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com

COM PA N I O N A N I M A L PR ACT I CE Appropriate treatment of areas

of gastric necrosis, which can
occur secondarily to gastric
dilation–volvulus, as shown
here, is vital to maximise a
patient’s chance of survival

Gastric dilation–volvulus syndrome

in dogs 2. Surgical and postoperative
management MICKEY TIVERS AND DAN BROCKMAN

GASTRIC dilation–volvulus (GDV) is a challenging but rewarding condition to treat. Appropriate

decision making and management can help to achieve a success rate of up to 95 per cent in cases
uncomplicated by gastric necrosis. This article, the second of two reviewing the management of canine
gastric dilation–volvulus syndrome (GDVs), describes the surgical and postoperative management of
GDVs in dogs. An article in the February issue (In Practice, volume 31, pp 66-69) discussed the diagnosis
and initial stabilisation of patients with GDVs.

Mickey Tivers
graduated from
Bristol in 2002. He SURGICAL MANAGEMENT Repeated gastric lavage with warm tap water will help to
is currently a staff complete gastric emptying. Complete gastric decompres-
clinician in small
animal surgery at
The aims of surgical management of acute GDV include: sion makes repositioning of the stomach easier and facili-
the Royal Veterinary ■ Gastric decompression and repositioning; tates all subsequent gastric manipulations. Assuming that
College (RVC). He
holds the RCVS
■ Assessment of the viability of abdominal organs;
certificate in small ■ Removal of devitalised tissue;
animal surgery and ■ Gastropexy.
is a diplomate of the Gastric repositioning
European College of Time should be taken to fully evaluate and treat an
Veterinary Surgeons. affected dog surgically. It has been shown that, provid-
ing all other aspects of preanaesthetic stabilisation and
anaesthetic administration are appropriate, increased
surgical time does not put an animal at additional
risk. The surgeon must be thorough and methodical
to optimise the chance of recovery.
The dog should be prepared aseptically for surgery
and a ventral midline coeliotomy performed. Care should
be taken when entering the peritoneal cavity to avoid
puncturing the dilated stomach. The incision should be
Dan Brockman
graduated from
as long as necessary to allow adequate inspection of all
Liverpool in 1987. abdominal organs and facilitate gastric decompression
He is currently
and gastropexy (typically from the xiphoid to beyond the
professor of small
animal surgery at umbilicus). Abdominal retractors (Balfour or Gosset
the RVC. He holds retractors) can be used to aid abdominal exposure.
RCVS certificates in
veterinary radiology
and in small animal Gastric decompression and repositioning
orthopaedics. He is
a diplomate of the A distended stomach is immediately obvious on entering
American College of the peritoneal cavity. In dogs with a 180 to 360º clock-
Veterinary Surgeons
and the European
wise gastric rotation, the stomach will have entered the
College of Veterinary omental bursa and will, therefore, be covered by an
Surgeons. omental leaf. Despite preoperative gastric decompres-
sion, further decompression during surgery is usually
helpful. This should be performed by an assistant passing Exploratory laparotomy in a dog with GDV. The dilated
stomach is covered by omentum, which is indicative of
In Practice (2009) an orogastric tube and is facilitated by the surgeon manu- a clockwise torsion
31, 114-121 ally guiding the tube through the cardiac sphincter.

114 In Practice ● MARCH 20 09

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the surgeon is standing on the dog’s right-hand side, the

pylorus is identified and grasped with the right hand Timing of surgical intervention
(typically on the dog’s left-hand side). Downward pres-
The timing of surgical intervention remains controversial. Some clinicians sug-
sure on the right side of the visible portion of the stomach
gest a period of prolonged stabilisation before surgery. The authors prefer a
with the left hand, coupled with gentle traction on the
shorter period of stabilisation followed by rapid surgical exploration. This may
pylorus, will aid gastric repositioning (see box below).
allow identification and treatment of the small number of dogs suffering from
If the passage of a stomach tube is not possible before
gastric necrosis or ongoing haemorrhage and, hence, improve the prognosis in
derotation, intraoperative needle gastrocentesis using
this group of patients.
a 16 gauge needle or intravenous catheter can be
performed before gastric repositioning.

