Surgery of the hepatobiliary system + pancreas

Question 1

What is the functional reserve of the hepatobiliary system?
What is resident in the hepatobiliary system? Significance?

Answer 1

• 70-80% can be removed with few ill effects
• Resident Clostridial population - will proliferate in avascular tissue

Question 2

What are indications for liver lobectomy?

Answer 2

• Neoplasia
• Abscessation
• Trauma

Question 3

What are consequences of Portosystemic shunts?

Answer 3

• Blood bypass liver + enter systemic circulation
  = toxins cause hepatic encephalopathy
• ammonia
• methionine / mercaptans
• short-chain fatty acids
• GABA

Question 4

What are different types of portosystemic vascular anomalies?

Answer 4

• Congenital intra + extrahepatic shunts
• usually single vessels, various locations
• Acquired extrahepatic shunts
• multiple, secondary to portal hypertension

Question 5

What animals are likely to get extra/intrahepatic shunts?

Answer 5

• Extrahepatic shunts = small breeds = yorkshire terriers, poodles, pekingese, minature schnauzers
• Intrahepatic shunts = larger breeds = GSD, Lab, Golden retriever, dobermann, irish setter, samoyed, irish wolfhound
• DSH cats

Question 6

What are presentations of Portosystemic shunts?

Answer 6

• Congenital = young <1y/o
• Acquired = 1-7y/o
• Poor growth, anorexia, depression, vomiting, PUPD, ptyalism (esp. in cats), behavioural changes
• Urate urolithiasis
• Hepatic encephalopathy =
• ataxia, weakness, head pressing, circling, depression, seizures or coma, often worse after high-protein meals
• Small liver

Question 7

How are portosystemic vascular anomalies diagnosed?

Answer 7

• Hx + CS
• Imaging =
• radiographs - small liver, abnormal positive contrast portogram
• US - directly visualise shunt vessel
• Scintigraphy
• Cytology
• Bloods + biochem

Question 8

What is seen on cytology / bloods / biochem of portosystemic vascular anomalies?

Answer 8

• microcytosis
• mild nonregenerative anaemia
• poikilocytosis
• low BUN
• Hypoalbuminaemia
• Occasionally increased ALT/AST/ALKP
• Elevated pre + postprandial bile acids

Question 9

What is medical management of postosystemic shunts?

Answer 9

• Highly-digestible soy protein diet
• Antibiotics to reduce enteric flora = neomycin, metronidazole, ampicillin
• Lactulose = Synthetic disaccharide, Traps ammonia in gut, Reduces ammonia production

Question 10

What is surgical management of portosystemic shunts?

Answer 10

• Gradual attenuation of shunting vessel

Question 11

What type of shunt is prognosis better in?

Answer 11

• Extrahepatic = small breeds

Question 12

Why would you perform bile flow diversion? What are your options?

Answer 12

• Obstruction of common bile duct
• Trauma to common bile duct
• Cholecystoduodenostomy (best) or cholecystojejunostomy

Question 13

How would you perform a partial pancreatectomy?

Answer 13

• Handle pancreas gently – pancreatitis!
• Simple encircling ligature for peripheral lesions
• Blunt dissection between lobules for central or peripheral lesions
• Individually ligate ducts and vessels supplying tissue to be excised

Question 14

What method of biopsy would you perform for the liver?

Answer 14

• Guillotine method for peripheral lesions
• Trucut biopsy / punch biopsy for central lesions

Question 15

How would you perform pancreatic biopsy?

Answer 15

• Trucut needle
• FNA
• Shave off affected tissue with a scalpel