How many of you have treated dogs after bloat, gastric torsion, and subsequently gastropexy?
I have one dog that I treat for maintenance on a monthly basis who has had this sequelae of events. Almost every time, I find a stiff and tender spot in his mid to caudal thoracic spine and associated ribs. No matter what manual therapy techniques I try, it’s always still stiff and painful. Usually when I get to the point of thinking, “What am I doing wrong??” I remember that this dog has had a gastropexy and I wonder if that is part of his issue.
So, for this blog I wanted to go into this surgical technique and discuss my thoughts on the [unintended] consequences of this surgery as they relate to the musculoskeletal (and visceral) systems. I am also looking for YOUR feedback on the topic as well!
Okay, so here goes:
The VCA website has the following:
“In what situations might my veterinarian recommend a gastropexy for my dog?
There are two primary indications for gastropexy:
1) Prophylactic gastropexy. This is a gastropexy performed to prevent GDV [gastric dilatation and volvulus]. This surgery is often performed in high-risk young dogs, frequently at the time that they are spayed or neutered. Prophylactic gastropexy is most frequently recommended in Great Danes, though it may be considered in any high-risk breed. It is estimated that 40% of Great Danes will develop GDV at some point during their lifespan; prophylactic gastropexy significantly reduces this likelihood.
2) Gastric dilatation and volvulus. Dogs who develop GDV require emergency surgery to untwist the stomach and gastropexy is a component of this surgery. Once the stomach has been restored to its normal position, a gastropexy is performed to tack the stomach in place to prevent a recurrence. Gastropexy reduces the risk of recurrence from 55% to only 4%.”
That’s dandy. I’m not debating WHETHER it should be used or not, just looking into WHAT happens in the surgery and why I am always seeing the same thing in my one patient.
Here’s what the surgery looks like:
Essentially the scar tissue created by suturing the stomach to the abdominal wall helps to keep the stomach in place (to prevent flipping / torsions) in the future.
So, why is my patient always painful in the mid-caudal thoracic spine and associated ribs? And what can I do about it?
I can tell you that manual therapy directed to the spine and ribs does not change the symptoms.
My next thought was visceral manipulation… but the goal with visceral manipulation is to break down scar tissue to allow for normal visceral mobility and motility. That sounds counter intuitive to the purpose of the surgery. The same holds true for myofascial release techniques.
However, I am not content to do nothing! The dog has some pain and discomfort. What would be safe to do?
I think that working with visceral Motility (i.e. the way organs should move naturally within the body) could be beneficial. In this case, we would just have to expect that the abdominal wall is part of the stomach. So it all moves. The stomach should ‘roll’ from superior/lateral/posterior to interior/medial/anterior (According to the teachings of the Barral Institute). Try to feel it on yourself with your hand over your stomach (just inferior to the ribs on the left side of your upper abdomen). For visceral motility work, you just follow the movement with your hand. Nudge it if it’s not moving and/or the movement is not equal in the two phases.
Working on Mobility, I don’t think we can do that in these cases. While I'm skeptical that visceral manipulation could 'undo' the gastropexy, I'm just not content to start tugging and pulling at the stomach. (At least not for now...)
How about the nervous system? What can I do there? Is that why the ribs and thoracic spine are tender and stiff? Are they the messengers of the visceral system? From this perspective, my manual therapies to the vertebra and ribs should work… but they don’t. So, perhaps I need to target the nerves in a different way. I could try skin stretching (a more superficial version of myofascial release) as a way to impact the dorsal roots of the affected thoracic segments. So I would fix the skin at the level of the spinous process and stretch the skin away from that part, likely along the length of the rib. However, I could try a variety of secondary points: The diaphragm, the stomach itself, anywhere along the abdominal wall or transverse abdominus muscle. Again, this is just a way to affect the nervous system. I’m not trying to stretch out the scar tissue.
To target nerves, of course I could use my laser. And I typically do. However, maybe in addition to the spinal levels, I also need to target the stomach itself.
Let’s really put our thinking caps on. What nerves supply the stomach?
The stomach receives innervation from the autonomic nervous system:
- Parasympathetic nerve supply arises from the anterior and posterior vagal trunks, derived from the vagus nerve.
- Sympathetic nerve supply arises from the T6-T9 spinal cord segments and passes to the coeliac plexus via the greater splanchnic nerve. It also carries some pain transmitting fibres.
Okay… So, this takes me down the path of treating the vagus nerve. (I admit, I am having a wee bit of fun doing this lately with my GOLPP dogs!) How do we stimulate the vagus nerve? You can massage the sternomastoideus muscle (along where the vagus nerve travels) and you can play with the skin just behind and below the ears (near where the vagus nerve exist from the brainstem). This has all the makings of a great Four Leg Rehab Minute video!!
Okay, so that is all that I can come up with to help my patient (and yours). Let me know if you have experienced the same issue with your post-gastropexy dogs? And let me know if you have any other ideas for treatment??
I look forward to hearing from you!
Weir M & Barnette C. Gastropexy https://vcacanada.com/know-your-pet/gastropexy April 28, 2022.
Rawlings C. Incisional gastropexy to prevent and treat canine gastric dilatation-volvulus. Compendium. April 2013. https://vetfolio.s3.amazonaws.com/40/d5/8503e43f4e238cf968151a46ba64/gastropexy-gdv.pdf
Smeak D. A Quick and Easy Incisional Gastropexy, the “Smeakopexy. WSMVA Congress Proceedings, 2019. https://www.vin.com/apputil/project/DefaultAdv1.aspx?pId=24437&SAId=-1&id=9382694
The stomach. Teach Me Anatomy. https://teachmeanatomy.info/abdomen/gi-tract/stomach/ Accessed April 28, 2022.