Stephen J. Birchard DVM, MS, Diplomate ACVS

Tuesday, September 10, 2013

Gastric Invagination for GDV Induced Necrosis: Safe and effective, or risky and ill advised?

Gastric necrosis along the fundus and body of an Irish Setter with GDV.
Note the abnormal color and sharp demarcation between normal and devitalized tissue.
The gastric invagination technique was first described in a series of experimental dogs in 1986.1 The necrotic area of stomach, instead of being removed by partial gastrectomy, was pushed into the stomach lumen and over sewn with inverting suture patterns. The devitalized tissue was left to be digested by the stomach enzymes allowing the healthy tissue to heal. Some of the dogs in the study had melena for several days and healing of the gastric wall took more than 2 weeks.

The technique seems to fly in the face of conventional surgical wisdom. Necrotic tissue is supposed to be removed.  Allowing the dead tissue to remain and then slough out in the stomach lumen would potentially result in a serious gastric ulcer and possible delayed healing of the stomach wall. In fact, a case report described that very scenario.2 A German Shepherd, 3 weeks after surgical treatment for GDV and gastric invagination, presented with a bleeding ulcer that required partial gastrectomy. The dog had also developed a splenic torsion.

Although anecdotal, many surgeons have reported performing gastric invagination on dogs with good success and minimal complications. Dr. John Williams, a respected and experienced surgeon in the United Kingdom, wrote in a book chapter: “Gastric invagination is a quick, safe, and effective technique.”3 Personally, I have performed the technique on only a few dogs over the years but they have done well and did not develop bleeding ulcers.

As with most controversial issues common sense probably lies somewhere in the middle ground. The accepted technique for treating necrotic stomach is partial gastrectomy. Stay sutures are placed around the necrotic area, the tissue removed and the stomach closed with a double layer inverting suture pattern (Cushing followed by Lembert patterns).

However, invagination could be considered in these situations:
  • The surgeon’s skills and facilities do not allow for a properly performed partial gastrectomy,
  • The dog is not stable under anesthesia and the surgery needs to progress quickly,
  • The necrotic area is relatively small and well demarcated,
  • PDS or similar suture is available for the closure,
  • Appropriate postoperative monitoring and care can be administered.
The invagination is begun by placing a continuous inverting suture
(Cushing pattern) with 2-0 PDS grabbing healthy tissue at the dotted lines.
This is the same dog as above after completing the invagination
with a second layer of inverting suture (Lembert pattern)

Here are a few other considerations. If invagination is performed, monitor the dog postoperatively for evidence of bleeding ulcer or other issues such as peritonitis. Also, treat the dog with gastric protectants like Sucralfate and antacids such as famotidine. These drugs should be continued for at least 1 month postoperatively.

Additional observations: If the the short gastric vessels have been ruptured or thrombosed as a result of the GDV, the spleen may also be infarcted and may have to be removed. Also, I have not had good success with stomach stapling for partial gastrectomy. Problems with delayed healing and leakage have been my experience and that of others.  The stomach tissue tends to be quite thick and I think the staples may not always properly engage and appose the tissues, particularly in dogs with GDV.

1. MacCoy DM, Kneller SK, Sundberg JP, Harari J. Partial invagination of the canine stomach for treatment of infarction of the gastric wall. Vet Surg 1986, 15:3, 237-245.

2. Parton AT, Volk SW, Weisse C. Gastric ulceration subsequent to partial invagination of the stomach in a dog with gastric dilatation-volvulus. J Am Vet Med Assoc. 2006 Jun 15;228(12):1895-900.

3. Williams JM. Gastric dilatation and volvulus. In: Williams and Niles, editors BSAVA Manual of Canine and Feline Abdominal Surgery. British Small Animal Veterinary Association, 2005, pg. 80.