Hi. I'd like to welcome you to this webinar. For the next hour, we are going to discuss about gastric dilatation and volus.
Which, of course, you all know in this, GB before starting, I'd like to plan the webinar right for the invitation. It's always my pleasure to be here with you guys. So this is an overview of what we're gonna talk about.
Diagnosis, emergency treatment, surgical management, prevention and prognosis, post-operative management complications, tips, and finally, a literature review. Are there any predisposing factor for the syndrome? Well, yes, we all know that, the A I DS plays a role.
It's twice as likely for dogs older than seven years old to suffer from the syndrome. We also know that, there are twice as likely possibilities for male dogs compared to females, dogs who suffer from the syndrome dogs that are stressed or hyperactive are three times more likely to suffer from the syndrome. Temperament plays a role, aggressive and fearful.
Those are usually the ones who get affected. And of course, history of GDV in a first degree relative, is also a predisposing factor for, adult to suffer from GDV breed may also play a role. We do know that large or giant pur breed Dogs are three times more likely to suffer from GB B compared to mixed breed dogs.
Grey, Dane, Saint Bernard, Way Moran and setters, can be, predisposed, chest confirmation. Also play a role. I mean, increased thoracic depth to width ratio, plays an important role.
And that is why we generally see more commonly GDD cases in dogs with deep and wide chest. Compared to those with deep and narrow chest and some nutritional aspects may predispose to the syndrome like the body condition score. Dogs with low body condition score are three times more likely to suffer from the syndrome.
Feeding habits play a role. Those are fed once daily, are more prone to the syndrome from those, fed twice or more. Food volume also play a role.
Big volumes of food may predispose our patients to G TV and, of course, eating habits. Fast eaters are five times more likely to suffer from the syndrome when you compare with, dogs that, eat, in a more normal way Patients suffering from GDD may have a history of a progressively distending and tympanic abdomen, or the dog may be found recumbent and depressed with a distended abdomen. Nonproductive retching hypersalivation and restlessness are also common.
There are also some cases that, we consider them to be chronic ones. And diagnosis, for these cases is more subtle because the clinical signs are not as dramatic as for an acute GDV. These dogs usually suffer from chronic vomiting, flatulence and weight loss.
G DB cases of clinical examination usually are presented in shock with pale mucus membranes, weak peripheral pulses, tachycardiac, hypia, dyspnea with a prolonged capillary file time, increased heart rate and possibly arrhythmias already present in almost, 25% of GDV cases are presentation, and then we'll as we'll see, and we'll discuss further, in the next slides. Arrhythmias are a negative prognostic factors if they are present, preoperatively, in the, outcome of the disease. And of course, distension of the abdominal cavity and a tympanic cranial abdomen can also be seen, at the initial natal examination.
Laboratory findings. CBC is seldom informative, in certain by MC profile. We may see hypoglycemia and, electrolyte abnormalities, which generally vary.
But the most common one that we see is hypokalemia, which is very important to be corrected in order to have a better outcome. Plain lactic acid is something that we need to talk a little bit more. We know that normal values range for a 0.5 to 2.5 mill more per litre.
We used to, see lactic acid as a predictor of gastric necrosis or even survival. But now we know that what it matters is, the decrease in plasma lactic acid concentration after 12 hours of fluid resuscitation. So a decrease in plasma lactic concentration more than 50% within 12 hours may be a much better indicator for survival of our patient.
This is a small anatomy review. You can see the part of the stomach, the cardio, the fundus, the body, the Antrim and the Pylos. And what is happening to GDV is that what you see now in this illustration is that the, stomach is distended.
And finally pylos, crosses the midline, and at the end, by the full volvulus, you have the full 360 volvulus, of the stomach. And finally, the pylos, entraps the Eagen junction performing at full G PV diagnostic imaging radiographs can help differentiate simple dilatation from dilatation plus Bulus. Affected animals should be decompressed before radiographs are taken.
And that is why stable patients only should have radiographs. We generally prefer the right lateral and dorsal red review. Presence of free air in the abdominal cavity may suggest, plastic rupture and air within the wall of the stomach wall, indicates necrosis, both of which are indications for emergency surgery.
