Routine Surgery is Not Always Routine.

Even though my human partner is a vet, she does not like doing surgery on her own animals. I have heard that this is true for human doctors, too--not wanting to practice on their own family. Anyway, my person took me to the veterinary hospital where she works, to have a spay and a gastropexy. I knew what it meant to be spayed, but I had never heard of a gastropexy, so I kept my ears open while my partner was telling her husband what it was. She explained that it is a procedure that is done to "tack" the stomach to the body wall, to prevent that really dangerous situation where the stomach fills with air and then twists--called gastric dilatation with volvulus, or GDV, for short. (See these two previous posts: http://ginnypuppysdogjournal.blogspot.com/2008/05/bloat-mother-of-all-emergencies.html and http://ginnypuppysdogjournal.blogspot.com/2008/03/surprising-bloat-prevention-findings.html) A gastropexy is "standard procedure" after repositioning the stomach during GDV surgery. As she said, it is much better to do this as an elective procedure than in an emergency, when a dog is in critical condition. So..... I was taken in for "routine surgery." My two humans took this opportunity for a trip out of town for a few days, figuring that I was going to have to be separated from them anyway.

Little did they know that my surgery was going to be anything but routine. Here's the story, as I experienced it. Any gaps in my memory were filled in by hearing my two humans discuss everything later, when I turned out to be fine. Apparently, the surgery had gone fine and I was soon back in a recovery cage, getting intravenous fluids and morphine. At some point, someone saw that I was bleeding more from my incision more than I should be and that my gums looked a little pale. My blood pressure was also too low. Someone checked my hematocrit (red blood cell percent) and saw that it had dropped. My surgeon got worried that I was bleeding somewhere and took me back to surgery. Apparently, he saw a disturbing amount of blood in my abdomen, most likely related to the spay procedure, but no obvious "bleeders." The gastropexy site was not bleeding at all. They ran some blood clotting tests and, even though my clotting times were normal, my blood platelets were a little lower than normal. Platelets form the initial plug on which a blood clot attaches. Anyway, my condition was stable overnight and during the next day, but by that night, my blood count had dropped little lower, so they gave me a blood transfusion. The other complication that was occuring at this time was a type of heart arrhythmia called "accelerated idioventricular rhythm," that occurs rather commonly after an episode of hypotension (low blood pressure). It resembles a string of premature beats called VPC's (or PVC's), but is actually not serious unless the heart rate is extremely fast. Nevertheless, it concerned my surgeon enough that I was put on a continuous IV infusion of antiarrhythmic medication. I gather that everyone was very worried about me, but I didn't know this until later. I was getting pain medicine, so I was pretty happy. I just slept a lot and waited for my people to come back to get me.

They finally came back and all was right with the world again. There was one more blood test they were waiting for, to see if my platelets had a defect caused by something called von Willbrand's Disease. The next week, when that test came back normal, my partner did some other test that involved pricking the inside of my lip with something, to see how long it took to stop bleeding. I guess that was normal, too, because after that, everyone had decided that there was nothing wrong with my platelets. I overheard my partner talking with one of the other doctors. Both seemed to agree that the "routine spay" on a large breed, mature female dog (which I guess I am) was sometimes anything but routine.

~ ~ ~

Oh, yeah........ In case anyone is wondering---I'm fine now.

"Bloat - The Mother of All Emergencies"

Ginny thought that this was a very important article to post. It was published on VeterinaryPartner.com In order to view the excellent images that go along with this article, go directly to the web address listed below.

Title: Bloat - The Mother of All Emergencies
Source: The Pet Health Care Library
Authors:
Address (URL): http://www.VeterinaryPartner.com/Content.plx?P=A&A=672

There are many injuries and physical disorders that represent life-threatening emergencies. There is only one condition so drastic that it overshadows them all in terms of rapidity of consequences and effort in emergency treatment. This is the gastric dilatation and volvulus - the bloat.

What is it and Why is it so Serious?

The normal stomach

The normal stomach sits high in the abdomen and contains a small amount of gas, some mucus, and any food being digested. It undergoes a normal rhythm of contraction, receiving food from the esophagus above, grinding the food, and meting the ground food out to the small intestine at its other end. Normally this proceeds uneventfully except for the occasional burp.

In the bloated stomach, gas and/or food stretches the stomach many times its normal size, causing tremendous abdominal pain. For reasons we do not fully understand, this grossly distended stomach has a tendency to rotate, thus twisting off not only its own blood supply but the only exit routes for the gas inside. Not only is this condition extremely painful but it is also rapidly life-threatening. A dog with a bloated, twisted stomach (more scientifically called gastric dilatation and volvulus) will die in pain in a matter of hours unless drastic steps are taken.

What are the Risk Factors for Developing Bloat?

