VETER NER CERRAH DERG S 61
Gastric Emptying of Nondigestible Radiopaque Markers After Modified Circumcostal Gastropexy in the Dog (Modifiye Sirkumkostal Gastropexy Yöntemi Uygulanan Köpeklerde Gastrik Bo almanın Sindirilemeyen Radyopak Maddelerle Gösterilmesi) ARICAN, M.1, EROL, M.1, UYARO LU, A.1, KÖYLÜ, Ö.2, TURGUT, K.3 1
Department of Surgery, Faculty of Veterinary Science, University of Selçuk, Konya 2 Department of Biochemistry Faculty of Internal Medicine University of Selçuk, Konya 3 Department of Internal Medicine Faculty of Veterinary Science, University of Selçuk, Konya Veteriner Cerrahi Dergisi (2004), 10 (1-2), 61-65
ÖZET Gastrik dilatasyon-volvulus (GDV); acil medikal ve cerrahi müdahaleye ihtiyaç duyan, etiyolojisi tam olarak bilinmeyen, hayati öneme sahip, öldürücü, akut bir sendromdur. Bazı hekimler tarafından, sirkumkostal gastropeksi tekni i, gerginli i koruması açısından gastrik dilatasyon-volvulus’un cerrahi yönden sa latımı için en iyi teknik olarak bildirilmi tir. Gastrik bo alma zamanlarının belirlenmesi için radyopak materyallerin katı gıdalarla alınmasını takiben, mideyi terk etme zamanları gösterecektir. Bu çalı mada, modifiye edilerek hazırlanan radyopak maddelerin kullanılması köpeklerdeki sirkumkostal gastropeksi sonundaki gastrik bo alma zamanlarını belirledi. Bu çalı manın amacı sirkumkostal gastropeksi operasyonu sonucu sindirilemeyen modifiye radyopak materyallerin kullanılarak gastrik bo alma zamanlarını belirlemektir. Sonuç olarak, Modifiye sirkumkostal gastropeksi operasyonu, teknik açıdan kolay ve çabuk uygulanabilir. Operasyonu takiben 3.günde gastrik bo almayı engellemedi i gösterilmi tir. Modifiye sirkumkostal tekni in cerrahi ve profilaktik amaçlar için kullanabilece i önerilmi tir. Anahtar Kelimeler: Köpek, gastrik dilatasyon, sirkumkostal gastropeksi, gastrik bo alma.
SUMMARY Gastric dilatation and volvulus are acute and often fatal disease syndrome of uncertain aetiology that requires rapid medical and surgical intervention. Circumcostal gastropexy has remained the favored technique by some surgeons because of its superior strenght. Early investigations noted that the movement of radiopaque particles from the stomach correlated with gastric emptying of solid food particles. In this article, using of modified nondigestible radiopaque markers to document gastric emptying in dogs after modified circumcostal gastropexy operations. The aim of the study, to document gastric emptying, some blood count and serum chemistry in dogs after modified circumcostal gastropexy of using modified nondigestible radiopaque markers. As a conclusion, modified circumcostal gastropexy is technically simple and quick. Thus, It does not delate any gastric emptying 3 days after operation procedure. Modified circumcostal gastropexy could be suggested for approaching of both surgical and prophylactic purposes. Key Words: Dogs, gastric dilatation, circumcostal gastropexy, gastric emptying.
INTRODUCTION Gastric dilatation and volvulus (GDV) are acute and often fatal disease syndrome of uncertain aetiology that requires rapid medical and surgical intervention [10, 11, 13, 23, 25, 26]. Many fixation techniques of the stomach to nearby structures have been described. These are included, gastropexy, tube gastrostomy, fundic gastropexy, gastrocolopexy, circumcostal gastropexy, belt loop gastropexy and many more [3, 4, 9]. All of these methods advantages and disadvantages have been documented. However, it is imperative that the operative time is minimised in order to limit surgical and anaesthetic stress to the patient. Numerous surgical techniques have been developed to reduce the rate of GDV recurrence, which is estimated to be as high as 80 % in cases in which a gastropexy technique has not been performed [2, 5, 27]. In the 1970s a tube gastropexy technique was commonly used [5]. In the 1980s, the incisional gastropexy and circumcostal gastropexy techniques gained popularity [18]. More recently other muscle flap techniques, such as belt-loop gastropexy and ventral line gastropexy have been come popular [19, 20, 28]. Circumcostal gastropexy is widely accepted and preferential technique by some surgeons because of its superior strenght, but the procedure is time consuming and can result in serious complications such as perforation of the stomach and diaphragm [6, 18, 22, 29]. Indigestible solid particles have been used as a measure of gastric emptying for decades in people suspected to have motility defects [8]. Early investigations noted that the movement of radiopaque particles from the stomach correlated with gastric emptying of solid food particles
62 VETER NER CERRAH DERG S [24]. Recently, reserachers have used bariumimpregnated polyethylene spheres (BIPS) to measure gastric emptying of solids in dogs [12, 21]. The BIPS are mixed with a meal and gastric emptying time is calculated from serial radiographic examinations [21]. The aim of the study, to document gastric emptying, some blood count and serum chemistry in dogs after modified circumcostal gastropexy of using modified nondigestible radiopaque markers.
MATERIALS and METHODS Skeletally mature 6 dogs used were of unselected breed, ages, both sexes and weighed between 15 + 5 kg. The absence of gastrointestinal diseases was confirmed by clinical examination. The operation procedures were carried out by quarantine and conventional health measures. The animals were anesthesized with intramusculer Xylazine hydrochlorid (Rompun, Bayer 23.32 mg/ml). And initially, it was entubated for 4% halotone and carried out 1.5-2 % halotone during the operation. After experiments, all animals were healty and returned back to the animals research facilities. Heparinised venous blood samples were obtained from each dogs under sterile conditions for times before and 3 days, 10 days and 21says after operation. Some blood count (Hct, Hb), blood gas analyses and serum chemistry (Na+, K+, Ca++, Cl-) were measured with ABL 555 Blood Gas System (Radiometer,Copenhagen). Circumcostal gastropexy Once prepared for aseptic surgery, they were positioned in dorsal recumbency for laparotomy. A skin incision made from the xiphoid to the prepuce in males and from the xiphoid to midway between the umbilicus and the pubis in females. The subcutaneus tissue and fascia were incised, and the peritoneal cavity was entered through an incision in the linea alba. The falciform ligament was incised and retracted to the right to provide wide visualization and good access to the last palpable rib on the right and to allow adequate visibility of the diaphragmatic insertion. The last palpable right rib, usually the 11th or 12th, was visualized by reflecting the most cranial part of the linea alba and attached falciform ligament with the left hand and pulling it laterally and dorsally. This maneuver created a 4 to 6 cm distance between the linea alba and gastropexy site. A 3-cm long incision was made with scalpel over the rib through the transversus abdominis muscle. Care was taken to identify and avoid the diaphragmatic insertion. A 3-cm wide tunnel was then created by sharp dissection around the lateral aspect of the rib. Allis tissue forceps were passed through the tunnel in a lateromedial directionend the seromusculer layer of the stomach in the pyloric antrum region was grasped. The forceps were then pulled back through the tunnel in a mediolateral direction and a 3-cm width of stomach wall was wrapped around the rib. At this point, a surgical assistant held the allis forceps with left hand and the linea alba with the right hand. Then the surgeon held the allis forceps without incisions serosa to serosa apposed using 0-1 absorbable monofilament suture material (Polyglactin 910, Vicryl, Ethicon). The
suture was always passed deep enough to grasp the submucosal layer on both sides of the wrap but did not enter the gastric lumen. The laparotomy incision was then closed routinely. Postoperative considerations After the surgical procedure, the cardiovasculer functions as well as electrolyte and acid-base status are monitored closely. Patients were not fed orally for 3 days; during this time, they receive a balanced electrolyte solution intravenously, at a rate of 90 mL/kg per day. Oral feeding is institude after 3 days with small portions of food offered five times daily, initially as a soup and later as a paste. Test Meal A gastric emptying study was conducted once in each dog. Food was with held from dogs for 18 hours before each study, which was carried out in the morning. Water was offered ad libitum. Additional for water was not offered during the course of the radiographic study, and sedation was not used. Preprandial radiography was performed to confirm that the stomach was empty. Ten small radiopaque markers were placed on a size 0.5 cm diameter and 0.7 cm lenght gelatin capsule and were administered during solid-food (25 g / kg Sportmix 速) meal. Gelatin capsules were used to facilitate ingestion and passage of the radiopaque markers into the stomach. Subsequent radiography revealed markers in the food within the stomach. Radiographic methods Ventrodorsal abdominal radiographs were taken once two hour for during twelve hours to make dogs swallow the ideal containing radiographic markers. First radiograph was just taken after the dogs fed with Sportmix速. Ventrodorsal abdominal radiographic views were obtained in dogs when gastric emptying of markers was considered to be totaly complete. Statistical analysis of gastric emptying Percent gastric emptying is calculated for each radiograph by counting the number of gelatin capsules remaining in the stomach and those that have passed out of the stomach. The formula used is as follows:
Mar ke r out x 100 Mar k er out + Mar k er in The times at which 100 % gastric emptying of markers was observed in dogs Statistical Analysis The data were analysed using the Wilcoxon-Rank test (Minitab).
RESULTS Clinical evaluation Dogs were examined after surgery at least once daily and monitored for complications at 21 days. Results of the study indicated that the technique was feasible and easy
VETER NER CERRAH DERG S 63 for approach. Median total surgery time was 30 minutes (range 25-35 minutes); complications were not encountered during surgery or recovery from anesthesia. Because dogs rested quitely and did not have signs of pain, additional analgesics were not administered after recovery from anesthesia. All dogs appeared clinically normal on the morning after surgery. Skin sutures were removed 10 days after surgery. Gastric emptying Gastric emptying times are shown in table 1. The times course of gastric emptying of radiopaque particles mixed with a standardized solid meal in six
dogs before modified circumcostal gastropexy, 100 % gastric emptying time were recorded within 4 hours. Gastric emptying was delayed 3 days after circumcostal gastropexy when the animals start to fed with soup meals. Dogs subjected to circumcostal gastropexy surgery had 100 % gastric emptying times similar to those of control dogs 10 days and 21 days after surgery. Serum chemistry profile Some blood count, blood gas analyses and serum chemistry levels in dogs are shown in table 2.
Table 1. The 100 % gastric emptying time (hour) of radiopaque particles fed with a solid meal in dogs before and after surgery A Control dogs Before gastropexy Hour
Number of Dogs
B Three days after Circumcostal gastropexy Hour
C Ten days after Circumcostal gastropexy Hour
D Twentyone days after Circumcostal Gastropexy Hour
1
2
12*
6
4
2
4
10*
4
4
3
4
10*
6
4
4
4
8*
4
2
5
4
6*
4
4
6
4
8*
6
4
* p< 0.05 A & B * control & 3 days after circumcostal gastropexy A&C control & 10 days after circumcostal gastropexy A&D control & 21 days after circumcostal gastropexy
Table 2. Some blood count and serum chemistry profile in dogs with control and after circumcostal gastropexy Control (mean+ SD) pH pCO2
7,36+0.27
10.days after circumcostal gastropexy
21.days after circumcostal gastropexy
(mean+ SD)
(mean+ SD)
7,37+0.06
7,34 +0.06
7,38+0,04
46,67+4,74
39,63+5,23
43,3+6,50
45,47+3,37
Hct
%
44,33+7,28
41,17+15,12
41,17+4,36
41,17+2,79
Hb
g/dL
14,42+2,34
13,33+4,80
13,47+1,52
15,45+0,78
+
mmHg
3.days after circumcostal gastropexy (mean+ SD)
mmol/L
153,38+3,93
162,90+7,40
146,13+1,79 *
150,40+2,12
mmol/L
3,62+0,24
2,95+0,21 *
3,52+0,55
3,64+0,17 b
mmol/L
0,93+0,15
0,56+0,09 *
0,69+0,2
0,79+0,07
Glu
mg/dL
87,33+13,52
98,67+12,50
86,67+8,59
84,17+9,85
BE
mmol/L
1,82+1,90
3,12+3,22
5,05+2,56
1,90+1,14
HCO-3
mmol/L
26,93+2,44
23,47+4,33
23,95+5,92
25,73+2,03
Clor
mEq/L
106,00+0,63
106,67+5,24
109,00+7,85
108,17+2,71
Na K+ Ca
++
* p<0.05 control & 3 days after circumcostal gastropexy control & 10 days after circumcostal gastropexy control & 21 days after circumcostal gastropexy
64 VETER NER CERRAH DERG S Sodium levels are decreased dogs 10 days after circumcostal gastropexy compare with control dogs before gastropexy, 10 days and 21 days after modified circumcostal gastropexy (p<0.05). Potasium and calcium levels are decreased dogs 3 days after circumcostal gastropexy compare with control dogs (p<0.05). Blood count (Hct,Hb) and some serum chemistry (Cl-, glucose, acid-base status) markers were not shown any significant differences compare with before and after gastropexy operations.
