Mastering Gastropexy: A Comprehensive Surgical Guide to Preventing and Managing Gastric Volvulus

Gastropexy is a surgical procedure primarily used to treat gastric volvulus, a condition where the stomach twists on its axis, leading to potentially life-threatening complications. It is also employed as a prophylactic measure in certain at-risk populations, such as large breed dogs prone to gastric dilatation-volvulus (GDV). In humans, gastropexy is most commonly performed to prevent recurrence of gastric volvulus or as an adjunct to other surgeries like bariatric procedures. This article delves into the indications, preoperative evaluation, contraindications, surgical techniques, postoperative care, possible complications, and recent advances in gastropexy.

Indications for Gastropexy

Gastropexy is indicated in several clinical scenarios:

1. Gastric Volvulus: The primary indication for gastropexy is gastric volvulus, a condition where the stomach twists along its longitudinal or mesenteric axis. This twisting can lead to obstruction, ischemia, and necrosis of the stomach, requiring immediate surgical intervention.
2. Gastric Dilatation-Volvulus (GDV) in Dogs: Although not common in humans, GDV is a significant concern in veterinary medicine, particularly in large breed dogs. Gastropexy is performed prophylactically during elective surgeries like spaying to prevent this life-threatening condition.
3. Recurrent Gastric Volvulus: Patients who have experienced one episode of gastric volvulus are at high risk for recurrence. Gastropexy is often performed to prevent future episodes.
4. Hiatal Hernia Repair: In some cases of hiatal hernia, particularly paraesophageal hernias, gastropexy is used to anchor the stomach and prevent herniation.
5. Bariatric Surgery: Gastropexy can be performed as an adjunct procedure during bariatric surgeries, such as gastric bypass, to secure the stomach and prevent complications.
6. Diaphragmatic Hernia Repair: Gastropexy may be indicated in the repair of diaphragmatic hernias to prevent recurrence of herniation.

Preoperative Evaluation

A thorough preoperative evaluation is essential to identify patients who would benefit from gastropexy and to optimize outcomes:

1. Patient History and Physical Examination: A detailed history and physical examination are crucial. Patients with a history of gastric volvulus, hiatal hernia, or other gastrointestinal issues should be evaluated for possible gastropexy.
2. Imaging Studies: Imaging studies, including X-rays, CT scans, and MRI, can help confirm the diagnosis of gastric volvulus or other conditions necessitating gastropexy. These studies also aid in planning the surgical approach.
3. Laboratory Tests: Basic laboratory tests, including complete blood count (CBC), electrolyte panel, and coagulation studies, should be performed to assess the patient’s overall health and readiness for surgery.
4. Cardiopulmonary Evaluation: Given the potential for significant intraoperative and postoperative complications, a thorough cardiopulmonary evaluation is necessary, particularly in older patients or those with comorbidities.
5. Nutritional Assessment: Malnourished patients or those with significant weight loss may require nutritional support before surgery to optimize healing and recovery.

Contraindications

While gastropexy is generally safe, certain contraindications must be considered:

1. Unstable Patients: Patients in severe shock or those with unstable vital signs may not be candidates for immediate surgery. Stabilization is necessary before proceeding with gastropexy.
2. Severe Comorbidities: Patients with severe cardiovascular or respiratory conditions may not tolerate surgery well and may require alternative management strategies.
3. Coagulopathy: Patients with bleeding disorders or those on anticoagulant therapy may need special consideration and management before undergoing gastropexy.
4. Previous Abdominal Surgery: Patients with significant abdominal adhesions from previous surgeries may have a higher risk of complications during gastropexy, necessitating careful planning and technique.

Surgical Techniques and Steps

Gastropexy can be performed using various techniques, depending on the clinical situation and the surgeon’s preference. Here, we discuss the most commonly employed techniques:

1. Open Gastropexy: The traditional approach involves an open laparotomy, where the stomach is sutured to the abdominal wall. This technique is often used in emergency settings or when other intra-abdominal conditions require open surgery.
   • Procedure: After gaining access to the abdominal cavity, the surgeon identifies the stomach and carefully mobilizes it. The seromuscular layer of the stomach is then sutured to the peritoneum or the posterior rectus sheath, securing the stomach in place. This prevents future rotation of the stomach, reducing the risk of volvulus recurrence.
2. Laparoscopic Gastropexy: Minimally invasive laparoscopic techniques have gained popularity due to their reduced postoperative pain and quicker recovery times.
   • Procedure: Laparoscopic gastropexy involves the use of small incisions and a camera to visualize the abdominal cavity. The stomach is mobilized, and sutures are placed to anchor it to the abdominal wall. Various methods, such as intracorporeal suturing or the use of tacks, can be employed.
3. Endoscopic-Assisted Gastropexy: In some cases, endoscopic techniques can be used to assist in gastropexy, particularly in patients who are not ideal candidates for open or laparoscopic surgery.
   • Procedure: Using endoscopic guidance, the stomach is manipulated and sutures are placed to secure it to the abdominal wall. This technique is less invasive but may be technically challenging.
4. Percutaneous Gastropexy: This technique involves placing sutures or tacks through the skin and into the stomach under imaging guidance.
   • Procedure: A needle is used to place sutures or tacks percutaneously, securing the stomach to the abdominal wall. This method is typically reserved for high-risk patients who cannot undergo more invasive procedures.