Classically, this condition affects dog breeds that are said to be deep chested, meaning the length of their chest from backbone to sternum is relatively long while the chest width from right to left is narrow. Examples of deep chested breeds would be the Great Dane, Greyhound, and the setter breeds. Still, any dog can bloat, even dachshunds and Chihuahuas. Dogs weighing more than 99 pounds have an approximate 20% risk of bloat

Classically, a dog who bloated had eaten a large meal and exercised heavily shortly thereafter. Still, we usually do not know why a given dog bloats on an individual basis. No specific diet or dietary ingredient has been proven to be associated with bloat. Some factors found to increase and decrease the risk of bloat are listed below:

Factors Increasing the Risk of Bloating Feeding only one meal a day Having closely related family members with a history of bloat Eating rapidly Being thin or underweight Moistening dry foods (particularly if citric acid is listed as a preservative) Feeding from an elevated bowl Restricting water before and after meals Feeding a dry diet with animal fat listed in the first four ingredients Fearful or anxious temperament History of aggression towards people or other dogs Male dogs are more likely to bloat than females Older dogs (7 - 12 years) were the highest risk group

Factors Decreasing the Risk of Bloat Inclusion of canned dog food in the diet Inclusion of table scraps in the diet Happy or easy-going temperament Feeding a dry food containing a calcium-rich meat meal (such as meat/lamb meal, fish meal, chicken by-product meal, meat meal, or bone meal) listed in the first four ingredients of the ingredient list. Eating two or more meals per day

Contrary to popular belief, the presence of cereal ingredients such as soy, wheat or corn in the first four ingredients of the ingredient list does not increase the risk of bloat.

In a study done by the Perdue University Research Group, headed by Dr. Lawrence T. Glickman:

The Great Dane was the number one breed at risk for bloat.

The St. Bernard was the number two breed at risk for bloat.

The Weimaraner was the number three breed at risk for bloat.

A study by Ward, Patonek, and Glickman reviewed the benefit of prophylactic surgery for bloat. Prophylactic surgery amounts to performing the gastropexy surgery (see below) in a healthy dog, usually in conjunction with spay or neuter. The lifetime risk of death from bloat was calculated, along with estimated treatment for bloat, versus cost of prophylactic gastropexy. Prophylactic gastropexy was found to make sense for at-risk breeds, especially the Great Dane, which is at highest risk for bloat.

How to Tell if Your Dog has Bloated

Radiograph showing typical gas distension of the stomach in a case of bloat The dog may have an obviously distended stomach, especially near the ribs, but this is not always evident depending on the dog's body configuration.

The biggest clue is the vomiting: the pet appears highly nauseated and is retching but little is coming up.
If this is seen, rush your dog to the veterinarian IMMEDIATELY.

What has to be Done

There are several steps to saving a bloated dogs life. Part of the problem is that all steps should be done at the same time and as quickly as possible.

First: The Stomach must be Decompressed
The huge stomach is by now pressing on the major blood vessels carrying blood back to the heart. This stops normal circulation and sends the dog into shock. Making matters worse, the stomach tissue is dying because it is stretched too tightly to allow blood circulation through it. There can be no recovery until the stomach is untwisted and the gas is released. A stomach tube and stomach pump are generally used for this but sometimes surgery is needed to achieve stomach decompression.

Also First: Rapid Intravenous (IV) Fluids must be Given to Reverse the Shock
Intravenous catheters are placed and life-giving fluid solutions are rushed in to replace the blood that cannot get past the bloated stomach to return to the heart. The intense pain associated with this disease causes the heart rate to race at such a high rate that heart failure will result. Medication to resolve the pain is needed if the patient's heart rate is to slow down. Medication for shock, antibiotics, and electrolytes are all vital in stabilizing the patient.

Also First: The Heart Rhythm is Assessed and Stabilized
There is a specific, very dangerous rhythm problem called a premature ventricular contraction or "PVC" that is associated with bloat and it must be ruled out. If it is present, IV medications are needed to stabilize the rhythm. Since this rhythm problem may not be evident until even the next day, continual EKG monitoring may be necessary. A disturbed heart rhythm that is already seen at the beginning of treatment is associated with a 38% mortality rate.

Getting the bloated dog's stomach decompressed and reversing the shock is an adventure in itself but the work is not yet half finished.

Surgery

All bloated dogs, once stable, should have surgery. Without surgery, the damage done inside cannot be assessed or repaired plus bloat may recur at any point, even within the next few hours and the above adventure must be repeated. Surgery, called gastropexy, allows the stomach to be tacked into normal position so that it may never again twist. Without gastropexy, the recurrence rate of bloat may be as high as 75%!

Assessment of the internal damage is also important to recovery. If there is a section of dying tissue on the stomach wall, this must be discovered and removed or the dog will die despite the heroics described above. Also, the spleen, which is located adjacent to the stomach, may twist with the stomach. The spleen may also need to be removed.

If the tissue damage is so bad that part of the stomach must be removed, the mortality rate jumps to 28 to 38%.

If the tissue damage is so bad that the spleen must be removed, the mortality rate is 32 to 38%.

After the expense and effort of the stomach decompression, it is tempting to forgo the further expense of surgery. However, consider that the next time your dog bloats, you may not be there to catch it in time and, according the study described below, without surgery there is a 24% mortality rate and a 76% chance of re-bloating at some point. The best choice is to finish the treatment that has been started and have the abdomen explored. If the stomach can be surgically tacked into place, recurrence rate drops to 6%.