Let's review a couple of radiographs as as the one that we saw here. You can see here this, raid dilation the next one what we call the double bubble image or else the Smurf sign. You can see the pillar is dislocated.
Right beneath, the spine. Also in this radiograph with Smurf sign. And in the DV view, you can see the pylos as a gas, which structure to the left of the midline, that pneumonic signs of raci, dilatation and borders.
In this photograph, you can see food content cables in the stomach and in this radiography, you can see a dilated, stomach, which is beneath the rib cage. And that is the reason why in some patients that suffering from a dilation, this is not very easily observed in the, abdomen because the stomach is hidden beneath the rib cage. So medical management starts with emergency treatment and emergency treatment and stabilisation of our patients.
And, this is our initial objective. Has decompression and treatment or shock are the mainstay of treatment, as an emergency, in the very beginning. And how are we decompressing our patients?
Of course, by using stomach tubes which have to be long enough reaching at least last rib in order for the, passing to be successful. Passing the tube may be successful in 80% of cases. And if that is happening, glava warm saline.
It's, very good for, our patient. Keep also in mind that passing the tube does not mean that there is no Bulus. If passing the tube is not an option or or you cannot make it, tr oration can be also done by using, a couple of large bore IV catheters with the style that initially, as shown in the video in the picture here, couple of spots are inserted.
And also, you can see the stomach tube passed. Sometimes, if there is a lot of content, in the stomach, the tube may be occluded, so keep in mind that occlusion should be addressed. Also, treating sock, of course, is a com.
Is a combination of fluids and antimicrobials. As you already know, we generally use for GDV cases large IV, catheters, usually a gauge, maybe one or two in, one or both cephalic veins. At an initial rate of 90 mil per kilo, lactated ringers.
Usually, what we usually do is giving 1/4 of the dose in, 20 minutes, and then we reassess the cardiac with important C RT. And if they get back to normal, then we go to normal to the mens administration values. It's always, a good option to add, potassium, in the fluids, to address, hypokalemia if it's present.
And, of course, that microbial should be broad spectrum bactericidal and combinations like, cefazolin plus and reflux or cefazolin plus metrozole are extremely, fine. For a situation like this. Uncertainty treatment may also, may also be needed.
Preoperatively ventricular tachy may be present. At the initial presentation, hardly create more than 160 poor quality, weak peripheral pulses. And in order to address that, we need to add some lidocaine, in the fluids.
Lidocaine, is ineffective when hypokalemia is present, and that is the reason why hypokalemia should be addressed. In order for lidocaine to be effective, the dose that we use is generally 2 to 4, milligramme per kilo given slowly IV in about five minutes after the total dose of exceed not exceeding eight milligrammes per kilogramme. If the cardiac rhythm gets back to normal, then we can, continue with the constant radius of 50 mcg per kilo per minute.
When it comes to anaesthesia. The anesthesiologist usually use combinations of opioids plus veso APS for, sedation and Omid date for induction of anaesthesia. Omid maintains cardiac output and is not artic, and that is the reason why the anesthesiologist may prefer to use this in this, setting in the cases, then we need to go to surgery.
And in surgery, we need initially to clip, extensively our patient. And usually it's a good, practise to clip from mid throat to pubis. Three things are very important to perform during surgery.
First of all, an an atomic requisition. Secondly, the expert for laparotomy to estimate, the viability of the abdominal organs and especially stomach and spleen, which are, more affected by the syndrome. And finally to prevent recurrence by performing what we call a Aspey an atomic reposition.
We will talk about that in a little bit more and a little bit, and after a couple of slides, but especially I'd like to talk a little bit more about, Expo laparotomy and how we estimate the viability of the stomach and the spleen. In surgery, you do know that colour plays a role. And, surgeons, we do like pink and red colour.
We we dislike black, grey or green, Black, grey or green means, that the tissue is not viable, and should be, we also need to see if there's any pulse in, gastric arteries or splenic arteries. If there is no pulse, then there is no, life. So, for example, if you have no pulse in the spleen, then splenectomy may be an option.
