Ch 95 Liver and biliary system Flashcards
Anatomy
- greater proportion of the liver’s mass lies to the right (3 : 2 in dogs)
- four lobes
(left medial and lateral, right medial and lateral, quadrate, and caudate caudate and papillary processes) - quadrate very attached to right medial
- right lateral lobe is usually fused at its base with the caudate lobe
attachments
- vena cava runs through the liver and is firmly attached
- coronary ligament attaches liver to diaphragm
- two right-sided triangular ligaments
- hepatorenal ligament (cuadate to right kidney)
- lesser omentum loosely surrounds the papillary process of the liver
blood supply
- hepatic artery provides ~20% of the blood volume and 50% of the oxygen supply
- portal vein supplies 80% of the blood flow and the remaining half of the oxygen
- hepatic artery usually divides into two to five branches that penetrate the different lobes (right lateral, right medial, left)
- cystic artery to the gallbladder originates from the left branch of the hepatic artery.
- portal vein is created by the confluence of the cranial and caudal mesenteric veins (+ splenic and gastroduodenal veins)
- canine: right and left main branch (+ central from left)
- feline: 3 main right, central, and left
epiploic foramen
- caudally by the mesoduodenum
- dorsally by the caudal vena cava
- cranially by the liver.
Temporary inflow occlusion > Pringle maneuver
biliary system
- canaliculi > interlobular ducts > lobar ducts > hepatic ducts as they exit the liver parenchyma
- hepatic ducts two to eight
- converge to form the common bile duct, which enters the duodenum at the major duodenal papilla
- first hepatic duct joins the cystic duct is the point at which the common bile duct commences
- gallbladder stores and concentrates bile and excretes
- ystic duct and common bile duct before entering the duodenum through the sphincter of Oddi
- major duodenal papilla 3 to 6 cm aboral to the pylorus.
Species Differences
dogs
- common bile duct enters the duodenum at the major duodenal papilla adjacent to, but not conjoined with, the pancreatic duct
- accessory pancreatic duct is actually the larger pancreatic excretory duct and enters at the minor duodenal papilla
cats
- common bile duct and pancreatic duct conjoin just before their entry into the duodenum
- only approximately 20% of cats have a smaller, accessory pancreatic duct
Physiology
- Synthesis and clearance of plasma proteins (albumin, globulins, coagulation proteins and enzymes, hypoalbuminemia does not occur until 70%-80% hepatic functional mass is lost)
- maintenance of carbohydrate and lipid metabolism (maintains plasma glucose concentrations through gluconeogenesis and glycogenolysis, store triglycerides)
- Almost all of the coagulation factors are synthesized in the liver (responsible for carboxylation of the vitamin K–dependent factors II, VII, IX, and X, anticoagulants and fibrinolytic agents)
- modifying immune function through its large reticuloendothelial system reserve
- production of bile and synthesis of certain hormones such as gastrin (80% of bilirubin is produced as a breakdown product of hemoglobin, Bile acids 10% is reabsorbed into the portal circulation)
- storage organ for a multitude of substances that include vitamins, fat, glycogen
- major clearance organ for many toxic metabolites such as ammonia
As few as 2% will hemorrhage spontaneously
Regenerative Capacity After Hepatic Resection or Injury
- experimental studies, normal dogs tolerated acute removal of 65% to 70% of total liver volume
- Mortality was not related to hepatic failure but portal hypertension
- near complete compensatory hypertrophy and hyperplasia on average is reached by 6 days
- Disruption in portal perfusion to the liver results in increased hepatic arterial perfusion
- In dogs, liver volumes increased 25% to 33% after portal vein branch embolization
- Biliary obstruction reduces portal blood flow and impedes hepatic regeneration
- Diabetes mellitus also impedes liver regeneration
Traumatic Biliary Tract Rupture
- most comon blunt abdominal trauma
- leakage almost always within the common bile duct or hepatic ducts; rarely from the gallbladder
- a force applied to the gallbladder leads to rapid emptying; simultaneous shearing force to the common bile duct or hepatic ducts
- ## tearing or avulsion injuries
Extrahepatic Biliary Obstruction
most common causes:
* pancreatitis,
* neoplasia,
* gallbladder mucoceles,
* cholangitis
* cholelithiasis
acute ligation in dogs > common bile duct dilatation and increase [bilirubin] within 24 to 48 hours > Dilatation of the loba ducts is by 4 to 6d.
pathophysiologic consequences of obstruction:
* hypotension (with lack of response to vasopressor agents)
* decreased myocardial contractility
* acute renal failure
* coagulopathies (including DIC)
* gastrointestinal hemorrhage
* delayed wound healing.
absence bile salts in GIT > bacterial overgrowth + endotoxin absorption
Bile Peritonitis
- Bile salts cause inflammation, hemolysis, and tissue necrosis (chemical peritonitis)
- Their hyperosmolality leads to significant fluid shifts from the vascular space into the peritoneal cavity > shock
- Bacterial infection profoundly worsens the pathology and subsequent prognosis (spetic bile peritonitis)
- partial or total absence of bile salt passage into the small intestine > not bind endotoxins > systemic endotoxemia
- common causes in dogs: trauma, necrotizing cholecystitis, and ruptured gallbladder mucoceles
Hepatobiliary Imaging
RADS
- Space-occupying lesions in the cranial abdomen
- Approximately 50% of canine choleliths and 80% of feline choleliths are radiopaque
ultrasoound
- focal or multifocal hepatic disease
- Color-flow Doppler can be used to evaluate hepatic vascular anomalies
- contrast-enhanced harmonic ultrasonography for hepatic neoplasms
- principal imaging modality for evaluation of the extrahepatic biliary tract
- normal diameter CBD ~ 3 to 4 mm in dogs and cats
- Monitoring the degree of obstruction over several days may be helpful (u/s may not be able to confirm patency)
- ID mucoceles and choleliths
Scintigraphy
- quantifying liver function and for diagnosis of cholestasis and extrahepatic biliary obstruction
- accumulate within the biliary tract and then pass into GIT within 3hr
CT/MRI
- can be used to try differentiate malignant/benign masses
- PSS
Endoscopic Retrograde Cholangiopancreatography
- Biliary and pancreatic ductal systems are imaged by retrograde injection of an iodinated contrast agent through the duodenal papillae.
- Minimally invasive stent placement
Preoperative Considerations for Hepatic Surgery - haemorrhage
Hemorrhage
- Preoperative evaluation of coagulation profiles, blood type, and cross-match
- essential for production of procoagulant (coagulation factors, fibrinogen, vitamin K, thrombopoietin) and anticoagulant (protein C, protein S)
- hepatic disease can increase risk for hemorrhage or thrombosis > most commonly associated with chronic hepatitis and cirrhosis
- approx. 50% have coag abnormalities
- clinical sequelae to prolonged coagulation times are unclear and an increased tendency for hemorrhage in dogs has not been demonstrated
- pretreatment with fresh whole blood, fresh frozen plasma, or vitamin K can be consdiered
Preoperative Considerations for Hepatic Surgery - hypoglycaemia
- uncommonly associated with end-stage liver disease
- Glucose supplementation considered undergoing extensive hepatectomy.
Preoperative Considerations for Hepatic Surgery - anaesthesia
- Drugs undergoing hepatic metabolism should be avoided (propofol, opiods, lignocaine)
- halothane has been demonstrated to have potential hepatotoxic effects (cf isofluorane)
- caudal thoracotomy, the anesthetist should be prepared to ventilate the patient.
Preoperative Considerations for Hepatic Surgery - bacteria
- bacteria/endotoxins normally removed via the liver’s mononuclear phagocytic system, primarily the Kupffer cells
- normal flora??: most common isolate was Clostridium perfringens, followed by Staphylococcus spp
- suspect isolates likely from GIT (e.coli, enteroccous, clostridium)
- suggested protocols
(1) fluoroquinolone, penicillin, and metronidazole
(2) fluoroquinolone and amoxicillin-clavulanate
(3) fluoroquinolone and clindamycin
Hemorrhage Control During Hepatic Surgery
- careful tissue handling and gentle dissection
- pressure
Products
- clips or staples
- gelatin sponge (Vetspon, gelfoam)
- oxidized regenerated cellulose (Surgicel)
- bovine collagen (Lyostypt)
- blood coagulant powder (bleedstop)
- cyanoacrylate glue
Inflow Occlusion With the Pringle Maneuver
- simultaneous compression of the portal vein and hepatic artery
- through the epiploic foramen into the omental bursa
- less than 20 minutes (dogs less tolerant of prolonged hepatic pedicle clamping.)
- Hemorrhage in dogs continues presumably via flow through the gastroduodenal vein of artery
Total Hepatic Vascular Exclusion
- occlusion of the suprahepatic and infrahepatic caudal vena cava + inflow occlusion
- cardiac return is dramatically reduced
Hepatic Artery Ligation
- intractable hemorrhage
- liver can remain viable with portal blood perfusion after hepatic artery ligation.
- gangrenous necrosis > antibiotics should be administered
- ligation should be limited to the lobar arteries
Liver Biopsy
- 3 to 12 portal triads can be obtained during sampling, diagnosis is likely to be reliable
- samples from multiple lobes are preferred
FNA
- fine needle aspirates agreed with histopathologic diagnosis in only 30%-50%
tru-cut
- 22% minor complication (relative hematocrit decrease > 10% with no required intervention)
- 6% major complication (requiring transfusion or fluid support, or resulting in death)
- prolonged APTT were also more likely to suffer complications
- Vagotonic shock has also been described in cats
- bile peritonitis
Open Surgical Technique
- suture fracture
- guillotine technique
- cup biopsy forceps
- vessel sealing device
- Biopsy punch (depths limited <1/2 the thickness of the lobe, gelatin sponge packed)
laparoscopic
- safe, effective technique for minimally invasive collection of high-quality specimens
- performed in isolation for a diffuse hepatopathy, a single instrument port will suffice in most cases
- 5-mm cup biopsy forceps
- tissue is grasped and gently twisted (or vessel sealing device or gelfoam)
- loop ligature to ligate the tip of the lobe before a biopsy sample
- conversion rates 1.9% to 4%
Partial Hepatic Lobectomy
Techniques
- blunt dissection with individual vessel sealing by cautery, Ligaclip, or ligation (iver capsule is first transected with a scalpel blade. The parenchyma is then separated by finger fracture or suction) > results in more blood loss compared to other tehecniques
- vessel sealing devices
- parenchymal and vascular crushing with thoracoabdominal staplers or encircling suture devices (surgitie).
Complete Hepatic Lobectomy
mortality?
tehcniques
- blunt dissection and suture ligation, s
- urgical stapling equipment,
- vessel sealing + ligation of larger vessels
approach to hilar dissection in dogs, advantageous in cases in which hepatic tumors encroach upon the liver lobe hilus
- most lobes had a single lobar portal vein and a single lobar hepatic vein.
- central division of the liver is best removed en bloc because of the anatomy
- AutoSuture TA 90 compared to dissection technique: dissection was slower, less complete, and more haemorrhage
- stapled lobectomies of the right and central liver division > a right paracostal incision can aid in placement of the stapling devices
- gallbladder can be removed with the lobe when necessary
staples
- 3.5-mm staples that close to 1.5-mm > vessels smaller than 1.5 mm may continue to bleed
- smaller: 30-mm long (2.5 mm closing to 1-mm diameter) in three rows
Surgitie
- no major intraoperative hemorrhages reported when at least two loops were placed before liver mass transection
Outcome
Acute mortality may be associated with hemorrhage, liver failure, or portal hypertension.
- if large resection planned, embolization initially to stimulate hepatic regeneration of the remnant liver
- portal vein arterialization via splenic arteriovenous shunting
transection of triangular ligaments facilitates mobilization of the lobe
relative hepatic volumes:
70% hepatectomy is considered the maximal achievable acute
- right lateral and caudate 28%
- right medial and quadrate 28%
- left lateral and medial lobes 44%
Regional Tumor Management: Hepatic Embolization and Ablation Techniques
- In people with nonresectable or metastatic hepatic tumors,
- Percutaneous tumor ablation techniques include radiofrequency ablation, microwave ablation, laser thermal ablation, cryoablation (for <4cm)
Intravascular techniques
- intra-arterial delivery of chemotherapy,
- transarterial embolization
- transarterial chemoembolization
- reduce tumor blood supply and oxygenation, and improve local tumor control
- tumors obtain 95% of their blood supply from the hepatic artery
Preoperative Considerations for Extrahepatic Biliary Tract Surgery
- Clinical icterus
- decreased albumin level; increased bilirubin, cholesterol, serum alkaline phosphatase (ALP), alanine aminotransferase (ALT), and γ-glutamyl transferase levels; and leukocytosis.
- coagulation disturbances can be highly variable in dogs with extrahepatic biliary obstruction
- effusion bilirubin concentration is >2x serum = bile peritonitis
Initial Patient Stabilization
- obstruction or peritonitis, often systemically compromised and require hemodynamic resuscitation
- isotonic crystalloid solution (lactated Ringer’s, Plasma-Lyte) +/- colloid
- Results of coagulation tests dictate the need for vitamin K1 supplementation or administration of fresh frozen plasma
antibiotic
- Positive culture results with extrahepatic biliary obstruction 17% to 39% of dogs
- 23% to 60% of dogs with gallbladder mucoceles
- 58% to 61% of bile peritonitis cases
- E. coli, Enterococcus spp., Enterobacter spp., Clostridium spp., and Bacteroides spp
- justified and important to collect samples for bacterial culture and sensitivity
- Intravenous antibiotic coverage should be initiated soon after diagnosis.
- second-generation cephalosporin (cefoxitin)
- Ampicillin to include Enterococcus spp
Decision Making in Extrahepatic Biliary Tract Surgery
The timing of surgery
- is debated.
- pancreatitis-induced obstruction, may improve with medical treatment
- small case series: cholecystocentesis may temporarily relieve the obstruction, but potential complications like bile leakage and peritonitis
- Surgical intervention is often recommended if hyperbilirubinemia and biliary tract distension worsen over 7-10 days.
- If hemodynamic compromise, biliary decompression should be done sooner.
CBD blocked
- If the common bile duct is blocked, a cholecystoenterostomy is preferred.
- Choledochoduodenostomy not recommended except with gallbladder necrosis and significant bile duct dilatation
- Biliary stenting when there is a reversible condition like pancreatitis or bile duct trauma
- can be done via celiotomy or endoscopically.
- cholecystostomy tube for temporary bile rerouting (pancreatitis cases where resolution is expected)
Cholecystectomy
- recommended for conditions like cholelithiasis, biliary mucocele, gallbladder neoplasia, or trauma
- performed after confirming CBD patency.
- gallbladder repair is possible, but necrosis of the gallbladder wall makes suturing risky.
- CBD leakage, primary repair with sutures + stent is an option
Choledochal Catheterization and Lavage
- normograde or retrograde manner
- red rubber catheter (usually an 8- to 12-Fr catheter for dogs and a 3.5- to 5-Fr catheter for cats).
- normograde: cholecystotomy incision or through the open cystic duct stump, challenging to pass the catheter around sharp bend
- retrograde: antimesenteric duodenotomy and catheterize the major duodenal papilla
- Thorough flushing of the duct
- cystic duct ligation site can be evaluated for leakage
- used to flush the choleliths
can also check patency by FNA of duodenum for bile
Cholecystotomy
- Few indications exist
- Removal of choleliths can be performed by cholecystotomy
- however, in most cases, cholecystectomy should be performed to prevent recurrence
Cholecystectomy
Traditional “Open” Cholecystectomy
- Demonstration of common bile duct patency by duct catheterization is recommended
- gallbladder is usually dissected out of the hepatic fossa before ligation of the cystic duct
- cotton-tipped applicators or the single-port inner cannula of a Poole suction tip
- haemostasis
- Double ligation of the cystic duct and artery should be performed with 0 or 2-0 +/- over sew
- area is thoroughly lavaged before closure
- histopath and C&S
Laparoscopic
- A four-port technique (subumbilical camera port (10 mm) and three instrument ports (5 mm)) or single-port device placed at the umbilicus
- Cranial retraction of the gallbladder so that the cystic duct is visible
- cystic duct and artery ligation ( intracorporeal suturing, vessel sealing devices, hemostatic clips, or extracorporeally tied knots)
- gallbladder is dissected out of its fossa with the aid of a vessel sealing device
Cholecystoenterostomy
complications?
- Cholecystoduodenostomy and cholecystojejunostomy
- reroute the biliary system because the CBD is usually too small and friable to permit choledochoduodenostomy
- Physiologically, a cholecystoduodenostomy should be chosen > allowing bile to continue into duodenum allows control (inhibitory feedback) of gastric acid secretion + prevent duodenal ulceration
Sx
- gallbladder must first be mobilized from the hepatic fossa
- antimesenteric border of the duodenum. The duodenocolic ligament can be transected to increase duodenal mobility
- previous flushing, that same incision in the duodenum can usually be used for anastomosis
- 3-0 or 4-0 monofilament absorbable material in a separate simple continuous pattern on each side
- small stoma (<2.5 cm) may predispose to obstruction from stricture formation
- 30-mm Endo GIA device
Complications
- hemorrhage,
- incisional dehiscence,
- stricture of the stoma,
- ascending cholangitis,
- gastric ulceration
Cholecystoenterostomy for treatment of extrahepatic biliary tract obstruction in cats: 22 cases (1994–2003)
Nicole J. Buote 2006
22 cats
Fourteen cats survived long enough to be discharged from the hospital, but only 6 survived > 6 months after surgery, all of which had chronic inflammatory disease. Median survival time for cats with neoplasia (14 days) was significantly shorter than that for cats with inflammatory disease (255 days).
overall prognosis for cats with EHBTO undergoing cholecystoenterostomy must be considered guarded to poor, and the incidence of perioperative complications is high.
Choledochal Stenting
- treatment of temporary, reversible extrahepatic biliary tract obstruction caused by pancreatitis or cholangiohepatitis
- Palliation of malignancy and temporary drainage
“Open” Choledochal Stenting Technique
- A red rubber catheter of appropriate size
- Care should be taken not to enter the pancreatic duct
- consider small hydrophilic 0.018- or 0.035-inch guide wire
- cholecystoenterostomy should be considered if not patent
- cut long enough to bridge the constriction while leaving 2 to 4 cm of stent residing in the duodenum
- sutured to the duodenal submucosa with one or two sutures of 2-0 or 3-0 absorbable monofilament
- human stent > flaps to prevent migration
- success in dogs > no extrahepatic biliary tract reobstructions occurred
- cats > small lumen prone to reobstruction
- Spontaneous passage of the stent in the feces was documented
- If the stent remains in place, stent removal by endoscopy 2 to 4 months postoperatively
Endoscopic Retrograde Choledochal Stenting Technique
- A sphincterotome is used to cannulate the major duodenal papilla, and a guide wire is advanced
- successful experimentally
Choledochotomy
- thin walled, dehiscence after choledochotomy is of great concern.
- cholelith is lodged in the common bile duct
- attempt can be made to break down the often brittle choleliths through the wall of the common bile duct and milk them into the duodenum
- duct incision is closed with 4-0 to 6-0 monofilament +/- stent
Hepatic Abscesses and Cysts
- affected animals are middle-aged to older and have nonspecific clinical signs, often include fever, abdominal pain
- increased serum alkaline phosphatase, leukocytosis
- Abdominal ultrasonography appears to be a sensitive tool for diagnosis
- Bacterial culture most often identified E. coli
- broad-spectrum antibiotics should be instituted,
TX
- some dogs responded well to systemic antibiotic treatment alone
- ultrasound-guided drainage
- surgical resection
- 10 of 13 animals had a favorable outcome with various tx
- Abscess recurrence was reported in some patients
- percutaneous drainage and alcoholization of focal hepatic abscesses
cats
- multiple macroabscessation or microabscessation more common
- solitary abscesses were located in the right liver lobes in cats
- Cats also tended to have a worse prognosis, with 11 of 14 (79%) cats in this study being euthanized or dying
Liver Lobe Torsion
- middle-aged to older large-breed dogs
- concurrently with liver abscessation, diaphragmatic hernia, tumor, GDV
- vomiting, lethargy, and anorexia with concurrent increased serum hepatic enzyme activities and a mature neutrophilia
- Doppler ultrasonography > identifying hepatic vessels with decreased blood flow.
- Torsion of the left lateral lobe is most commonly reported
- surgical emergency to avoid further hepatic necrosis, hepatic abscessation, and related sequelae > lobectomy
- risk in large-breed dogs and possible ligamentous laxity > prophylactic gastropexy
- Prognosis is considered excellent after prompt diagnosis
Gallbladder Mucocele - etiology
described in only two cats
- underlying lesion = cystic mucosal hyperplasia.
- Hypersecretion of mucus leads to an accumulation of thick, gelatinous bile within the gallbladder
- Increased viscosity over weeks or months leads to filling of the entire gallbladder lumen + common bile duct and hepatic ducts.
- may lead to obstruction or bile peritonitis secondary to gallbladder rupture.
cause
- largely unknown, but genetic factors may play a role.
- Shetland Sheepdogs predisposed though not specifically to mucoceles.
- A gene mutation linked to cholestatic disorders in humans was also found in dogs
- Studies suggest that cholestasis, could contribute to the disease’s development.
- observed association between endocrinopathies: Dogs with hypothyroidism are 3x more likely, and those with hyperadrenocorticism are 29x more likely; However, no causal relationship has been established from these studies.
hyperA
odds of a dog with hyperadrenocorticism having a mucocele was 29.0 times greater
- 21% of dogs with gallbladder mucocele had hyperadrenocorticism, compared with 2% in the control group
Diagnosis of gallbladder mucocele
- alanine aminotransferase, alkaline phosphatase, and aspartate aminotransferase levels.
- Serum bilirubin concentration is increased in most affected dogs but is often normal in early cases.
- A leukocytosis is present in half of the cases
ultrasonography
- contains echogenic material with a typical stellate or finely striated bile pattern (“kiwi fruit” gallbladder) that differs from biliary sludge by the absence of gravity-dependent bile movement
- rupture is suggested by gallbladder wall discontinuity, the presence of pericholecystic hyperechoic fat, or accumulation of fluid in the abdomen
- sensitivity of ultrasonography for gallbladder rupture is 85.7%
- Study, dogs with the most advanced ultrasonographic signs of mucocele were not necessarily the most likely to rupture, suggesting that ultrasonographic appearance should not be used as a sole basis for making treatment recommendations
centesis
- if fluid present
Medical Management
ursodiol
S-adenosylmethionine
famotidine
- unknown success rate
Incidental Mucoceles
- controversial.
- Care must be taken to avoid confusing early mucocele formation with the presence of biliary sludge
- No controlled studies exist to compare surgical and conservative management of incidentally discovered mucoceles
- Friesen et al: death 6% elective vs 23% non-elective
surgery
- gallbladder mucocele is cholecystectomy
- gallbladders not healthy enough to allow a viable cholecystoduodenostomy; progressive wall necrosis has been reported
- Evidence is somewhat conflicting as to whether infection is common
- positive cultures 0-75%
- Gallbladder rupture with subsequent bile peritonitis is encountered in 23% to 60%
- ensure the common bile duct is free of congealed mucus (evidence of obstruction, hyperbilirubinemia or duct distension)
- Concurrent extrahepatic biliary obstruction in up to 30% of cases
complications
- leakage of bile from the surgery site,
- pancreatitis
- reobstruction of duct with gelatinous bile
- death
- peritonitis
- hypotension
- pulmonary thromboembolism
- aspiration pneumonia,
- sepsis and multiple organ failure
prognosis
mortality rate?
- mortality rates from cholecystectomy 16% to 40%
- for mucocoele 21-28%
- prognosis thought to be favorable when dogs are treated early > however mortality rate still quite high!
- mortality rate within 2 weeks after surgery was 7% but increased to 26% by 2 months after surgery
- recent found higher death rate with non-elective compared to elective
cholelithiasis - pathophysiology
- present in fewer than 1% of dogs with biliary tract disease
- formation differs significantly from humans.
- bile is much less saturated with cholesterol in dogs, and choleliths are typically made up of calcium carbonate (cats) or calcium bilirubinate.
- Factors such as cholestasis, infection, and other conditions may contribute
- In dogs, blocking the bile duct experimentally leads to cholelith formation quickly
- Obstruction results in bile sludge = precursor to cholelith formation
- mucoceles > overproduction of mucin forms the stones.
- Infections linked to cholelith formation
- Studies show high rates of positive cultures
- Bile in healthy dogs is sterile, bacteria may indicate pathology.
- Some bacteria produce enzymes that convert soluble bilirubin to insoluble forms
diagnosis
- one study, 26% of dogs were asymptomatic
- some visible on plain abdominal radiography
- Abdominal ultrasonography is an effective diagnostic imaging tool
Treatment and Prognosis - liths
- Cholecystectomy is the treatment of choice for removal of choleliths and prevention of their recurrence
- choledochal choleliths are first flushed back into the gallbladder and that the patency of the common bile duct is confirmed
- choledochotomy or cholecystoenterostomy may be required
- mortality 3-25%
- Recurrence of cholelithiasis after cholecystectomy has not been reported, fter cholecystoenterostomy has been seen
Hepatobiliary Neoplasia
- four general types: hepatocellular, cholangiocellular, neuroendocrine, or mesenchymal.
- Metastatic tumors are more common
- Mast cell tumors found as primary or secondary tumors
- usually nonspecific signs or may be secondary to hepatic failure
- Laboratory abnormalities are also very variable
- Hypoglycemia paraneoplastic syndrome
- coagulation profile recommended > 21% of dogs with hepatocellular carcinoma had abnormal coagulation parameters
diagnosis
- rads may confirm mass
- ultrasonography is useful for evaluating hepatobiliary neoplasia and to discern focal, multifocal, and diffuse disease
- Contrast-enhanced harmonic ultrasonography increases the ability to differentiate between benign and malignant hepatic nodules, with sensitivity and specificity, respectively, of 100% and 94.1%
- MRI and triple-phase helical computed tomography (CT) may be able to differentiate between benign and malignant
biopsy
- fine needle aspiration of cells, needle core biopsy, laparoscopic liver biopsy, or “open” surgical biopsy
- aspirates and needle core biopsies are often not concordant
- one study, only 70% of histopathologic results from needle core samples were concordant with surgical biopsy
Hepatocellular Tumors
Benign:
- About 30% are benign adenomas,
- usually asymptomatic and found incidentally
Hepatocellular carcinomas (HCCs)
- most common malignant
- three forms: massive (61%), nodular (29%), or diffuse (10%)
- The massive form in left lobe in ~ 67% of cases
- low metastasis rate (4.8%) but higher at necroscopy 36%, >90% for nodular/diffuse
- metastasis affects the lymph nodes (39%), lungs (38%), and peritoneum (18%).
Surgery
- preferred treatment for massive tumors,
- MST >1460 days in one study
- perioperative mortality rate was 4.8%.
- not a good option for diffuse and nodular forms > incomplete surgical resection is common and the metastatic rate is high
Chemotherapy and radiation therapy
- generally not considered effective
- Chemoembolization may be promising for nonresectable or diffuse tumors.
prognosis
- Dogs with nonresectable HCC have a poorer prognosis, though some can live for extended periods despite disease progression.
- MST >1460 days in one study with sx for HCC
Hepatocellular Tumors in Cats:
- less common
- adenomas more frequent than carcinomas.
- Metastasis observed in 25%
- There is limited information on optimal treatment and prognosis in cats.
Cholangiocellular (Bile Duct) Tumors in Dogs:
- Cholangiocellular adenomas are benign bile duct tumors, accounting for 12% of primary liver tumors in dogs.
- Cholangiocellular carcinoma makes up 22% of primary liver tumors in dogs.
- Most bile duct carcinomas (79-92%) are intrahepatic, while 4-21% are extrahepatic, and 1-4% originate from the gallbladder.
- Metastatic disease was found in 88% of cases in one necropsy study.
- Carcinomas are categorized as massive (46-50%), nodular (28-54%), and diffuse (22%).
- A link between cholangiocellular carcinoma and Chinese liver fluke infection exists in humans and was reported in one canine case, though evidence in most dogs and cats is lacking.
Cholangiocellular (Bile Duct) Tumors in Cats:
- Bile duct tumors are the most common primary hepatic neoplasms in cats.
- Benign bile duct adenomas (biliary cystadenomas) are twice as common as bile duct carcinomas.
- Prognosis for benign biliary cystadenomas is good with surgical excision, but some cases show precancerous changes.
- Malignant biliary tumors have a poor prognosis, with 100% perioperative mortality in one surgical study.
- Metastasis was present in 67% of cases in one necropsy study.
Mesenchymal (Soft Tissue) Liver Tumors in Dogs and Cats
Dogs:
* Hemangioma of the liver is rare, while hemangiosarcoma is more common but usually metastatic from other organs.
* Primary hepatic hemangiosarcoma is present in 6% of cases and may behave differently than metastatic forms.
* Other mesenchymal liver tumors in dogs include leiomyosarcoma, osteosarcoma, fibrosarcoma, mesenchymoma, and chondrosarcoma.
* Surgery is the preferred treatment, but prognosis is poor due to frequent metastasis.
* In a study on hepatic leiomyosarcoma, all cases had diffuse disease, and all dogs died or were euthanized in the perioperative period.
Cats:
* Hemangiosarcoma is the most common followed by leiomyosarcoma, rhabdomyosarcoma, osteosarcoma, and fibrosarcoma.
* 35% of cats with visceral hemangiosarcoma had liver involvement, with multifocal disease being common.
* Prognosis is poor, with 71% of cats euthanized perioperatively and the rest having a median survival of 77 days (range: 23-296 days).
mast cell tumors
- because mast cell tumor involving the liver is part of a disseminated disease process, few cases are amenable to surgery
- In dogs, visceral involving the liver usually holds a grave prognosis, with no dogs surviving beyond 2 months after admission in one study.
- In cats, most cases of visceral mast cell tumor originate in the spleen or intestine
- cats splenectomy: MST 19 months reported, even in cases in which metastatic spread was present
Neuroendocrine Carcinomas in Dogs and Cats
- Rare tumors
dogs:
* 100% of cases involve diffuse liver involvement.
* Some cases affect the gallbladder.
* Metastasis occurs in 93% of cases, often spreading to the peritoneum and lymph nodes.
cats:
* More cases are extrahepatic, bile ducts, though some involve the gallbladder.
* Metastasis is common
* In some cats, (cholecystectomy) has been associated with longer survival.
Prognosis
- poor in both species due to the diffuse nature of the disease, making surgical excision unfeasible.
* No studies exist on the effectiveness of chemotherapy or radiation therapy for these tumors.
Clinical use of uncovered balloon-expandable metallic biliary stents for treatment of extrahepatic biliary tract obstructions in cats and dogs: 11 cases (2012–2022)
Bergen 2024
Retrospective single institutional study.
Animals: Eight dogs and three cats
Median duration of short-term follow up was 16 days (6–45 days).
Improved biochemical abnormalities and resolution of clinical signs were
recorded in 10/11 cases. Two dogs died within 2 weeks of surgery
Bile-duct patency was maintained for (median: 446 days) in three cats and (median: 650.5 days) in four dogs
uncovered balloon-expandable metallic biliary
stents should be considered as an alternative to temporary choledochal luminal
stenting or cholecystoenterostomy to manage EHBO
Near-infrared fluorescence cholangiography in dogs: A pilot study
Larose 2024
, intraoperative cholangiography (IOC) is recommended during cholecystectomy to prevent biliary tract injury. Although indocyanine green
(ICG) cholangiography has been extensively reported in human medicine, only one study
has been conducted in veterinary medicine. Therefore, this study aimed to demonstrate the
use of ICG for IOC to identify fluorescent biliary tract images and determine the patency of
the common bile duct during cholecystectomy in dogs.
Based on these results, 0.05 mg/kg of ICG administered at anesthetic premedication, or as early as 3 h prior to laparoscopic surgery should yield optimal fluorescence images.
Concurrent hepatopathy in dogs with gallbladder mucocele:
Prevalence, predictors, and impact on long-term outcome
Sara A. Jablonski 2024
Multicenter, retrospective study of dogs with GBM undergoing cholecystectomy
with concurrent liver biopsy.
51/52 (98%, 95% CI [89%, 99%]) dogs with GBM had at least 1 hepatic histologic
abnormality. Hepatic fibrosis (37/51; 73%, 95% CI [59%, 83%]), biliary hyperplasia
(29/52; 56%, 95% CI [42%, 68%]), and portal inflammation (25/52; 48%, 95% CI
[35%, 61%]) were most common.
A higher portal fibrosis score might be associated with shortened
long-term survival after cholecystectomy for dogs with GBM
Hepatic lobectomy in dogs using a stapling device
with a vascular cartridge: a retrospective study of
13 cases
D Szwec, A Singh & M Gatineau 2023
NZVJ
Endo GIA surgical
stapling device with a vascular cartridge
oozing from the transected liver parenchyma in 6/13 dogs
All patients survived until discharge and were alive at the 2-week
left hepatic division and in this study had low rates of intra-operative and post-operative complications.
Therapeutic response and prognostic factors of 14 dogs
undergoing transcatheter arterial embolization for
hepatocellular masses: A retrospective study
Yuta Kawamura
JVIM
The median survival time was 419 days
The mean
reduction percentage was 51% ± 40%
History of intra-abdominal hemorrhage and large pre-TAE tumor volume/
body weight ratio could be predictive factors for adverse outcomes after TAE
Laparoscopic cholecystectomy using
the subserosal layer dissection technique
in dogs: 34 cases (2015-2021)
M. Kondo 2023
Thirty-four dogs were included. The most common preoperative diagnosis was cholecystolithiasis
(n=29). Operative time was 190 minutes (range: 110 to 330 minutes). Subserosal layer dissection of more
than 90% of the gall bladder bed was achieved in 27 (79%) dogs. Conversion to open surgery was required
in three (8.8%) dogs. There were no cases of intraoperative bleeding, bile duct injury, or reoperation
need to comapre to other traditional tehcnqiues
laparoscopic cholecystectomy (LC) was reported to be useful in uncomplicated cases of gall bladder disease such as gall bladder mucoceles and cholecystitis in dogs
conventional LC in dogs has yielded unsatisfactory completion and complication rates
reported a 20-30% open conversion rate
intraoperative complications resulted from bleeding from the liver parenchyma
fundic dissection-first technique, commonly used in human LC when
excessive adhesions impede access to the cystic duct, was actively
adopted (as apposed to retrograde)
Histopathologic findings and survival outcomes of dogs undergoing liver lobectomy as treatment for spontaneous hemoabdomen secondary to a ruptured liver mass: retrospective analysis of 200 cases (2012–2020)
Reist 2023
Well-differentiated hepatocellular carcinoma, benign masses, hemangiosarcoma, and other malignant tumors accounted for 36% (72/200), 27.5% (55/200), 25.5% (51/200), and 11% (22/200) of cases, respectively. Overall survival time for all dogs was 356 days and for the above categories was 897 days, 905 days, 45 days, and 109 days
The majority of dogs (63.5%) were diagnosed with well-differentiated hepatocellular carcinoma or a benign process, resulting in favorable long-term survival
Computed tomography angiography aids in predicting resectability of isolated liver tumors in dogs
Christopher Smola 2023
Prospective study of 20 dogs with 21 isolated hepatic masses
The radiologist was more accurate in lesion localization compared to the surgeon (P = .023). Seventeen (17/21) masses were grossly resectable in surgery. Two additional (2/21) masses that were deemed grossly resectable were incompletely excised on histopathologic analysis. Both the surgeon and radiologist were accurate in their prediction of gross resectability and complete excision.
Major vascular involvement, multilobar involvement, and right-sided laterality negatively affected resectability.
Features, management, and long-term outcome
in dogs with pancreatitis and bile duct obstruction treated medically and surgically: 41 dogs (2015–2021)
Cleary 2023
18 of 19 (95%) surgical patients survived, while 12 of 21 (57%) medical patients survived
The mortality rate of surgery for EHBO secondary to pancreatitis may be lower than previously described, and in this cohort of dogs, those treated surgically had improved survival at 2 and 12 months compared to those treated medically.
12 cholecystoduodenostomies and 3 cholecystojejunostomies.
2 CBD flushed, 1 stent
There was no difference in the common bile duct diameter between the medical (mean, 7.2 mm; range, 3.4 to 11 mm) or surgical (mean, 7.1 mm; range, 3.4 to 19 mm) groups or between survivors (mean, 7 mm; range, 3.4 to 19 mm) and nonsurvivors (mean, 7.7 mm; range, 4.7 to 11 mm).
In conclusion, the optimal management for pancreatitis-associated biliary obstruction remains unknown. alleviation of biliary obstruction via surgical decompression may be a reasonable therapeutic option.
Increasing age and severe intraoperative hypotension associated with nonsurvival in dogs with gallbladder mucocele undergoing cholecystectomy
Ullal 2024
A prospective, multicenter cohort study
25 dogs that underwent cholecystectomy for removal of GBM and 20 healthy control dogs.
76% (19/25) and 68% (17/25) of dogs survived
Gallbladder perforation not associated with increase mortality
Outcome in 38 dogs surgically treated for hepatic
abscessation
Vanna Dickerson 2023
Retrospective.
Peritoneal effusion was documented in 32/38 dogs preoperatively,
with septic peritonitis confirmed in 21/23 samples
A single organism was cultured in 24/35
dogs, most commonly Escherichia coli. Hepatic neoplasia was identified in
11/36 dogs.
Two dogs died intraoperatively, and 6 dogs died prior to discharge.
No abscess recurrence was noted
Dogs treated surgically for hepatic abscessation have a
high risk of perioperative complications but favorable long-term prognosis and
apparent low risk of recurrence
Further research is needed to determine indications for surgical treatment versus medical therapy alone
Association between divisional location and short-term
outcome of liver mass resection in 124 dogs
Moore 2023
Retrospective case series
more common in the left (72) division than
the central (34) and right (18) divisions.
Intraoperative complications occurred in 14/124 dogs (11.3%)
and postoperative complications in 35/122 dogs (28.7%). No association was
detected between mass location and mortality in 8/124 dogs (6.5%).
Postoperative
complications were more likely if the incision extended to the thorax
(P < .001), which was more common during resection of right divisional
masses (P = .020). Postoperative complications were less likely when surgery
was performed with a thoracoabdominal (TA) stapler (P = .005), by a specialist
surgeon (P = .033), and in heavier dogs
Blood products were administered to
33/124 dogs (26.6%).
Hemorrhage
requiring an intraoperative or postoperative blood
transfusion occurred in 7 dogs and injury to major blood
vessel requiring direct repair occurred in 11 dogs.
Major vessels
injured included the caudal vena cava (6 dogs), adjacent
hepatic vein (4 dogs), and the splenic vein in 1 dog
Right divisional masses were prone to intraoperative (haemorrgahe, greater vessel injury) but not
postoperative complications.
Clinical significance: Clinicians should anticipate an increased risk of intraoperative
complications when planning treatment of right divisional masses
The effect of flushing of the common bile duct on
hepatobiliary markers and short-term outcomes in
dogs undergoing cholecystectomy for the management
of gall bladder mucocele: A randomized controlled
prospective study
Tom L. Hernon 2023
Randomized, controlled, prospective study.
Animals: Thirty-two client-owned dogs.
Flushing was performed in a normograde fashion, followed by a
routine cholecystectomy
Border terriers
were overrepresented (20/31). Overall, there were marked reductions from preoperative
to 3 days postoperative in serum bilirubin (p = .004), ALP
(p = .020), ALT (p < .001), GGT (p = .025), and cholesterol (p < .001) values.
There was no difference in any marker between groups. Survival to discharge
was 90.3% (28/31 dogs).
Postoperative complications were high overall with a complication rate of 58.1%. This
The findings of the study do not support routine flushing of the CBD during cholecystectomy for GBM in dogs.
The presence of peritoneal fluid was
previously identified as an indicator of rupture of the
gallbladder; however, the results from the current study
identified low sensitivity (29%) for this
The use of catheterization/flushing of the CBD is discussed
in multiple studies; however, none provides evidence
of a benefit for its use
Evaluating preoperative coagulation panels in dogs
undergoing liver lobectomy for primary liver tumors: A
multi-institutional retrospective study
Samuel J. Burkhardt 2024
Conclusion: Coagulation panels including PT and aPTT are unlikely to
detect substantial deficiencies in secondary hemostasis in most dogs with
primary liver tumors except in dogs with a histopathological diagnosis of
hemangiosarcoma.
Clinical significance: PT and aPTT testing is low yield as an elective preoperative
screening test in dogs with primary liver tumors except in dogs where
there is a hemoabdomen or high suspicion for hepatic hemangiosarcoma.
Hemangiosarcoma is a volatile tumor arising
from malignant endothelial cells which may explain each
of these correlations. Oncogenic cells are known to promote
a thrombotic state through disruption of Virchow’s
triad leading to venous thromboembolism and, in the most
severe cases, DIC.
case-by-case
basis in dogs to include those with a history of a bleeding
tendency, a potential hereditary predisposition to a coagulopathy,
clinical and biochemical evidence of synthetic
hepatic dysfunction, unknown etiology of cavitary bleeding,
or concurrent anticoagulant medication.
Computed tomography scan accuracy for the prediction
of lobe and division of liver tumors by four
board-certified radiologists
Brian J. Thomsen 2024
Retrospective.
Animals: A total of 67 client-owned dogs
Overall accuracy of mass localization was 217/292 (74.3%) by lobe
and 264/300 (88%) by division.
This study supports CT as a useful modality for liver
mass localization based on division. CT localization to specific lobes should be
interpreted with some caution.
Histologic findings of gastrointestinal biopsies and clinical outcome in dogs undergoing cholecystectomy for gallbladder mucoceles: 71 cases
(2014-2021)
M. Gondolfe1 and E. C. Hans
Enteritis was present in 85.9% (61/71) of cases with the majority being lymphoplasmacytic (53.5%). Twelve dogs (16.9%) underwent gastrointestinal biopsies from multiple sites, which revealed the same enteritis type at each location. A total of 87.3% (n = 62) dogs survived, including 90.4% elective and 86% emergent cases. No significant differences in enteritis severity or patient survival were found between elective and emergent cases
Bleeding risk and complications
associated with percutaneous
ultrasound-guided liver biopsy
in cats
Michelle Pavlick 2019
bleeding was classified as minor or major when the absolute change in packed cell volume (ΔPCV)
was <0 and >-6% or ⩽-6%, respectively. Complications were defined as physiologic compromise necessitating
an intervention, or death.
All cats had a decrease in PCV after biopsy
Minor and major bleeding occurred in 13/30 (43.3%) and 17/30 (56.7%)
Complications occurred in 5/30 (16.7%) cats. A transfusion
or resuscitative fluids were required in three and two cats, respectively
Cholecystectomy in 23 cats (2005-2021)
Matthew Simpson 2022Clinical retrospective study.
Cholelithiasis was the
major indication for cholecystectomy followed by cholecystitis. Intraoperative
hypotension and postoperative anemia were commonly encountered. Nine cats
required a postoperative blood product transfusion. Cardiopulmonary arrest and
death occurred in five cats. Eighteen cats (78.3%) survived to discharge
Fifteen cats survived over 6 months
Perioperative mortality rate was 21.7%.
Conclusion: The draining pattern of hepatic veins varied widely in all liver
lobes, especially the left lateral liver lobe.
Clinical significance: Veterinary surgeons should consider the potential presence
of multiple hepatic veins and their draining pattern when performing
hilar liver lobe resection. Attentive evaluation of a preoperative CTA is recommended
for surgical planning.
Impact of intra-operative hypotension
on mortality rates and post-operative
complications in dogs undergoing
cholecystectomy
R. Hattersley 2020
total mortality was 19 dogs (17%). Hypotension lasting over 10 minutes during
general anaesthesia occurred in 65 dogs (54.6%),
Intra-operative hypotension or the number of hypotensive episodes did not appear to be associated
with in-hospital or 28-day mortality
Association between biliary tree manipulation and outcome
in dogs undergoing cholecystectomy for gallbladder
mucocele: A multi-institutional retrospective study
Piegols 2021
Study design: Multi-institutional retrospective cohort study.