Assessment of gastric viability If the stomach wall appears grey/green, purple or

and gastric resection black, has areas of seromuscular tearing or is much thin-
Gastric necrosis is reported in 10 to 37 per cent of dogs ner than the adjacent stomach wall, ischaemia is likely
with GDV (Glickman and others 1998, De Papp and oth- and subsequent tissue necrosis is probable. Obviously,
ers 1999). It is associated with a poor prognosis and this is a subjective assessment. Gentle palpation for pul-
appropriate treatment is vital to maximise the chance of sations in the gastric and splenic vessels can also be
survival. Once the stomach has been decompressed and helpful. If there is still some doubt about the viability
repositioned, it should be checked carefully for areas of of the stomach, it should be assessed by looking for
ischaemia and necrosis. If the stomach appears grossly active bleeding following partial-thickness incisions in
normal, an assistant should lavage it with warm water the gastric wall.
via the stomach tube. A gastrotomy may occasionally be
necessary to remove impacted food or foreign bodies.
The junction between the fundus and the gastric body
along the greater curvature of the stomach is the most
common site for necrosis following GDV and should be
thoroughly examined. In cases of GDV, the serosa is often
bruised, so five to 10 minutes should be allowed for it to
recover before a full assessment is carried out. The most
practical indicators of gastric wall condition are:
■ Colour;
■ Wall thickness;
■ Presence of pulses in local vessels;
■ Bleeding from partial thickness (seromuscular) inci-
Necrotic gastric wall
sions in the gastric wall; seen during exploratory
■ Presence of thrombi in the gastric vasculature. laparotomy

Repositioning of the twisted stomach pictured The dilated stomach in a normal position
on the left following derotation

In Practice ● MARCH 20 09 115

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In dogs suspected of having an area of gastric wall

devitalisation or in cases of necrosis, a partial gastrectomy
must be performed. Gastric necrosis without partial
gastrectomy has been associated with unacceptably high
mortality. A safe partial gastrectomy can be performed
manually but is much easier using surgical stapling equip-
ment. This alternative method has the advantage of reduc-
ing operating time, which potentially offsets the increased
cost of the procedure. The authors recommend the use of
Partial gastric resection either a gastrointestinal anastomosis stapler (GIA-50 or
due to gastric wall necrosis. GIA-90; US Surgical/Tyco) or a thoracoabdominal stapler
The necrotic portion of the
stomach is resected using a (TA-90; US Surgical/Tyco) with a 4·8 mm (green) staple
GIA-90 stapler (US Surgical/ cartridge. The staple lines should be reinforced using a
Tyco)
continuous Cushing or Lembert suture pattern.
The gastric cardia and distal oesophagus should also
be carefully evaluated for necrosis. Successful resection
Open resection and reconstruction of this area is extremely challenging
and the prognosis for dogs with this injury is grave.
■ Place stay sutures in the stomach wall using 2 or 3 metric polypropylene to
Gastric necrosis occasionally leads to perforation and
allow manipulation
contamination of the peritoneal cavity. Treatment is as for
■ Pack the stomach off from the rest of the abdomen with large, moist laparot-
dogs requiring gastric resection with additional therapy
omy sponges
for peritonitis. Typically, such dogs are more severely
■ Sharply excise the affected portion of the gastric wall and continue the resec-
affected in a global sense and are therefore at greater risk
tion until the cut edges are actively bleeding. This should ensure healing without
of additional disease processes such as systemic inflam-
further necrosis
matory response syndrome (SIRS) and disseminated
■ Close the stomach in two or three layers. A simple continuous suture pattern
intravascular coagulation (DIC). These animals are the
in the submucosa should be followed by a simple interrupted pattern in the mus-
most challenging to treat.
cularis and serosa. Oversewing the suture line with a continuous or interrupted
inverting pattern (eg, Cushing or Lembert) can reinforce this closure. Size 2 or 3
Assessment of the spleen and splenectomy
metric polydioxanone (PDS; Ethicon) or polyglactin 910 (Vicryl; Ethicon) are suit-
Once repositioned, the spleen should be assessed for
able suture materials
evidence of vascular compromise. The splenic vessels

Incisional gastropexy

A B
(A) Identify the pyloric antrum following gastric (B) Make a 5 cm seromuscular incision longitudinally in the
decompression pyloric antrum, taking care not to enter gastric lumen

