Gastric Dilatation and Volvulus: Stabilization and Surgery

Gastric Dilatation and Volvulus: Stabilization and Surgery
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Desiree Rosselli, DVM, DACVS (Small Animal), VCA West Los Angeles Animal Hospital, Los Angeles, California

Gastric dilatation and volvulus (GDV) is an acute, life-threatening disorder in dogs, characterized by abnormal twisting of the stomach on its mesenteric axis, with subsequent gastric gas accumulation and distention. Sequelae of GDV can include decreased venous return to the heart, hypovolemia, gastric ischemia, systemic hypotension, myocardial injury, portal hypertension, shock, sepsis, and disseminated intravascular coagulation.


Large and deep-chested dog breeds are considered to be the most at risk for GDV, including the German shepherd, Great Dane, standard poodle, Saint Bernard, Doberman pinscher, Irish setter, and Weimaraner.1 Even medium- and small-breed dogs with a deep chest conformation, including shar-peis, basset hounds, and cocker spaniels, can develop GDV. Most patients are middle-aged to older, and incidence of GDV increases with increasing age.2 The most commonly reported potential risk factors for GDV are listed in Box 1.2–9

BOX 1 Risk Factors Associated With Development of GDV2–9
  • Large- or giant-breed dog
  • Deep chest conformation (increased thoracic depth-to-width ratio)
  • Increasing age
  • Familial history, particularly having a first-degree relative with a history of GDV
  • Previous episode of gastric dilatation
  • Preexisting gastrointestinal disease or gastric foreign body
  • History of previous splenectomy
  • Large volume of food fed once daily
  • Eating a meal quickly
  • Dry dog food
  • Eating from a raised food bowl
  • Anxiety or stress

Clinical signs can include restlessness or pacing along with nonproductive vomiting or retching. Ptyalism, abdominal distention, weakness, or collapse may be observed. Dogs can present anywhere on a spectrum of clinical signs, from alert and wagging their tail, with normal pulse quality and only mild abdominal distention, to collapsed, in decompensated shock, or even dead.10


Abdominal radiography, particularly the right lateral projection, is diagnostic for GDV. A healthy dog typically has no gas in the pylorus in right lateral recumbency. Conversely, in a dog with GDV, the stomach is dilated with gas, and radiography depicts the hallmark sign of compartmentalization (the “double bubble”) that signifies craniodorsal displacement of the pylorus, as shown in Figure 1. Ideally, an orthogonal projection (dorsoventral view) is also acquired, depending on patient stability. Presence of pneumoperitoneum suggests gastric rupture.

Ideal blood analysis consists of complete blood count, serum chemistry, and a coagulation profile. Efficiently obtaining the results from these diagnostic tests is sometimes not possible; therefore, point-of-care assessment is often more practical: packed cell volume/total solids; blood glucose; and venous blood gas, including electrolytes and lactate. Lactate, a marker of hypoperfusion and anaerobic metabolism, has been evaluated as a prognostic tool in patients with GDV. Study findings are summarized in Table 1.11–14 Overall, higher lactate values are more suggestive of gastric necrosis and have a negative correlation with survival, particularly if hyperlactatemia does not substantially improve after fluid resuscitation. Regardless of the lactate value, surgical intervention is always recommended.

Table 1 Prognostic Variables Associated With Plasma Lactate

de Papp et al, 199911; 102 dogs99% survival with lactate <6 mmol/LMedian lactate was 6.6 mmol/L in dogs with gastric necrosis
58% survival with lactate >6 mmol/LMedian lactate was 3.3 mmol/L dogs without gastric necrosis
Zacher et al, 201012; 64 dogs23% survival with final lactate >6.4 mmol/L
10% survival with absolute change in lactate ≤4 mmol/L
15% survival with percentage change in lactate ≤42.5%
Green et al, 201113; 84 dogsSignificant relationship with initial lactate <4.1 mmol/L for predicting survival Significant relationship with initial lactate >2.9 mmol/L for predicting gastric necrosis
Decrease in lactate ≥50% in 12 h was good indicator for survival
Beer et al, 201314; 78 dogsInitial lactate ≥7.4 mmol/L was 88% accurate for predicting outcomeInitial lactate ≥7.4 mmol/L was 82% accurate for predicting necrosis

Blood pressure and electrocardiography (ECG) are useful diagnostic tools to assess patient stability, monitor effectiveness of volume resuscitation, and evaluate for cardiac arrhythmias (see Preoperative Treatment and Stabilization).