Then you have after the rotation of the stomach, you have to give some time for the G I tract to reperfus and to see. And then you, think if there are any peristaltic waves in the G I tract, if peristaltic waves are present, then it's OK if they're absent, there is a problem. We also need to take care of the stomach wall and see what about the thickness and the texture of the stomach wall is.
And in order to do that, we are using our thumb and index finger to pinch the stomach wall and see what is happening. Usually, what is happening in a normal stomach wall when when you tense it with your thumb and index finger is that you can feel the LASIK mucosa slipping between the your two fingers. In GDD cases, maybe the thickness of the stomach wall is not so good, and it's not thick but thin.
And this may be an indication, for, removal. If you have any doubts about, the viability of for the stomach, then all you have to do is just cut it. If you cut it, you will see if it bleeds or not.
If it bleeds is alive. If it doesn't, it means that it should be removed. And of course, finally, Astro Taxi.
So let's see what is happening with the stomach. We usually have a clockwise, ch to the right. And that is how, as I've already shown you a couple of slides before, you remember how the pylorus, was dislocated from one side to another performing a complete, voles, which may range from 90 degrees to 360 with more usually seen at 270 degrees.
Rotation. Now, when we when you enter the abdominal cavity, if you have a clockwise GDV what you first see is momentum, which fully covers the stomach, and this is what you will see upon entering the abdominal cavity momentum covering the stomach. And now what do you see to to reduce that to perform what we call the anatomical rehabs position.
You're just using your hands. You're putting your left hand. on the las, wall on on the stomach and with your right hand, you are grasping the pylos.
And what you do is pushing the front of the stomach towards the spine. And you're getting the pylos from one side of the body to the other, in a counterclockwise rotation in order to perform reposition. And, of course, when that happens, the momentum fully disappears.
from the stomach. And, of course, Then you palpate the vop junction in order to assure that everything now is OK. Sometimes the rotation is not possible.
So, if you get trouble by doing it, don't lose time. Remove spleen from the abdominal cavity to create more space for your hand to work with, or try to remove more air from the stomach, either by using a stomach tube if that's possible. And you have an assistant or an anaesthetist to help you or by using your suction unit and by, adjusting, a 21 gauge needle in your suction and removing air from the stomach by doing a person thesis of the stomach wall.
Sometimes G DB may be the left counterclockwise. In these cases, pylos can be found adjacent to the oesophagus. The greater curvature of the stomach is located along the midline, and the stomach is not covered by oum counterclockwise.
Rotations for the stomach does not exceed 90 degrees. And how are we relieving those? We are just grasping the greater curvature of the stomach with our right hand and we rotate it clockwise.
And at the same time, we are palpating the causes for the junction to ensure complete reposition. Of course, sometimes when black spots are there, as shown in this slide, gastrectomy should be performed. And, gastrectomy, is something that we usually do.
Unfortunately, during GDV cases, suing with long acting absorbable monofilament sutures is an option. Of course. If you have staplers available a T a 90 for example, that is also a great choice because it gives you, speed.
And they are very efficient. In closing, gastric sites. People usually ask, how many can we remove?
I mean, 60% of the stomach wall can be safely removed. Without, any problem as you can see here, this, gastrectomy site has been closed. Using, a simple, continuous acquisition T pattern of, P DS, three.
If I recall. Well, don't forget about the spleen. Spleen can also suffer during T TV.
And, splenectomy may be, a good choice. Several times. Always see what is happening on the splenic hilo and see if you have, pulse in the splenic arteries if there is no pulse, You see, thrombosis always do, Aspar.
And of course, after that, what you have to do is to prevent recurrence. And in order to prevent recurrence, we need to perform some kind of gastropexy either an incisional one or a belt loop. As I will show you.
After a few slides, my preference is an incisional gastropexy. And, what is an incisional gastropexy? I will show you, in this video how we perform this.
We are making without scalp blade, a 4 to 6 centimetre incision in the P Antrim. And we are making this to be a S. Muscular one 4 to 6 centimetre incision in the se muscle layer of the pyloric.