E F
Suture the edges of gastric wall incision to the edges of the body wall incision with two simple continuous sutures using
3 metric polydioxanone. (E) Place the first suture dorsally on the cranial border of the incisions. (F) Appose the cranial
borders of the incisions with a simple continuous suture

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should also be inspected for avulsion and thrombosis. If
the splenic vein or artery contains palpable thrombi,
both vessels should be ligated and the spleen removed
promptly to prevent the release of thrombi into the sys-
temic or portal circulation. If no intravascular thrombi
are present, the spleen should be allowed to recover
while perfusion returns to normal. Black areas of spleen
are consistent with infarction, so a partial or complete
splenectomy should be performed, depending on the
amount of spleen affected. The authors do not recom-
mend attempting a partial splenectomy without surgical
stapling equipment. If the spleen has undergone com-
plete torsion, a splenectomy should be performed before
reducing the twist to prevent the risk of releasing toxins,
myocardial active substances and thromboemboli into
the circulation.
Gastropexy
A gastropexy should be performed in all cases of GDV
or gastric dilation (GD) to prevent recurrent GDV.
Recurrence of GDV is common in dogs that do not
undergo gastropexy. Most gastropexy techniques aim to
fix the pylorus, which is the most mobile part of the
stomach, to the right abdominal wall. A gastropexy can
be carried out using incisional (see box below), belt-loop,
circumcostal and tube (see box on pages 118 to 119)
techniques. Incisional, belt-loop and tube gastropexies
are all quick to perform and create strong adhesions. A
tube gastropexy has the advantage of providing enteral
access for postoperative nutrition and allows gastric
decompression should postoperative dilation occur. For
C D
(C) and (D) Make a matching incision in a ventrodorsal direction in the peritoneum and transverse abdominal muscle
on the right abdominal wall, caudal to the last rib
G
(G) Place another suture dorsally at the caudal border
of the incisions and appose the caudal borders of the
incisions with a simple continuous suture
In Practice ● MARCH 20 09
these reasons, this technique can be particularly useful
in dogs with chronic GD or those that have undergone
gastric resection.
Following surgery, the abdomen should be lavaged,
ideally with a balanced and buffered electrolyte solution,
and closed in a routine fashion.
POSTOPERATIVE MANAGEMENT
Frequent, careful monitoring of a patient’s physical
parameters, including pulse rate and quality, respiratory
rate, temperature, mucous membrane colour, capillary
refill time (CRT) and evidence of abdominal distension,
will enable early detection of complications. Packed cell
volume (PCV) and serum total solids (TS) should also
be measured every two to four hours initially. As men-
tioned in Part 1, frequent quantification of urine produc-
tion and evaluation of urine specific gravity is easy to
perform and gives extremely useful information about
the perfusion state of an animal. Ideally, 1 to 2 ml/kg/
hour of urine should be produced. Additional monitor-
ing, including continuous electrocardiography, invasive
or non-invasive blood pressure measurement, central
venous pressure assessment and urine output, is helpful,
if available.
Fluid therapy is maintained by intravenous adminis-
tration of a balanced electrolyte solution at a rate of 4 to
10 ml/kg/hour for the first 24 hours, depending on the
assessment of cardiovascular parameters. The intra-
venous fluid rate and composition should be regularly
H
(H) The finished gastropexy
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assessed and tailored to the perceived needs of the ani-
mal, based on changes in subjective (mucous membrane
colour, CRT, pulse rate and quality) and objective (arte-
rial blood pressure, PCV/TS, urine output) data. After 24
hours, if the patient is progressing well, fluid therapy can
be gradually withdrawn.
Postoperative analgesia is an important aid to recov-
ery. Initially, morphine at a dose of 0·2 to 0·4 mg/kg intra-
muscularly or methadone at the same dose intravenously,
every four hours, is recommended. After the first 24
hours, buprenorphine at 0·01 to 0·03 mg/kg intravenously
should be adequate. Non-steroidal anti-inflammatory
drugs (NSAIDs) should generally be avoided initially
because of their potentially devastating effects on renal
and gastric mucosal blood flow in hypotensive animals.
Once a dog has recovered from surgery and remains
euvolaemic, NSAIDs can be prescribed to provide further
postoperative analgesia. If recovery is uneventful, water
and small amounts of food can be offered orally the day
after surgery and the fluid rate reduced. Patients should
remain hospitalised for three to five days following
surgery to ensure a complication-free recovery.
COMPLICATIONS AND PROGNOSIS
The prognosis for dogs treated for GD and GDV is excel-
lent and good, respectively. Many reports cite a survival
rate of almost 100 per cent for dogs with GDV that do not
require gastric resection. For patients requiring partial
gastrectomy, the survival rate is up to 70 per cent.
Hypoperfusion and hypotension
Dogs occasionally remain hypotensive and, therefore,
hypoperfused after surgery. This hypotension is most
commonly due to inadequate fluid therapy in the periop-
erative period. Hypotension may also occur secondarily to
ongoing haemorrhage because of inadequate primary sur-
gical haemostasis. In addition, it can be caused by reduced
colloid osmotic pressure and subsequent loss of fluid from
the intravascular space or abnormal fluid distribution as a
result of altered peripheral vascular tone. Poor cardiac
function can sometimes lead to hypotension (see below).
Pulse rate and quality, CRT and urine output should all
be monitored carefully. Poor pulse quality, tachycardia,
slow CRT and the production of a reduced volume of con-

Tube gastropexy

A B
A large (24 to 26 gauge) Foley catheter or de Prezzer mushroom-tipped catheter (the authors prefer
the latter in most cases) should be used for the tube. (A) Make a stab incision in the body wall
approximately 2 to 5 cm lateral to the ventral midline and 2 cm caudal to the last rib on the right-
hand side. (B) and (C) Pass the tube through the stab incision into the abdominal cavity with the
aid of forceps
C

F
(F) Tightly tie the purse-string suture around the catheter and, if using a
Foley catheter, inflate the bulb with saline.
G
(G) and (H) Preplace four pexy sutures using 3 metric polydioxanone
around the gastric and abdominal wall incisions (a box suture), taking
care to avoid including the end of the catheter in these sutures

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centrated urine are all indicative of hypotension and hypo-
volaemia. Direct or indirect arterial blood pressure moni-
toring provides an objective measurement of hypotension
and is a useful indicator of response to treatment. PCV and
TS should be measured in patients responding poorly to
fluid therapy. In a hypotensive animal, PCV and TS sug-
gestive of haemoconcentration indicate the need for more
aggressive fluid therapy (boluses of balanced electrolyte
solution). If the PCV and TS are low in a hypotensive ani-
mal, the administration of blood products or synthetic col-
loids may be indicated. Patients should be re-evaluated
frequently following changes in fluid therapy.
Cardiac arrhythmias
Cardiac arrhythmias are reported in approximately 40 to
50 per cent of dogs following an acute episode of GDV.
They are most frequently ventricular in origin, ranging
from intermittent ventricular premature conductions to
sustained ventricular tachycardia. Arrhythmias can be
due to myocardial injury, persistence of circulating myo-
cardial active substances or electrolyte imbalances. It is
therefore important to check a dog’s acid–base status
and electrolytes (especially potassium and, if possible,
magnesium), and correct any underlying abnormality as
well as addressing the arrhythmia.
The impact of an arrhythmia on a dog’s cardiac func-
tion should be evaluated before considering treatment.
Assessment of hypoperfusion as described above will
help to determine the significance of the arrhythmia.
Persistent hypoperfusion despite adequate fluid therapy
suggests that the arrhythmia is affecting cardiac per-
formance and should be treated. Dogs with ventricular
arrhythmias should be treated with lidocaine in the first
instance. A bolus of 1 to 2 mg/kg is given intravenously,
slowly, over 30 seconds. This dose can be repeated up to
a total of 8 mg/kg. Rapid bolus injection often results in
vomiting. Overdosage causes seizure activity, although
this is typically short lived. If a favourable response is
seen to lidocaine therapy (ie, conversion to sinus rhythm,
slowing of the ventricular rate), a constant-rate infusion
should be started at a rate of 50 to 80 μg/kg/minute. As
lidocaine is proarrhythmic at low doses, this dose should
not be tapered, but stopped abruptly when therapy is no
longer required.