Thoracic radiographs can also be obtained in the preoperative period. Historically, this has been recommended in older patients to check for thoracic metastasis or other comorbidities, particularly if owners are having difficulty deciding whether to pursue surgery. One study found a negative association between survival and the presence of cardiomegaly, despite a low incidence of pulmonary nodules, demonstrating the prognostic utility of preoperative thoracic radiography.15


For most patients, especially those that are severely affected, stabilization and treatment must be performed before or in conjunction with diagnostic testing. Immediate treatment goals are correction of hypovolemia and gastric decompression. Box 2 summarizes therapeutic measures to consider during stabilization of a patient with GDV.

BOX 2 Therapeutic Measures for Stabilization of Dogs With GDV
  • IV fluids: balanced isotonic crystalloids with or without colloids, hypertonic saline
  • Gastric decompression: orogastric intubation or percutaneous trocharization
  • Analgesia: pure mu agonist opioid
  • Antibiotics: broad-spectrum, particularly in patients with suspected gastric necrosis
  • Antiarrhythmics if needed, lidocaine: can also serve as a free radical scavenger
  • Consider procainamide or sotalol if lidocaine is ineffective
  • Oxygen supplementation: particularly in patients with poor perfusion measures
  • Fresh frozen plasma: for patients with prolonged coagulation times
  • Drugs that reduce reperfusion injury: unknown efficacy

Prompt vascular access is obtained with large-gauge, short IV catheters (16 or 18 gauge). Cephalic veins or jugular veins should be used because of the lack of blood flow from the caudal half of the body. Initial volume resuscitation with a balanced isotonic crystalloid solution is recommended. Initial fluid volumes should be administered in rapid boluses of one-third to one-quarter shock volumes. Monitoring perfusion parameters (Box 3) after fluid boluses is important in assessing response to therapy. Additional fluid boluses and addition of synthetic colloid boluses or hypertonic saline may be required, depending on individual patient needs.

BOX 3 Parameters to Monitor for Effectiveness of Fluid Resuscitation
  • Mentation
  • Heart rate
  • Peripheral pulse quality
  • Mucous membrane color
  • Capillary refill time
  • Blood pressure
  • Lactate

Gastric decompression should be performed as soon as possible. This can be achieved by passing a smooth-surfaced orogastric tube or via percutaneous trocharization. When an orogastric tube is passed in an awake patient, sedation (with a pure mu agonist opioid) is typically required, as is holding the patient’s mouth open with a roll of tape or gauze between the incisor teeth. Alternatively, the orogastric tube can be passed with the patient under general anesthesia; the presence of an endotracheal tube will help limit the risk for accidental aspiration of gastric contents.

Before an attempt to pass a gastric tube, the tube should be lubricated and premeasured to the level of the last rib. Twisting the tube when slight resistance is felt can facilitate passage of the tube into the stomach; however, caution must be used to avoid perforating the esophagus. When passing the gastric tube is difficult, decompression via trocharization may facilitate passage. After successful passage of the tube, observation of hemorrhage or mucosal tissue in the gastric contents can provide an index of suspicion of gastric necrosis and mucosal sloughing.

Trocharization can be performed in an awake or anesthetized patient: To perform trocharization, an area of skin on either side of the cranial dorsolateral abdomen should be clipped and aseptically prepared before puncture of the skin, body wall, and stomach with a large-bore needle (ie, 14 gauge) or over-the-needle catheter. The site of greatest distention or greatest tympany can be used. Gas and liquid may escape; pressure can be applied to the body wall to facilitate decompression.

A rationale exists for the use of antibiotics in patients with GDV: there is the presumed risk for bacterial translocation with gastric mucosal compromise and increased mucosal permeability, as well as venous stasis and poor hepatic perfusion, likely resulting in inhibition of reticuloendothelial function.