Postoperative Care

Postoperative care is crucial for a successful outcome following gastropexy:

1. Pain Management: Adequate pain control is essential. Nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, or regional anesthesia techniques like epidurals can be used.
2. Nutritional Support: Patients may require enteral or parenteral nutrition postoperatively, especially if there is a delay in the return of normal gastrointestinal function.
3. Monitoring for Complications: Close monitoring is necessary to detect complications such as infection, bleeding, or gastric perforation. Patients should be monitored for signs of abdominal pain, fever, or changes in vital signs.
4. Gradual Reintroduction of Diet: Once bowel function returns, a gradual reintroduction of oral intake should be started, beginning with clear liquids and advancing to a regular diet as tolerated.
5. Mobilization: Early mobilization is encouraged to reduce the risk of deep vein thrombosis (DVT) and promote recovery.

Possible Complications

While gastropexy is generally safe, complications can occur:

1. Infection: As with any surgical procedure, there is a risk of wound infection. Proper sterile technique and postoperative care are essential to minimize this risk.
2. Bleeding: Intraoperative or postoperative bleeding can occur, particularly in patients with coagulopathies or those on anticoagulant therapy.
3. Gastric Perforation: If the sutures or tacks penetrate too deeply, there is a risk of gastric perforation, which can lead to peritonitis and sepsis.
4. Recurrence of Gastric Volvulus: Although gastropexy is intended to prevent recurrence, in rare cases, patients may experience a recurrence of gastric volvulus, necessitating further surgical intervention.
5. Adhesions and Obstruction: Postoperative adhesions can lead to bowel obstruction, which may require additional surgery.

Different Techniques and Variations

Several variations of gastropexy exist, each with its advantages and disadvantages:

1. Belt Loop Gastropexy: This technique involves creating a loop of stomach wall tissue and suturing it to the abdominal wall. It provides a strong anchor but may be technically challenging.
2. Incisional Gastropexy: In this method, an incision is made in the stomach wall, and the edges are sutured to the abdominal wall. This technique is simple but may carry a higher risk of gastric perforation.
3. Tube Gastropexy: A feeding tube is placed through the stomach and secured to the abdominal wall. This method is often used in patients requiring prolonged enteral nutrition.
4. Circumcostal Gastropexy: The stomach is anchored around a rib, providing a secure fixation. This technique is less commonly used but may be considered in certain cases.

Prognosis and Outcome

The prognosis following gastropexy is generally good, with most patients experiencing a significant reduction in the risk of recurrent gastric volvulus. The success of the procedure depends on factors such as the underlying condition being treated, the patient’s overall health, and the surgical technique used.

1. Long-Term Outcomes: Most patients have favorable long-term outcomes, with a low risk of recurrence or complications. Regular follow-up is essential to monitor for any signs of recurrence or other issues.
2. Quality of Life: Patients typically experience an improvement in quality of life following gastropexy, particularly those who have suffered from recurrent gastric volvulus.
3. Cost-Effectiveness: Gastropexy is considered a cost-effective intervention, particularly in preventing the recurrence of life-threatening conditions like gastric volvulus.

Alternative Options

In some cases, alternative treatments to gastropexy may be considered:

1. Medical Management: For patients who are not surgical candidates, medical management with medications to control symptoms or prevent volvulus may be an option. However, this approach is generally less effective than surgery.
2. Endoscopic Techniques: Endoscopic techniques may be used to treat or prevent gastric volvulus in patients who cannot undergo surgery. However, these methods are less definitive and may require repeat interventions.
3. Observation: In some cases, particularly in asymptomatic patients with incidental findings of gastric volvulus, observation with close monitoring may be considered. This approach is generally reserved for high-risk patients or those with contraindications to surgery.

Average Cost

The cost of gastropexy varies depending on the surgical technique used, the patient’s location, and the healthcare facility. In general, laparoscopic gastropexy tends to be more expensive than open surgery due to the specialized equipment and expertise required. The cost may range from several thousand to tens of thousands of dollars, depending on the complexity of the case and the region.

Recent Advances

Recent advances in gastropexy include the development of minimally invasive techniques, such as laparoscopic and robotic-assisted surgery, which have improved patient outcomes by reducing recovery times and minimizing complications. Additionally, new materials for sutures and tacks, as well as advances in imaging techniques, have enhanced the safety and efficacy of the procedure.

Research is ongoing to refine these techniques and explore new indications for gastropexy, including its potential role in preventing other gastrointestinal disorders. Future developments may include the use of bioengineered tissues or advanced robotic systems to further improve the precision and outcomes of gastropexy.