D E
(D) Surgeon’s view of the abdominal contents, with the pylorus in the centre of the image. The tube can be seen entering through the right abdominal
wall. Place stay sutures in the stomach to allow manipulation. (E) Preplace a purse-string suture in the pyloric antrum using 3 metric polydioxanone.
Make a stab incision into the stomach through the suture and place the catheter into the lumen

I
(I) Omentalise the pexy site. (J) Draw up the balloon or
mushroom tip to the stomach wall and secure the tube
on the outside of the skin with a Chinese finger-trap
suture. Place an abdominal bandage postoperatively to
protect the tube. The gastropexy tube should remain in
place for seven to 10 days, and should be kept clean and
protected with a bandage. Remove the tube by traction
H and leave the stoma to heal by secondary intention J

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Although arrhythmias are a potentially serious com-
plication, they do not appear to influence survival if
treated appropriately.
Aspiration pneumonia
Retching and vomiting before surgery, perioperative and
postoperative regurgitation and oesophagitis place dogs
with GDV at risk of developing aspiration pneumonia.
An abnormal respiratory rate and pattern, crackles on
thoracic auscultation, depression and pyrexia are sugges-
tive of pneumonia. Thoracic radiographs, arterial blood
gas analysis and tracheal or bronchoalveolar lavage with
cytology and culture will help to confirm this clinical
suspicion. Dogs with aspiration pneumonia should be
treated with appropriate antibiotics, nebulisation and
coupage, and supplemental oxygen, as required.
Abnormal gastric motility
Following successful GDV surgery, some dogs, especially
those having undergone partial gastrectomy, may suffer
from reduced or absent gastric motility. Such dogs may
vomit or remain anorexic. Metaclopramide (1 to 2 mg/kg/
day intravenous infusion) or a very low dose of erythro-
mycin (0·5 to 1·0 mg/kg every eight hours) may help to
improve motility.
Dogs that have suffered mucosal damage may benefit
from the administration of a proton pump inhibitor such
as omeprazole (1 mg/kg intravenously once daily) or a
gastric protectant such as sucralfate (2·5 to 5 ml orally
every eight hours).
Gastric necrosis and perforation
Gastric necrosis and perforation can occur up to five days
postoperatively despite careful intraoperative gastric wall
assessment. It may be due to dehiscence of a gastrectomy
repair and highlights the importance of careful assess-
ment at the time of surgery and good surgical technique.
This complication is suspected in dogs that deteriorate or
fail to improve following surgery or show signs of sepsis.
Radiography, ultrasonography and cytological evaluation
of peritoneal fluid can help to confirm the diagnosis.
Surgical treatment is necessary and involves an explora-
tory coeliotomy, debridement and repair of the gastric
wall defect, and appropriate management of peritonitis.
The prognosis is grave in cases with postoperative gastric
necrosis, perforation and septic peritonitis.
Systemic inflammatory response syndrome,
sepsis and disseminated intravascular
coagulation
Dogs suffering severe problems such as GDV are at risk
of SIRS. This is the clinical manifestation of systemic
inflammation in response to a variety of serious insults.
Patients showing persistent hypoperfusion or hypoten-
sion despite adequate volume resuscitation, pyrexia or
decreased mentation should be monitored carefully.
SIRS increases the risk of multiorgan dysfunction and
every effort should be made to stabilise these animals
promptly. The presence of a documented infection in the
presence of SIRS is classified as sepsis.
DIC may also be seen in severely affected dogs. The
systemic release of inflammatory mediators causes
widespread endothelial damage and activates the coagu-
lation system and microvascular thrombosis. Eventual
depletion of coagulation factors results in coagulopathy
and clinical signs of bleeding.
In Practice ● MARCH 20 09
Client education
Owners of dogs suffering from GDV should be warned that the condition could
recur. The signs associated with recurrence should be made clear and the clients