Ventricular arrhythmias are reported in up to 40% of dogs with GDV; therefore, continuous ECG should be monitored.1 Ventricular arrhythmias that could decrease cardiac output or develop into ventricular fibrillation (specifically, ventricular tachycardia, R-on-T phenomenon, or multiform ventricular premature contractions) should be treated with IV lidocaine boluses initially, followed by a constant rate infusion if the bolus is successful in converting the rhythm to a sinus rhythm. If lidocaine is not successful in converting the rhythm, procainamide or sotalol can be administered (Box 2).

Other therapeutic modalities to consider include oxygen supplementation, especially in patients with signs of poor perfusion; fresh frozen plasma transfusion if indicated based on prolonged coagulation times or evidence of disseminated intravascular coagulation; or dextrose supplementation if a patient is hypoglycemic from septic shock. There may be a role for pharmacologic methods to reduce reperfusion injury, but consistent data on their efficacy are lacking.16

When possible, complete fluid resuscitation (characterized by normalization of perfusion measures listed in Box 3) should be attempted before surgery because increased time from presentation to surgery has been associated with a lower mortality rate.17 Survival is positively affected by the time spent adequately stabilizing the patient; however, surgery should always be performed in a timely manner to limit the duration of splenic and gastric ischemia.

General anesthetic protocols vary depending on patient status; anesthetic agents that are arrhythmic or cardiac depressants should be avoided. Typical premedications consist of a pure mu agonist opioid and a benzodiazepine, induction agents (such as etomidate or propofol), and an inhalant to maintain anesthesia. Monitoring of response to treatment and adjusting fluid therapy accordingly are still crucial during the intraoperative period.

Survival is positively affected by the time spent adequately stabilizing the patient; however, surgery should always be performed in a timely manner to limit the duration of splenic and gastric ischemia.


Surgery has 3 goals:

  1. Reposition the abnormally positioned stomach. Typically, a clockwise volvulus has occurred; therefore, the fundus can be pushed dorsally while pulling the pylorus ventrally and toward the right.
  2. Critically evaluate the abdominal viscera. Allow time for organs to reperfuse, and confirm correct gastric positioning. If necessary, perform partial gastric resection or splenectomy to remove necrotic tissue.
  3. Perform a right-sided gastropexy to create a permanent adhesion between the pyloric antrum and the adjacent right body wall.

Gastric Repositioning

A ventral midline celiotomy is performed. Adequate exposure is essential and the incision should extend from xiphoid to pubis. When the surgeon first enters the abdomen, the greater omentum is usually covering the stomach and should be gently retracted. Derotation of the stomach is facilitated by decompressing the gas distention, either by the anesthetist passing an orogastric tube or by the surgeon evacuating the air with a large-gauge needle. The typical direction of volvulus is clockwise, with rotation of 180° to 270° being most common. In most cases, the stomach can be repositioned with the surgeon standing on the dog’s right side to push the fundus dorsally and to the dog’s left while simultaneously gently pulling the pylorus (located on the left initially) ventrally and toward the surgeon on the right.

After repositioning, confirmation of normal gastric position is crucial. Although rare, a counterclockwise volvulus or a rotation through a rent in the splenic mesentery is possible, so the surgeon should always verify correct stomach positioning via careful observation and palpation of the gastroesophageal junction.

Evaluation of Abdominal Viscera

There is often free peritoneal blood due to avulsion of the short gastric arteries and veins when the stomach distends and rotates. Bleeding has typically ceased by the time of surgery, but if hemorrhage is ongoing, these vessels should be ligated.

It is important to allow time for organs to reperfuse after gastric repositioning and before performing splenectomy or partial gastrectomy. The stomach should be palpated for any evidence of foreign material,4 and the entire stomach, especially the greater curvature and dorsal aspect, should be carefully evaluated for necrosis. Gastric necrosis is reported in 13% to 20.5% of patients.1,17–19 Necrotic areas can be identified by their black, grey/white, or green serosal color; thin texture on palpation; or lack of serosal capillary perfusion. If gastric necrosis is present, placement of stay sutures in visibly normal tissue helps to manipulate the stomach, plan gastric resection, and limit potential spillage of gastric contents into the abdomen.