DISCUSSION The goal of any gastropexy is to permanently fix the stomach to the abdominal wall in an anatomic position that prevents stomach rotation. Obviously the best technique is quick and safe and provides an adequate permanent adhesions. The advantages of the classic circumcostal gastropexy are that it is stronger than the tube and incisional gastropexy does not require prolonged hospitalization, and eliminates the risk of the removing a gastrostomy tube [9]. Also classic circumcostal gastropexy does not impair gastric motility [4, 14, 16, 17, 22]. In this study, using of modified circumcostal technique is less time-consuming and easier to perform than the original technique. In the original technique it can be difficult to create the two flaps, and the gastric lumen can be easily perforated especially in dogs with a thin and distended gastric wall. Degna et al., (2001) [6] mentioned similar result of their study. Clinical evaluation of dogs show that they were examined after surgery at least once daily and monitored for complications during the study. Complications were not encountered during surgery or recovery from anesthesia. Modified circumcostal techniques are safe to use for dogs with GDV problems. On the other hand, another study suggested that the circumcostal gastropexy procedure also does not cause major alterations in gastric electrical and contractile activities [1, 7, 15]. The noninvasive radiographic technique used to assess gastric emptying in our study was easily performed, economical and acceptable to the dogs. Hall et al., (1992) [16] suggested that Radioisotopic methods are well tolerated and if available, provide the most accurate means of evaluating gastric emptying. In this study, markers 0.5 cm in diameter and 0.7 cm long were used. Therefore, we predicted that the radiopaque particles would pass in the fed state along with the meal. On the basis of visual inspection of radiographs most of these markers passed with food in the fed state. However, some of the particles remained in the stomach after food had passed. Total gastric emptying time in dog, using mini chunks meals (25 g / kg Sportmix速). A bariummeal contrast procedure was reported to range from 5 to 10 hours in one study and 7- 15 hours in another study. Because the rate of gastric emptying of a meal can be predicted on the basis of energy density and initial meal volume. In this study, dogs subjected to modified
circumcostal gastropexy surgery had 100 % gastric emptying times similar to those of control dogs 10 days and 21 days after surgery. The other important finding in the study was that circumcostal gastropexy does not appear to alter gastric emptying in experimental dogs. Eventhough, thus, circumcostal gastropexy could be recomended as prophylactic surgery in healty dogs of breeds prone to develop GDV, because abnormalities of gastric emptying are unlikely as a result of the surgery. In the study, hypokalemia and hypocalcaemia have been seen 3 days after circumcostal operation. Hypokalemia is the most common electrolyte abnormality, resulting from excessive loss of potasium because of anorexia. Hypocalcemie could be result of delayed of gastric emptying of 3 days after circumcostal gastropexy. So, decrease level of calcium and potassium concentrations were became normal levels when the dogs fed orally with small portions of food. During the study, we have not seen any cardiac arrhythmias, this could be indicate that modified circumcostal gastropexy was not effect in electrolyte concentration imbalances and acid-base abnormalities. As a conclusion, modified circumcostal gastropexy is technically simple and easily learned. The method is rapid, does not prolong the surgical time, and keeps duration of anesthesia as short as possible. The integrity of the gastropexy site easily can be assessed radiographically. Any complication has not been seen after operations. Thus, it does not delate any gastric emptying 3 days after operation procedure. Therefore, modified circumcostal gastropexy could be suggested for approaching of both surgical and prophylactic purposes.
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