blocked with material, an incision into the stomach and direct removal of contents may be necessary
The stomach is then tacked to the body wall just behind the ribcage down low, so that it cannot twist again out of position. This tacking procedure holds the stomach in place for life in most patients, though rarely, the surgical adhesion breaks down. A small line is cut in the stomach wall and the opening is sewn to the cut muscle lining on the abdomen wall. Abdominal flushing is done with warmed sterile saline (dilute salt solution) poured in then suctioned out, which helps to ensure the abdomen is very clean before the incision is stitched closed. At this stage, a whole new surgery pack and gloves are used, and drapes changed to remove any soiled materials from the surgery site area.
Closing the incision requires a few layers of stitches be placed in the body wall tissues, most commonly the body wall fibrous layer, then subcutaneous tissues, and then skin, though some surgeons bury their third layer in the subcuticular layer (just under the skin) so that there are no stitches or staples to remove post op.
Suture materials are chosen carefully for size and absorption, and the type of needle varies depending on what type of tissue is being sewn. Skin staples are a quick way to close the skin layer and are very durable since the pet cannot chew them out like stitches.
Sometimes with these very ill dogs, blood pressure is difficult to maintain in longer surgeries so fluid boluses (fast flow) and colloids such as artificial starch-type solutions are used to maintain adequate blood pressure.
The recovery phase involves slowly weaning the dog off the anesthesia, and if the ventilator has been used, they are weaned off this as well. When awake enough to swallow, removal of the endotracheal (ET) tube occurs, with constant monitoring until the dog is up and around. The patient is then moved to the recovery area. In some cases, repair is done to remove dead stomach wall. Sometimes the damaged area is pushed into the stomach and over-sewn, other times the dead section is excised (cut out) and carefully closed. If the spleen is damaged, it is removed in its entirety. If a stomach repair and/or splenectomy need to be done, the surgery time may be quite long – easily a few hours.
This phase is just as important as the surgery! The close monitoring continues, and if heart arrhythmias occur, treatment may be needed to stabilize. Repeat blood tests may be needed.
System wide infection, coagulation disorders and death are more likely when the condition is treated late in the process.
Post-op concerns can evolve over the next few days that may require additional therapies and testing. If all goes well our lucky dog will usually be ready for release about 2-3 days post-op, after being slowly introduced to easily-digested food given in small frequent meals.
Stitches will usually stay in a week or two depending on the healing, and daily monitoring of the incision at home will be done by the owners. Sometimes a neck cone will be sent home to prevent the dog from chewing at the incision. The shaved patch where the IV catheter was will grow back in a short while, as will the belly hair.
Sometimes in large dogs with deep chests, a veterinarian may tack the stomach at the time of the spay surgery to prevent possible episodes of GDV in future, as a protective measure.
From the front lines: Commentary
Our guest surgeon commentary is from Dr. Rita Ghosal of the Niagara Veterinary Emergency Clinic. She has seen many GDV patients over the years, and performed many challenging surgeries. Here are a few of her thoughts.
“One of my favourite emergencies is the GDV! The reason being, you never know what you are going to get. What comes along with the twisted stomach is the real challenge. Post-op complications include arrhythmias, stomach motility problems, pain, infection, aspiration pneumonia and multiple organ failure”. She shares a case, “I had one dog do poorly after surgery and I discovered she had *Addison’s disease that was previously undiagnosed”. Her truism is that “you can never assume that any of these patients will read the book”. She finds great reward in managing such complicated and challenging surgery, since most of these patients will survive with appropriate management.
*Addison’s disease is hypoadrenocorticism, or poorly functioning adrenal glands.