Results of a Statistical Study

In 1993, a statistical study involving 134 dogs with gastric dilatation and volvulus was conducted by the School of Veterinary Medicine in Hanover, Germany.

Out of 134 dogs who came into the hospital with this condition: 10% died or were euthanized prior to surgery (factors involved included expense of treatment, severity/advancement of disease, etc.) 33 dogs were treated with decompression and no surgery. Of these dogs, 8 (24%) died or were euthanized within the next 48 hours due to poor response to treatment. (Six of these 8 had actually re-bloated) Of the dogs that did not have surgical treatment but survived to go home, 76% eventually had another episode of gastric dilatation and volvulus. 88 dogs were treated with both decompression and surgery. Of these dogs, 10% (9 dogs) died in surgery, 18% (16 dogs) died in the week after surgery, and 71.5% (63 dogs) went home in good condition. Of the dogs that went home in good condition, 6% (4 dogs) had a second episode of bloat later in life. In this study, 66.4% of the bloated dogs were male and 33.6% were female. Most dogs were between ages 7 and 12 years old. The German Shepherd dog and the Boxer appeared to have a greater risk for bloating than did other breeds.

(Meyer-Lindenberg A., Harder A., Fehr M., Luerssen D., Brunnberg L. Treatment of gastric dilatation-volvulus and a rapid method for prevention of relapse in dogs: 134 cases (1988-1991) Journal of the AVMA, Vol 23, No 9, Nov 1 1993, 1301-1307.)

Another study published December of 2006 looked at 166 dogs that received surgery for gastric dilatation and volvulus. The point of the study was to identify factors that led to a poor prognosis. A 16.2% mortality rate was observed. The mortality rate for dogs over age 10 years was 21%. Of the 166 going to surgery, 4.8% were euthanized during surgery, and the other 11.4% died during hospitalization (2 of dogs died during surgery). All dogs that survived to go home were still alive at the time of suture removal. 34 out of 166 dogs had gastric necrosis (dead stomach tissue that had to be removed). Of these dogs 26% died or were euthanized. Post-operative complications of some sort occurred in 75.9% of patients. Approximately 50% of these dogs developed a cardiac arrhythmia. Risk factors significantly associated with death prior to suture removal included clinical signs of bloating for greater than 6 hours before seeing the vet, partial stomach removal combined with spleen removal, need for blood transfusion, low blood pressure at any time during hospitalization, sepsis (blood infection), and peritonitis (infection of the abdominal membranes).

(Beck, J.J., Staatz, A.J., Pelsue, D.H., Kudnig, S.T., MacPhail, C.M., Seim H.B, and Monnet, E. Risk factors associated with short-term outcome and development of perioperative complications in dogs undergoing surgery because of gastric dilatation-volvulus: 166 cases (1992-2003). Journal of the AVMA, Vol 229, No 12, December 15, 2006, p 1934-1939.)

In is crucially important that the owners of big dogs be aware of this condition and prepared for it. Know where to take your dog during overnight or Sunday hours for emergency care. Avoid exercising your dog after a large meal. Know what to watch for. Enjoy the special friendship a large dog provides but at the same time be aware of the large dog's special needs and concerns.

Copyright 2007 - 2008 by the Veterinary Information Network, Inc. All rights reserved.

Surprising Bloat Prevention Findings

After I heard about a nasty disease that could kill me, I decided to listen very carefully to everything my people said about it. The disease is "Bloat" or Gastric-Dilatation-Volvulus syndrome (GDV). It can be a serious killer of large and giant breed dogs. After I heard my partner say that there were some new findings on prevention of GDV coming out of Purdue University's veterinary school, I made sure I found out what they were all about. Some of the findings were opposite to what I had originally learned. Here is the summary:

"Dietary Risk Factors for Gastric Dilatation-Volvulus (Bloat) in 11 Large and Giant Dog Breeds" http://www.vet.purdue.edu/epi/dietrisk.htm

(1) Having a raised food bowl increases the risk of bloat (GDV). This is opposite to what most people have thought in the past.
(2) If the dry food has fat listed in the first 4 ingredients, the risk of bloat is increased. In fact, one-third of all cases of bloat in this study could be attributed to feeding dry foods containing fat among their first 4 ingredients.
(3) The risk of bloat is increased dramatically if the dry food fed contained citric acid and was also moistened prior to feeding. Almost one-third of all cases in this study could be attributed to this.
(4) Dry foods containing a rendered meat meal with bone among the first four ingredients significantly decreased GDV risk.

Wow....This is pretty dramatic. My partner has told me that she has seen a lot of bloat cases in her life. If caught early, surgery can be very successful, but the studies on prevention have not been terribly helpful in the past.

Here is a list of articles about GDV: http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&DbFrom=pubmed&Cmd=Link&LinkName=pubmed_pubmed&LinkReadableName=Related%20Articles&IdsFromResult=15683769&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA