GDV SURGERY PUZZLE

RE: GDV SURGERY PUZZLE

Alistair Graham-Evans — Sat, 29 Jul 2017 13:34:52 GMT

Whatever the details of the original surgery, the dog survived which is always a great achievement in these cases and I would be letting the owner know that whatever technique was used it saved the dog's life on that occasion. It certainly sounds complicated as it continued to bloat and be unwell. It will be interesting to see what happens in the future and if it is comfortable after the latest surgery.

I would be interested to know what type of pexy people are doing now.

My prophylactic ones are simple incisional. My emergency ones are tube pexies because they are reasonably quick, easier to do with no surgical assistant, give me access to the stomach if needed post-op and have always worked. What is the demand and supply of prophylactic ones and is there any good statistical data of their success?

RE: GDV SURGERY PUZZLE

J G Wray — Sat, 29 Jul 2017 08:09:16 GMT

[quote user="Robin Grimmer"]That's exactly my point. That's what the OP should have done.[/quote]

I have made this point often enough in the past. This thread is not a discussion purely about the medical/surgical management of this case. The clients' concerns and Dr Mellor's worries have been clearly articulated as well and have become indistinct from the purely professional discussion. There is a mix here. That is a problem, because this is beginning to look like a discussion of case management in all its aspects without at least two key elements, the participation of any of the original protagonists, clients or vets and all the circumstances and facts. That's the definition of a kangaroo court, all protestation and indignation notwithstanding.

RE: GDV SURGERY PUZZLE

Alistair Graham-Evans — Fri, 28 Jul 2017 23:18:08 GMT

We do a prophylactic RIGHT paracostal gastropexy on high risk dogs. Can do with 5 - 7 cm skin incision and gastroscopy aided. Same site as I would put a feeding tube. Always inform owner that dog can still get seriously ill with bloat which should still be treated as an emergency and can still twist other organs.

Sounds as if the original surgeon was a bit confused - I would have told owner that there are lots of different techniques for pexy which implies that none are perfect , that they can still re-bloat, and original surgeon may be interested in feedback.

RE: GDV SURGERY PUZZLE

Robin Grimmer — Fri, 28 Jul 2017 20:18:50 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Robin Grimmer"] Then contact VDS before being too judgmental of the other vet with the client. (But it sounds like it might be a bit late for that.)[/quote]

Why be judgmental of the other vet with the client at all? Why not resist the temptation to be a busybody, and keep your lip buttoned?

[/quote]

That's exactly my point. That's what the OP should have done.

RE: GDV SURGERY PUZZLE

Evelyn Barbour-Hill — Fri, 28 Jul 2017 19:36:44 GMT

[quote user="Robin Grimmer"] Then contact VDS before being too judgmental of the other vet with the client. (But it sounds like it might be a bit late for that.)[/quote]

Why be judgmental of the other vet with the client at all? Why not resist the temptation to be a busybody, and keep your lip buttoned?

RE: GDV SURGERY PUZZLE

Robin Grimmer — Fri, 28 Jul 2017 15:36:50 GMT

I agree with JGW, in a case like this, by all means post on here, but after you have spoken to the vet(s) who did the original surgery. I would have a frank and honest discussion with them, saying exactly what you found and give them a chance to explain their side. Then contact VDS before being too judgmental of the other vet with the client. (But it sounds like it might be a bit late for that.)

RE: GDV SURGERY PUZZLE

Neil Wheadon — Fri, 28 Jul 2017 11:44:43 GMT

[quote user="Chris Milligan"]I had the displeasure recently of opening a re-torsed GDV after an older technique had been performed where the stomach had been sutured into the midline closure and the stomach had fistulated through the muscle and was leaking contents into the subcutaneous space. I also nearly cut the gastric artery on the way in. Fun times![/quote]

This is commoner than you may think. We were warned about this at Vets Now

Even if done properly they can still torsion again

Good luck approaching the original vet (if you do)

Remember this though

If 8 vets are in a lift, they will all press the button as they feel the other 7 can't do it properly

Neil

RE: GDV SURGERY PUZZLE

Chris Milligan — Fri, 28 Jul 2017 10:47:16 GMT

[quote user="Jill Butterworth"] It's not entirely beyond the realms of credibility, if you use the LDA analogy..[/quote]

sorry but it is - the only reason to do a left-sided gastropexy is in weird cases caused by certain types of diaphragmatic hernias and oesophageal complications. I agree there have been many techniques posited over the years but the accepted standard in surgical practice now is a generally a right-sided technique anchoring the pylorus to the abdominal wall ventrolaterally, usually at the level of the 12th rib. Anchoring the body does not keep the stomach from retorsing and anchoring on the left side can promote abnormal stomach positioning leading to gastric reflux and/or pyloric outflow obstruction.