Animals: Dogs (n = 252)
Catheterized dogs had higher American Society of Anesthesiologists
scores (P = .04), higher total bilirubin (P = .01), and were more likely to have
dilated CBD at the time of surgery
Incidence of major and minor
intraoperative complications was similar between the two groups
postoperative pancreatitis was associated with performing CBD catheterization
developing postoperative pancreatitis was not different between normograde
and retrograde catheterization
catheterization was not associated with a more rapid rate of decline of serum
bilirubin levels postoperatively.
better mortality rates recently > this may reflect a trend toward earlier treatment of dogs in which GBM has been diagnosed.
catherisation may cause reflux or temporray inflammation/occlusion
Influence of normograde versus retrograde catheterization
of bile ducts in dogs treated for gallbladder mucocele
Putterman 2021
Retrospective study.
Animals: Dogs (n = 117) with GBM
Conclusion: Retrograde catheterization was associated with more postoperative
concerns than NG catheterization, but similar survival times. Surgery
should be performed by diplomates experienced in biliary surgery to minimize
complications.
Dogs catheterized RG were more likely to experience any postoperative
complication (p = .0004) including persistence of gastrointestinal signs
(p = .0003).
Total bilirubin (TB) decreased by 70.3% after NG
catheterization compared to 39.1% after RG catheterization
Perioperative
mortality (13.7%) was similar to mortality rates of 9%–19.6% reported in other recent studies
possible that
entry into the gastrointestinal tract was still an additional
source of morbidity, contributing to gastrointestinal complications
such as ileus, persistent vomiting, regurgitation,
ptyalism, diarrhea, or anorexia
Clinical findings for dogs undergoing elective and nonelective cholecystectomies for gall bladder mucoceles
Friesen 2021
A multi-institutional retrospective case series
The mortality rate was 2 (6%) out of 31 for dogs undergoing an elective cholecystectomy and 21 (23%) out of 90 for dogs undergoing a nonelective cholecystectomy. The complication rate was 52% for the elective cholecystectomy and 50% for nonelective cholecystectomy.
- mortality rate: elective 2/31 (6%) vs 21/90 (23%) non-elective
- 33% with gallbladder rupture
- complication rate: elective 52%, non-elective 50% - majority minor
- method of catheterisation: post-op hyperthermia in 35% retrograde, 4% normograde, 7%
no catheterisation
Computed tomography features for differentiating malignant and benign
focal liver lesions in dogs: A meta-analysis
Larger maximum dimensions and volume (positive
SMD), and lower attenuation values (negative SMD) were more associated with malignancy. This meta-analysis
provides the evidence base for the interpreting CT imaging in the characterization of FLL.
Diaphragmotomy to aid exposure
during hepatobiliary surgery:
a multi-centre retrospective review
of 31 dogs
B. Dean 2020
Diaphragmotomy appears safe and increases abdominal exposure of hepatobiliary
lesions. The benefit of improved exposure must be carefully weighed up against the risks inherent in
inducing pneumothorax.
Peri-operative mortality rate was 9.7% (3/31 cases)
though none of these deaths were considered attributable to diaphragmotomy. Post-operative
complications
were encountered in 67.9% (19/28) cases that survived the peri-operative period, of
which 25.0% (7/28) suffered complications that were considered attributable or likely attributable
to diaphragmotomy. These seven complications resolved following non-surgical intervention
Ability of positive and negative contrast computed tomographic
peritoneography to delineate canine liver lobe fissures
Luis R. Rivas
Prospective cross-sectional study.
Animals: Canine cadavers (n = 10).
40 mL/kg of 2.5% iohexol
When assessment of all fissures was combined, measurements were
obtained in 96 to 108 of 120 (80%-90%) positive contrast studies, 56 to 96 of
120 (47%-80%) negative contrast studies, and 12 to 32 of 120 (10%-27%)
precontrast CT images.
These results justify further studies to determine the ability
to locate large hepatic masses in dogs with positive CT. Positive contrast CT
peritoneography may assist treatment planning in dogs with large hepatic tumors.
Use of a cavitron ultrasonic surgical aspirator for
parenchyma-sparing and complex liver resections in dogs
Clément Sellier 2020
- CUSA enables removal of parenchyma/nodules whilst preserving vasculature
- blood loss: median 77ml (9.9-161) → 4.3% (0.8-23.2%) blood volume
- complications: cholangiohepatitis (resolved with medical management), necrotising pancreatitis (death)
- segmentectomy performed according to Couinaud classification of hepatic segments
- left lateral → cranial, middle, distal segments
- left medial
- quadrate
- caudate process, papillary process
- right medial → ventral, dorsal segments
- right lateral
- portal branches and corresponding hepatic veins for each listed segment
Laparoscopic Cholecystectomy with Single Port Access System in
15 Dogs
Allen Simon DVM, MS | Eric Monnet 2020
An additional cannula was added in
12 cases. In the last 10 cases, the additional cannula was placed at the beginning of
the procedure. Dissection began at the cystic duct in 11 dogs (73%). In three cases
(20%), the SPAS procedure was converted to a laparotomy; two of these conversions
were elective, and one was emergent.
no icterus or peritonitis
The rate of conversion to laparotomy was 20%
Fourteen dogs were discharged from the hospital (93%) survival
Short-term mortality rates between 0% and 5% have been reported after laparoscopic
cholecystectomy for nonobstructed gallbladder disease.
Elective cholecystectomy with laparotomy has been associated with a mortality rate of 2%.20
Rogatko 2023 – CT response criteria for chemoembolization for non-resectable hepatic carcinoma
- ‘drug-eluting bead transarterial-chemoembolization’ (DEB-TACE)
- doxorubicin beads
- MST: overall 337d
- tumour measurements (initial, follow-up or changes in 1D, 2D or 3D) not associated with
survival
- shorter survival associated with: larger 2D/3D tumour measurement adjusted to bWt
higher %necrosis on initial CT
Kanai 2022 – intra-op cholangiography and bile duct flushing during laparoscopic cholecystectomy
- median time for BDF and IOC 4min (2-248), no complications
- IOC detected common bile duct stricture/obstruction not observed with BDF only
multiport laparoscopy
