GDV & Emergency Surgery

So lets start with this presenting case…

So what are the typical signalments of GDV

So how do they present?

http://twitter.com/Seh_Fid/status/467018927005249536

So now we know how they present, we need to make a decision what to do

Yep its a true emergency, cancel your plans & get thinking what your going to do!

So we need to give fluids to the dog, what are we going to do?

http://twitter.com/Seh_Fid/status/467020515698573313

The recommended protocol for stabalizing GDV’s is 2 large bore catheters into the cephalic veins & start aggressive IVFT with hartmanns. Re-assess CVS status in 15-20 mins..
Dogs can also be pretty painful so analgesia is recommended and an opiod (methadone or fentanyl), we also recommend putting an ECG on the dog- they can get dysrhythmias and its best to be able to monitor these.
So now the dog is more stable we go for X-ray

http://twitter.com/Seh_Fid/status/467021971776368641

So not your typical GDV presentation, there is some gas in the abdomen ‘pneumoperitoneum’

http://twitter.com/Seh_Fid/status/467023265878523904

So the gas in the abdomen is bad news, it suggests a leakage or rupture somewhere so the surgical success rate is greatly reduced!

http://twitter.com/Seh_Fid/status/467024003459461120

So we need to advice the owners that the prognosis is worse now we have a rupture, compared to a standard GDV
So we decide the dog needs surgery, but we need to do a few things first.
The stomach needs to be decompressed- we use a orogastric tube which can be well tolerated under sedation (those opiods we gave earlier & possibly some diazepam which isn’t much of a CVS depressant) if you can’t pass the stomach tube you can do percutaneous decompression.
Such as in this case, a suspected rupture ab’s are certauinly recommended peri & post-operatively &  cefuxorime or amoxiclav IV are both used routinely.

So we were all a bit uncertain what seeing the omentum meant, but this basically means that its likely a clockwise rotation.

So what else would we want to look at In the abdomen?

So we need to check the stomach is viable & whether there is any necrosis present- the picture below shows the most likely position of necrosis occurring.

So what if the stomach is necrotic?

So we can cut it out if needed, but if there is a large amount of necrosis especially around the cardia & oesophageal spinchter this suggests a poor prognosis!

So once we have removed the necrotic tissue, what pattern will we use to close?

So have faith in your sutures and a simple continuous should be fine!
After checking the stomach what else should we check…

So if we can’t feel a pulse? Its not good news- a total splenectomy needs to be performed!
But don’t get too carried away now you’ve done all the hard work, remember what else you need to do

We need to perform a gastropexy to prevent a recurrence of the GDV, and some people even recommend doing these prophylactically at neutering in deep chested breeds.

So we need to pexy the stomach, and the pylorus the most mobile part of the stomach is the bit you pexy, to the right body wall. Fixing to the left there is still a chance of getting a GDV occurring again!
And what type of pexy is personal preference, but here is an example of an incisional gastropexy.
You can also undertake belt loop, circumcostal & tube.

Once you’ve finished the surgery you need to lavage the abdomen with warm saline.

Well done to everyone involved, you’ll be pleased to hear the dog lived!

Here are some good in practice articles on GDV’s which have helped me write up the case hope they help!
 http://inpractice.bmj.com/content/31/2/66.full.pdf+html?sid=8edb0429-f9a2-40f0-a11e-1001e780bc4d 

 http://inpractice.bmj.com/content/31/3/114.full.pdf+html?sid=8edb0429-f9a2-40f0-a11e-1001e780bc4d