Partial gastrectomy can be performed via resection and hand-sewn 2-layer closure or by using surgical stapling equipment. All nonviable tissue should be resected; normal tissue will have bleeding from the cut surface, particularly the muscularis layer. The appearance of the mucosal tissue should not be used to guide resection. The limiting factor for the surgeon’s ability to perform resection is the anatomic location of necrosis and concern for esophageal lumen diameter, specifically when necrotic areas involve the cardia and esophagus.

The need for splenectomy because of irreversible vascular devitalization or thrombosis is reported in approximately 16% to 22% of patients.17–19 A nonviable spleen has a spongy texture, lack of pulse in the splenic artery, and a black or grey color that does not improve after gastric repositioning. Splenectomy may be performed using ligation, stapling equipment, or vessel sealant devices.

Right-Sided Gastropexy

A gastropexy is the creation of a permanent adhesion between the stomach at the level of the pyloric antrum and the adjacent right body wall. Numerous techniques for performing right-sided gastropexy for GDV are described, including incisional, belt-loop, circumcostal, ventral incision/incorporating, stapled, tube, and laparoscopic assisted. For successful adhesion formation, the muscular layers of the body wall and the stomach should be joined. Achieving an anatomically correct gastropexy is important to prevent potential complications, such as gastric outflow obstruction.20 No study has compared all the different techniques simultaneously; however, these techniques reportedly have similar rates of morbidity, adhesion formation, strength, and recurrence.21–23

Technique for Right Incisional Gastropexy

Right incisional gastropexy is the most commonly performed technique because of its technical ease, low risk of morbidity, no need for additional instrumentation, and effective production of a permanent adhesion.24 The site of gastropexy is first planned by manually apposing the stomach to the body wall to ensure an anatomically appropriate site. To aid in visualization, the Balfour retractor can be removed, and assistants standing on the right side of the dog can retract the abdominal wall with towel clamps or Army-Navy retractors. The surgeon can change position at the table and stand on the dog’s left side for improved access for suturing.

An incision is made along the right body wall, completely through the transversus abdominis muscle. The incision can be oriented vertically or horizontally, as demonstrated in Figure 2. It is important for the incision to be located caudal to the last rib to prevent penetration of the diaphragm and subsequent pneumothorax. The incision should be located dorsal enough to be in an anatomic position, as well as to avoid interference with abdominal closure or decrease risk for inadvertent damage to the stomach if future laparotomy is performed.

Next, an incision of similar length is made in the seromuscular layer of the stomach at the level of the pyloric antrum. A location on the stomach without visible vasculature is chosen. Figure 3 demonstrates the completed incision and the ability to appreciate the difference between the seromuscular layer and the underlying mucosa/submucosal layer.

Two rows of sutures are placed, typically in simple continuous fashion, beginning at the craniodorsal aspect of the respective incisions, as demonstrated in Figure 4. The deep edge of the transversus abdominis incision is sutured to the deep edge of the gastric seromuscular incision, with care taken to make wide bites (at least 3 mm) on each side. Typical suture choice is a 2-0 monofilament long-lasting absorbable suture material. After completion of the first suture line, a second suture line is performed in identical fashion to oppose the superficial or ventral aspect of the respective incisions. The completed gastropexy is shown in Figure 5.




Without gastropexy, the rate of recurrence of GDV is 55% to 75%, and median survival times are significantly shorter than for patients treated surgically.10,21,25 Therefore, surgery should always be recommended. In two studies,26,27 the rate of recurrence of GDV after gastropexy was 0%, but recurrence has been documented rarely.10,28 Occurrence of gastric dilatation after gastropexy is reported as 5% to 11%.21,25–27


Postoperative treatment is typically a continuum of care from pre- and intraoperative therapy. Continued volume resuscitation may include IV isotonic crystalloids (90–120 mL/kg/day); colloids, such as hydroxyethyl starch (10–30 mL/kg/day); and fresh frozen plasma or other blood products, depending on individual patient needs. For analgesia, injectable opioids are recommended. Nonsteroidal anti-inflammatory drugs are avoided because of the decreased gastric perfusion associated with GDV and the high possibility of gastric ulcers. Gastroprotectants, such as sucralfate, histamine-2 receptor antagonists, or proton-pump inhibitors, can be administered. Antibiotic administration for 2 to 3 days after surgery is often indicated based on the presumed risk for bacterial translocation.