An and we're pulling the stomach to the, right abdominal wall in the transverses abdomen, this muscle to create the blood mark. And, then we're taking our, knife and make this identical incision. And then all we have to do is to suture the two more dorsal incisions with the two more ventral incisions in order to create a continuous air positional switch pattern and finally completing our gastro taxi.
There are some variations of this technique, like the modified incision that pers that I will. So you decide immediately after this one. Where some of our colleagues suggest that, we can, do a couple of full thickness, sutures at the start and end of the initial incisions between the stomach wall and the, transverse sub minus muscle.
In order to tackle the stomach closely, to the abdominal wall in order to perform more easily. Our, latro. It's just a matter of preference.
I see no difference between those two techniques, but OK, if you like it, you can go on and do it. The first line is secured with an Aberdeen knot, and then you go back to the two more ventral incisions. Your body should be generous enough in order to have a fibrous connective connective tissue formed in the next couple of weeks.
So 4 to 6 centimetre incision is very important in order to have a successful outcome for both five. The pillar Antrim and the transverses of the mind is muscled in the right abdominal wall. And this is how this incision is completed.
This is the modified incisional gastropexy. I've already talked to you about, one more time, too. Full thickness, simple interrupted sutures.
added, from, stomach to body wall. No significant differences in overall complication rates. So if you feel, that you, you know, engaging the gas mucosa is important for you, then, OK, you can go on and use it.
However, the period of one technique, over the other cannot, be determined yet be aspex is always a good option, a good alternative and can be performed and sold here in the slide. We are creating, a serial master flap from the polar Anto with at least two arteries being incorporated. We're making a loop, in the right abdominal wall, the death loop.
And we are tossing the flap from that loop and it back at the point where where was initially harvest. And this is the final product. You can add some more features if you want, and so, by the black arrow, in order to have a more secure the GASTROPEXY had completed, there are a couple of more choices circum causes of gastropexy and tube gastropexy.
I'm not gonna talk more about those because those two techniques are not those that, most of the surgeons like to perform in seasonal and, be loop gast toxic techniques. When we compare, those techniques are very easy to perform. They create strong adhesions and they can be performed in a very, few minutes.
So this is a great plus for them, on the other. The tube gastro has a main disadvantage. And that is the fact that the tube, the the tube, has to stay in place for at least 7 to 10 days in order to create strong adhesions.
And if, by any chance the tube is dislocated, then you have perit in front of your gates. On the other hand, C cost of Gex is technically more demanding, more time consuming. And during manipulations you may perform, a rib.
You may have a rib fracture or, accidentally, you may create an erogenic pneumothorax. Believe me, you don't know those things to happen during a G DB. Surgery.
So incisional gastropexy or belt loop are the best choices. We can have. This is a great video from CLINICIANS.COM.
You can, access it online. It's free. Go to the surgeon's corner.
And if you have available, 11 minutes, see, what our colleague have saying can tell you about, some real cases. It's a very nice video with very good things that you can see that may happen. During, a GDV case management in the, surgery.
Now, let's talk about prevention. Prevention of the syndrome is just by making what we call a preventive, gastro Pepsi. And, I always like to talk with the owners, about, preventive gastropexy.
Especially when I have from the very early in the beginning, when they have, dogs that, risk factors, are recognised. And it's always a good, practise to combine preventive arthro, for example, with, lab space. and it can even be done laparoscopically.
So, many options are available today for people if they want to perform, preventive gastropexy talk with the owners. Many of them, will hear you and perform gastropexy to the their dogs in order to prevent, GDV in the future. Regarding prognosis, Prognosis is generally grave to good, but believe me, it can be considered fair with timely admission and surgery.
A couple of more things I want you to remember is that despite a appropriate medical and surgical management of GDP, the reported mortality rates depending, Of course, on the paper that you read, are considered high. It's about 10 to 28% and recurrence rates for dogs that are operated for GDV in which the stomach has been repositioned, but the gastropexy not perform a approaches is 80%. So, if you go to surgery, and if you're not familiar with, gastropexy, believe me, just, performing res position is not, a good practise.