advised to seek veterinary attention as soon as possible if they are concerned.
Advice on feeding remains unclear. The authors recommend dividing food up
into several small meals and advise owners to keep mealtimes as stress-free as
possible.
Prophylactic gastropexy
Some consideration should be given to prophylactic gastropexy in dog breeds
that are predisposed to GD and GDV. Dogs with relatives that have experienced
GDV are significantly more likely to be affected themselves and there may be
good reason for prophylaxis in these animals. Gastropexy can be performed
as an elective procedure or preferably at the time of an ovariohysterectomy or
other abdominal procedure. The risks and complications related to the surgery
must be weighed up against the risk of GDV, which remains uncommon (prev-
alence of 0·8 to 2·8 per cent). Laparoscopic gastropexy may facilitate surgery
(Rawlings and others 2002).
Dogs at risk of SIRS and DIC should be monitored
closely. Coagulation parameters, acid–base status and
blood gas levels should be determined before further
treatment. Prolonged prothrombin and activated partial
thromboplastin times, low platelet count, decreased
fibrinogen and increased fibrin degradation products or
D-dimers are indicators of DIC. Treatment with fresh
frozen plasma to replace coagulation factors may be
indicated in these patients. The prognosis for animals
with these complications is very poor.
References
DE PAPP, E., DROBATZ, K. J. & HUGHES, D. (1999) Plasma lactate
concentration as a predictor of gastric necrosis and survival among
dogs with gastric dilatation–volvulus: 102 cases (1995-1998).
Journal of the American Veterinary Medical Association 215, 49-52
GLICKMAN, L. T., LANTZ, G. C., SCHELLENBERG, D. B. &
GLICKMAN, N. W. (1998) A prospective study of survival and
recurrence following the acute gastric dilatation–volvulus
syndrome in 136 dogs. Journal of the American Animal Hospital
Association 34, 253-259
RAWLINGS, C. A., MAHAFFEY, M. B., BEMENT, S. & CANALIS, C.
(2002) Prospective evaluation of laparoscopic-assisted gastropexy
in dogs susceptible to gastric dilatation. Journal of the American
Veterinary Medical Association 221, 1576-1581
TIVERS, M. & BROCKMAN, D. (2009) Gastric dilation–volulus
syndrome in dogs 1. Pathophysiology, diagnosis and stabilisation.
In Practice 31, 66-69
Further reading
BROCKMAN, D. J. & HOLT, D. E. (2000) Management protocol for
acute gastric dilatation–volvulus syndrome in dogs. Compendium on
Continuing Education for the Practicing Veterinarian 22, 1025-1034
BROCKMAN, D. J., HOLT, D. E. & WASHABAU, R. J. (2000)
Pathogenesis of acute canine gastric dilatation–volvulus
syndrome: is there a unifying hypothesis? Compendium on
Continuing Education for the Practicing Veterinarian 22, 1108-1113
BROCKMAN, D. J., WASHABAU, R. J. & DROBATZ, K. J. (1995)
Canine gastric dilatation–volvulus syndrome in a veterinary
critical care unit: 295 cases (1986-1992). Journal of the American
Veterinary Medical Association 207, 460-464
BUBER, T., SARAGUSTY, J., RANEN, E., EPSTEIN, A., BDOLAH-
ABRAM, T. & BRUCHIM, Y. (2007) Evaluation of lidocaine
treatment and risk factors for death associated with gastric
dilatation and volvulus in dogs: 112 cases (1997-2005). Journal of
the American Veterinary Medical Association 230, 1334-1339
MONNET, E., LHERMETTE, P. & SOBEL, D. (2008) Rigid endoscopy:
laparoscopy. In BSAVA Manual of Canine and Feline Endoscopy
and Endosurgery. Eds P. Lhermette and D. Sobel. Quedgeley,
BSAVA Publications. pp 158-174
RASMUSSEN, L. (2003) Stomach. In Textbook of Small Animal Surgery,
3rd edn. Ed D. Slatter. Philadelphia, Saunders Elsevier. pp 592-643
WILLIAMS, J. M. (2005) Gastric dilatation and volvulus. In BSAVA
Manual of Canine and Feline Abdominal Surgery. Eds J. M.
Williams and J. D. Niles. Quedgeley, BSAVA Publications. pp 80-95
121
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Gastric dilation−volvulus syndrome in dogs:

2. Surgical and postoperative management
Mickey Tivers and Dan Brockman

In Practice 2009 31: 114-121

doi: 10.1136/inpract.31.3.114

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http://inpractice.bmj.com/content/31/3/114

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