Postoperative monitoring includes blood pressure, urine output, and emesis watch. Gastric atony and delayed gastric emptying can occur after gastric dilatation, so antiemetics or prokinetics can be administered if vomiting or regurgitation is observed postoperatively. Continuous ECG should be closely monitored because more than half to three-quarters of patients experience postoperative arrhythmias within the first 12 to 24 hours after surgery,17,19 although not all patients require antiarrhythmic therapy. Repeated blood analysis and electrolyte measurement help to guide fluid therapy. Rechecking coagulation profiles may be warranted in patients at risk for disseminated intravascular coagulation.

Food and water may be offered several hours after surgery to an awake, alert patient.


Animals treated surgically for GDV have an overall 10% to 28% mortality rate.1,10,16–19 Poor prognostic indicators include the following:

  • Lactate level not responding to fluid resuscitation12,13
  • Need for splenectomy17–19
  • Gastric necrosis and need for partial gastrectomy1,10,16–18
  • Preoperative arrhythmias17,18
  • Increased time between clinical signs and admission16,19
  • Severity of physical condition at the time of presentation10
  • Hypotension at any time during hospitalization19
  • Peritonitis or sepsis19
  • Disseminated intravascular coagulation19


The immediate goals of stabilization of a patient with GDV are fluid resuscitation to correct hypovolemia and gastric decompression to make the patient as stable as possible for anesthesia. Surgical goals are prompt gastric repositioning, critical evaluation of the abdominal viscera, and right-sided gastropexy. With timely surgery, the prognosis for most patients is fair. Negative prognostic indicators include gastric perforation, the need for splenectomy and partial gastrectomy, lactate levels that do not respond to fluid resuscitation, and preoperative arrhythmias.

Desiree Rosselli, DVM, DACVS (Small Animal), is a surgeon at VCA West Los Angeles Animal Hospital. She received her doctor of veterinary medicine degree from the University of California Davis. She completed a rotating internship at the University of Wisconsin-Madison, a surgical specialty internship at Dallas Veterinary Surgical Center, and a residency in small animal surgery at the University of Georgia. Following her residency, she was employed as a clinical instructor at the University of Georgia.