Are there any negative prognostic factors involved? Yes, there are. And we have already talked about two of those, lactic acid.
Not responded, to fluid menstruation and presence of preoperative cardi riskiness. There are some more clinical science duration for more than six hours. The need for concurrent gastrectomy or splenectomy or previous splenectomy can be, a negative prognostic factor.
Hypertension, T, IC and perit. What about the post-operative management now? Three things we need to take care of during the post-operative period, to maintain adequate hydration to correct any le, imbalances and abnormalities that we see.
And, of course, if indicated to treat arrhythmias. And how are we doing all those things? Of course.
By providing fluids and multimodal analgesia, nonsteroidals, are out of the questions for the patients. I don't think I need to say anything more about that. We all know that.
We need to check, the electrolytes, especially for the first three or four days. Postoperatively taking good care, especially of the potassium deficits. Antimicrobials should be administered.
as usual, if needed. And, pro kinetics, may be a good option. And especially metoclopramide, in order to avoid, postoperatively.
G I atomy and vomiting and a I DS two blockers. Or sate may be a good option to alleviate signs of, a gas N, problems. Water, can be offered, in the form of ice cubes after 12 hours.
Food can also be offered after 12 hours if no gastrectomy was performed. If a vasectomy was performed, it's a good option, and it's a good practise to offer food. At about 24 hours post operatively complications.
Believe me, you cannot avoid complications. You may avoid, surgical mistakes, but, you cannot avoid complications. And, there are a lot of them may be seen postoperatively with most important, be the one in, in red.
Of course, you can have post operative cases like ulcerations necrosis, perton nights and recurrence. But, you should have already deal with those during surgery. And that is why Now I'm gonna talk more about the red ones.
Cardiac arrhythmias can be seen in almost 50% of cases in, 1.5 day. After, surgery.
And that is why it's a good, practise to use ECG, in the post operative period in order to, being alert to identify him as quickly as possible. Fluids and electrolytes and plus lidocaine is, what we do for treatment. If lidocaine doesn't work, you may consider adding some of this chloride or even subtle and, about potassium deficits.
This can be seen as in our patients post operative. How, you have a patient who is lethargic, feeling weak or even having arrhythmias in in in this setting, potassium deficit should be, addressed. And of course, shock may also be present as a complication postoperatively just because of anaesthesia or because of intraoperative, blood loss.
Or even, because of inadequate preoperative, management. People ask if the occurrence or cases, of dogs that have, an incision of gastro performed Well, yes, but the percentages are very low. If gastropexy was performed is less than 5% and 5% is, only, vid patient.
And not all of this for those, not, performed gastro py. The cancer rate can be as high as 80%. So that is why LaTroy either an incisional one or a bed flu asy, is the mainstay of treatment.
For all our patients who suffer from, GDV. This is what I call the black stomach. Unfortunately, even if you, in this case, we, allowed some time for the abdominal organs to reperfus after, res position.
Unfortunately, the stomach, was, black for a long time. And so we had nothing to do other than euthanize our patient. Sometimes it's impossible to rotate the stomach.
And the reason is that there is a large amount of food and the stomach is very heavy, As shown in this case here. What we did is to to perform an astro in order to manually, remove, almost 3 kg of food. And then we close, the, asy site.
And, the rotation was much easier to perform in this case after gastropexy and, in the post-operative period, what we had after, one day was an interception. And, what we did is to go to the OR again. The day after And, after, reducing the intersection.
Fortunately, there there was no need for intestinal resection nerve miosis. And we treated our patient with, enter application as shown here. The the recovery was, uneventful.
This is another case where a gast orex was performed and this patient came back, after two days, also with an interception. Ba was fortunate one more time, and we were also fortunate. No need for, resection of intestines was needed.
We reduced the interception and perform interation again. And the recovery of the patient in the post-operative period was uneventful after that. This is another case where, the incision of gas topex that was tried to be performed was not a good one.
You can see here, a very small, incision in the right abdominal wall. And transverses abdomen is muscle. It's only a couple of centimetres long.