I had the displeasure recently of opening a re-torsed GDV after an older technique had been performed where the stomach had been sutured into the midline closure and the stomach had fistulated through the muscle and was leaking contents into the subcutaneous space. I also nearly cut the gastric artery on the way in. Fun times!

As for the flank approach...your guess is as good as anyone's - not a technique I've ever heard of before.

However you do make a very salient point Jill - that this dog survived and even if it is a screw-up it can be fixed. Everyone makes lots of mistakes, but the key is not to make the same one twice. And it never hurts to check a reference before embarking on something like this.

RE: GDV SURGERY PUZZLE

Lucy Fleming — Thu, 27 Jul 2017 16:25:04 GMT

I've heard of a paracostal approach being used for a prophylactic gastropexy, but as far as I'm aware that would still be on the right. I don't know any other details so not sure if it would be useful for an actual GDV.

RE: GDV SURGERY PUZZLE

Beats — Tue, 25 Jul 2017 19:42:36 GMT

[quote user="Andrew Mellor"]the pexy site looked to have stretched into quite a thin band and the stomach had flipped over[/quote]

FWIW I've seen this once before a number of years ago with a right-sided pexy done 7 years previously (by another vet) on an Irish Setter IIRC. After being decompressed on 2 sequential evenings by the boss, I re-pexied it the third night and did fine.

You can do a left-sided flank approach when placing a gastrostomy tube (for feeding purposes) - if tube gastropexy done for GDV however traditionally would be done on the right I believe (I'm sure a surgery textbook can confirm/refute this)

RE: GDV SURGERY PUZZLE

Evelyn Barbour-Hill — Tue, 25 Jul 2017 17:45:57 GMT

[quote user="Anthony Todd"]

[quote user="Anthony Todd"]Not really provided, it is reasoned, justified and fair; it's the anonymous, unjustified, one star that must be stamped out![/quote]

Would "not justified in any way" clarify it better??

[/quote]

No.

RE: GDV SURGERY PUZZLE

Anthony Todd — Tue, 25 Jul 2017 16:54:24 GMT

[quote user="Anthony Todd"]Not really provided, it is reasoned, justified and fair; it's the anonymous, unjustified, one star that must be stamped out![/quote]

Would "not justified in any way" clarify it better??

RE: GDV SURGERY PUZZLE

vs0u — Tue, 25 Jul 2017 16:39:43 GMT

No comment on the technique used, but I remember being taught that recurrence is a recognised complication even after gastropexy

RE: GDV SURGERY PUZZLE

Anthony Todd — Tue, 25 Jul 2017 16:33:39 GMT

[quote user="Bob Russell"]No naming and shaming that I can see. That would be inappropriate for a site such as this.[/quote]

Not really provided, it is reasoned, justified and fair; it's the anonymous, unjustified, one star that must be stamped out!

RE: GDV SURGERY PUZZLE

Bob Russell — Tue, 25 Jul 2017 16:19:50 GMT

Clearly a technique that did not work in this case! Any failure should be assessed and learned from if possible even if it was not the poster that performed the procedure.

The OP seemed perfectly acceptable to me. It was a question regarding a technique that the poster had not seen before.

No naming and shaming that I can see. That would be inappropriate for a site such as this.

(Might make an exception for pricey special sea water or magic crystals or cushions that bring the dead back to life. Probably not even then).

RE: GDV SURGERY PUZZLE

Andrew Mellor — Tue, 25 Jul 2017 16:01:11 GMT

yes I could, if I had sat and thought about it, but I do have genuine concerns about the profession and it's leaders/ teachers.

RE: GDV SURGERY PUZZLE

J G Wray — Tue, 25 Jul 2017 15:38:35 GMT

[quote user="Andrew Mellor"]That is exactly why I asked the question here , there are members of the profession from all corners of the globe on this forum and as procedures are often done differently in different parts of the world I was keen to find out if this was normal practice anywhere.[/quote]

Do you think you could have done this without mentioning the context of what actually worried you?