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eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Provides practical, peer-reviewed articles focused on the latest diagnostic and treatment techniques to enhance your knowledge and confidence.&lt;/div&gt;' id='choice_6_15_4' /> <label for='choice_6_15_4' id='label_6_15_4'>Today's Veterinary Practice eNewsletter<br><div style="font-size: 12px; color: #808080;">Provides practical, peer-reviewed articles focused on the latest diagnostic and treatment techniques to enhance your knowledge and confidence.</div></label> </li><li class='gchoice_6_15_5'> <input name='input_15.5' type='checkbox' value='VetFolio eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Discover online CE resources offered in a variety of formats including videos, podcasts, webinars and more.&lt;/div&gt;' id='choice_6_15_5' /> <label for='choice_6_15_5' id='label_6_15_5'>VetFolio eNewsletter<br><div style="font-size: 12px; color: #808080;">Discover online CE resources offered in a variety of formats including videos, podcasts, webinars and more.</div></label> </li><li class='gchoice_6_15_6'> <input name='input_15.6' type='checkbox' value='Partner Emails&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Exclusive deals and information from our partners.&lt;/div&gt;' id='choice_6_15_6' /> <label for='choice_6_15_6' id='label_6_15_6'>Partner Emails<br><div style="font-size: 12px; color: #808080;">Exclusive deals and information from our partners.</div></label> </li></ul></div></li><li id='field_6_19' class='gfield gfield_html gfield_html_formatted field_sublabel_below field_description_below gfield_visibility_visible' ><br></li><li id='field_6_22' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' >Do you want to be added to our postal mailing list?</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_22'><li class='gchoice_6_22_1'> <input name='input_22.1' type='checkbox' value='Yes, I love mail!' id='choice_6_22_1' /> <label for='choice_6_22_1' id='label_6_22_1'>Yes, I love mail!</label> </li><li class='gchoice_6_22_2'> <input name='input_22.2' type='checkbox' value='No thank you.' id='choice_6_22_2' /> <label for='choice_6_22_2' id='label_6_22_2'>No thank you.</label> </li></ul></div></li><li id='field_6_10' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' >Please provide your mailing address below.<span class='gfield_required'>*</span></label> <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_6_10' > <span class='ginput_full address_line_1' id='input_6_10_1_container' > <input type='text' name='input_10.1' id='input_6_10_1' value='' aria-required="true"/> <label for='input_6_10_1' id='input_6_10_1_label' >Street Address</label> </span><span class='ginput_full address_line_2' id='input_6_10_2_container' > <input type='text' name='input_10.2' id='input_6_10_2' value='' /> <label for='input_6_10_2' id='input_6_10_2_label' >Address Line 2</label> </span><span class='ginput_left address_city' id='input_6_10_3_container' > <input type='text' name='input_10.3' id='input_6_10_3' value='' aria-required="true"/> <label for='input_6_10_3' id='input_6_10_3_label' >City</label> </span><span class='ginput_right address_state' id='input_6_10_4_container' > <input type='text' name='input_10.4' id='input_6_10_4' value='' aria-required="true"/> <label for='input_6_10_4' id='input_6_10_4_label' >State / Province / Region</label> </span><span class='ginput_left address_zip' id='input_6_10_5_container' > <input type='text' name='input_10.5' id='input_6_10_5' value='' aria-required="true"/> <label for='input_6_10_5' id='input_6_10_5_label' >ZIP / Postal Code</label> </span><span class='ginput_right address_country' id='input_6_10_6_container' > <select name='input_10.6' id='input_6_10_6' aria-required="true"><option value='' selected='selected'></option><option value='Afghanistan' >Afghanistan</option><option value='Åland Islands' >Åland Islands</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Anguilla' >Anguilla</option><option value='Antarctica' >Antarctica</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Aruba' >Aruba</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Bouvet Island' >Bouvet Island</option><option value='Brazil' >Brazil</option><option value='British Indian Ocean Territory' >British Indian Ocean Territory</option><option value='Brunei Darussalam' >Brunei Darussalam</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Cayman Islands' >Cayman Islands</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Christmas Island' >Christmas Island</option><option value='Cocos Islands' >Cocos Islands</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the</option><option value='Congo, Republic of the' >Congo, Republic of the</option><option value='Cook Islands' >Cook Islands</option><option value='Costa Rica' >Costa Rica</option><option value='Côte d&#039;Ivoire' >Côte d&#039;Ivoire</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Curaçao' >Curaçao</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)</option><option value='Ethiopia' >Ethiopia</option><option value='Falkland Islands' >Falkland Islands</option><option value='Faroe Islands' >Faroe Islands</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='French Guiana' >French Guiana</option><option value='French Polynesia' >French Polynesia</option><option value='French Southern Territories' >French Southern Territories</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Gibraltar' >Gibraltar</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guadeloupe' >Guadeloupe</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guernsey' >Guernsey</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Heard and McDonald Islands' >Heard and McDonald Islands</option><option value='Holy See' >Holy See</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Isle of Man' >Isle of Man</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jersey' >Jersey</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macau' >Macau</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Martinique' >Martinique</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mayotte' >Mayotte</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Montserrat' >Montserrat</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Caledonia' >New Caledonia</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Niue' >Niue</option><option value='Norfolk Island' >Norfolk Island</option><option value='North Korea' >North Korea</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Norway' >Norway</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine, State of' >Palestine, State of</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Pitcairn' >Pitcairn</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Réunion' >Réunion</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Barthélemy' >Saint Barthélemy</option><option value='Saint Helena' >Saint Helena</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Martin' >Saint Martin</option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia' >Serbia</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Sint Maarten' >Sint Maarten</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='South Georgia' >South Georgia</option><option value='South Korea' >South Korea</option><option value='South Sudan' >South Sudan</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Timor-Leste' >Timor-Leste</option><option value='Togo' >Togo</option><option value='Tokelau' >Tokelau</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Turks and Caicos Islands' >Turks and Caicos Islands</option><option value='Tuvalu' 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