Not a long one. And as you can probably see, only the cirrhosis was incorporated and not the muscular. So, it was almost impossible to hold the gastropexy, site in that.
And you can also see the same thing happening in the pyloric an A very small incision. Always involve also, involving, only the sclerosis and, the pseudo master layer of the P. And that is why, I have to tell one more time that when you perform, an incision, for gastro in the P andru, you need at least 4 to 6 centimetres the macular layer incision, in order to be, safe that the gastropexy side will last.
So some key points, from the things that we have already talked about is first of all, the preoperative management is very important for us to stabilise our patients, initially, in order to have a better outcome after that, it's very important to decompress the patient as soon as possible. And if you're not familiar to, perform, G DB surgery, you send your patient to a colleague who does refer your patient after the compression. It's very important to perform the gastropexy during surgery.
Keep in mind that, ventricular tachyarrhythmias are often seen post operatively, and also keep in mind that has necrosis if identified before surgery carries poor prognosis. These are some very important key points that you should know, and you should always communicate all those with your clients. Some tips I like to share with the owners is that I, suggest that they should feed their animals at least two or three meals per day and avoid, feeding their pay their animals one meal per day.
Avoid any stress during feeding. Several small meals are much better from one large meal. I always advise them to put the football in the ground.
Advise them from very early in their life to keep in mind that at some point they should consider performing a prophylactic gast XY because they have a large breed dog. And I do see some risk factors in front of my face. Of course, we do know that GDV may happen to any dog, but, we can see in our, patients, some risk factors.
So any time that you recognise a risk factor for GDV is a very good practise for you to advise your owners, about prophylactic gastro in order for them to know and to decide, if and when they want it to be done. And of course, what I say to the owners is that when they see the animal suffering from an acute abdominal distension, call your vet immediately and go to them. As far, as soon as possible.
And of course, it's very important not to breed dogs with a first degree relative who has suffered from GDV. Especially then for a working dog. It's very important to reduce exercise.
One hour before and one hour after feeding after feeding, don't exercise your dogs. And, during this, period of time, let's do a literature review. Now, this is a very nice papers, with discussing, negative prognostic factors of the syndrome that we have already, discussed, in the beginning And, the one from my dear friend era Kelman says, Well, we've already said that despite appropriate medical and critical treatment, despite how good things can be done from our side, the reported mortality rate for dogs with GDV is high 10 to 28%.
It's very important during the post-operative period to focus on maintaining tissue perfusion. And it's very important also, to identify early any need of your patient for re exploration. This is very important not to lose time.
Of course, the syndrome has many, systemic effects. Not only cardiovascular, but also effects on the respiratory tract on the GIG I dysfunctions, coagulation dysfunctions. So understanding the potential for all these systemic effects of GDV allow us to monitor our patients, more efficiently and, intervene as early as possible in order to maximise their chance to survive.
Retrospective analysis of, 503 36 cases of canal involves, as you can see here, what our colleagues did is to try to see, if there was a difference between the survival rate for patients operated by general surgeons or specialists, as you can see, Yes, there is a small, significantly. statistically, significantly, difference. So keep that also in mind.
And also keep in mind that prophylactic Asplin may be considered in dogs undergoing eeny, particularly if other risk factors for GDV are always present. And, for those of you that you believe that GDV cases is all about dogs, well, that's not true anymore. Can also be seen in cats in felon patients and can be seen in two different clinical settings, either in combination with traumatic diph Matic hernia or or without a history of trauma or diag.
Matic hernia. So, if you have a Fallon patient with respiratory distress and abdominal distention, keep in mind that maybe, you should consider GDV as a potential cause. Nope.
That's it. It was a GDV Webinar. Hopefully now you can, deal with GDV cases.
Much better. I hope you enjoyed the webinar. I will be more than happy to answer any questions you may have regarding GDV.
Read your notes. Please feel free to send me an email or use my social media to get in contact with me. I'd like to thank the webinar.
Wait one more time for the invitation and, until our next webinar Goodbye, everybody, and have fun