[quote user="Andrew Mellor"]Vets that do own OOH, perform by a young vet supervised by Advanced practitioner in small animal practice - this is what worries me.[/quote]

RE: GDV SURGERY PUZZLE

Andrew Mellor — Tue, 25 Jul 2017 13:38:17 GMT

That is exactly why I asked the question here , there are members of the profession from all corners of the globe on this forum and as procedures are often done differently in different parts of the world I was keen to find out if this was normal practice anywhere.

to answer a question about how the stomach had twisted when there was a pexy in place. the pexy site looked to have stretched into quite a thin band and the stomach had flipped over between oesothagus and this left side pexy position. I wonder if all pexy sites stretch , I cannot remember in the last few decades going back into a pexy dog - for any reason and having a chance to see the pexy months or years later . does anyone else have experience of seeing a pexy site after time has passed?

Also who routinely does a splenectomy on these cases to reduce the swing of the stomach?

RE: GDV SURGERY PUZZLE

Anthony Todd — Tue, 25 Jul 2017 11:44:34 GMT

[quote user="J G Wray"]Are there any of the veterinary surgeons at your OOH support practice, or their friends for that matter, on this forum?[/quote]

I hope they are!

Probably the most important function of this forum is so that everyone can learn as much as possible without fear or favour.

RE: GDV SURGERY PUZZLE

J G Wray — Tue, 25 Jul 2017 07:23:03 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Jill Butterworth"] Before you and the client judge too harshly, remind yourself that the dog survived his or her treatment that night, even if their subsequent prevention plan didn't work.[/quote]

The client may be judging, but there's no reason for you to get involved at all. Refrain from interference or comment, whatever you might be thinking.

[/quote]

Are there any of the veterinary surgeons at your OOH support practice, or their friends for that matter, on this forum?

RE: GDV SURGERY PUZZLE

Evelyn Barbour-Hill — Mon, 24 Jul 2017 23:52:34 GMT

The client may be judging, but there's no reason for you to get involved at all. Refrain from interference or comment, whatever you might be thinking.

RE: GDV SURGERY PUZZLE

Jill Butterworth — Mon, 24 Jul 2017 22:21:45 GMT

I've posted to another emergency forum, and they haven't heard of what you are describing either...

RE: GDV SURGERY PUZZLE

Niall Taylor — Mon, 24 Jul 2017 21:24:05 GMT

[quote user="Andrew Mellor"]... she had 180 degree twist on opening her ventrally, stomach repositioned, original surgeon had done gastropexy to left abdominal wall from body of stomach.[/quote]

How did it manage to do a 180 rotation with a pexy in place? I struggle with how useful a left sided pexy would be. I thought the whole point was to fix the position of the pyloris.

[quote user="Andrew Mellor"]perform by a young vet supervised by Advanced practitioner in small animal practice[/quote]

What exactly is the advanced practitioner's area of expertise? You need to speak direct to the vets concerned (after speaking to VDS first). At the very least they need to know the technique hasn't worked in this case.

I've never done or heard of a flank approach for a GDV and I've never seen a left side pexy recommended on its own.

Keep us posted,

Niall

RE: GDV SURGERY PUZZLE

Jill Butterworth — Mon, 24 Jul 2017 16:09:45 GMT

Tread carefully. Can you try to speak to the vet who did the surgery, in a benign, interested way, as there may be some new things being recommended at the coal face, as these cases are such high risk at the best of times, and of relapse. Maybe they were so confident of no torsion and early diagnosis, they decompressed and pexied.. It's not entirely beyond the realms of credibility, if you use the LDA analogy...All kinds of recommendations have been tried and changed over the years and some people have probably developed their own idiosyncrasies. I worked with a vet who used a teaspoon, I even know of vets who recommended it prophylactically at spay. When I qualified, pexy with a foley catheter and open granulation was recommended till too many were rotted by stomach acid, then fundus plication was in fashion... Before you and the client judge too harshly, remind yourself that the dog survived his or her treatment that night, even if their subsequent prevention plan didn't work. That happens to the best of surgeons, occasionally...

RE: GDV SURGERY PUZZLE

Emily Rainbow — Mon, 24 Jul 2017 16:07:44 GMT

I would probably ring original vet and inform them of what's happened and see if they offer an explanation. If not a call to VDS might be needed for advice.