Biliary tract surgery in the dog and cat: Indications and techniques

Ivan Doran BVSc Cert SAS MRCVS Alasdair Hotston Moore MA VetMB Cert SAC Cert VR Cert SAS MRCVS
DEPARTMENT OF CLINICAL VETERINARY SCIENCE, UNIVERSITY OF BRISTOL, LANGFORD HOUSE, LANGFORD, BRISTOL. BS40 5DU

ANATOMY (Fig. 1)

G

G

Extramural causes of biliary obstruction include neoplasia (duodenal, pancreatic) and pancreatitis (Fig. 3). Biliary peritonitis (Fig. 4) occurs when bile leaks from the extrahepatic biliary system.This can occur

Gall bladder

Hepatic ducts Cystic duct Hepatic ducts Common bile duct Duodenum Intramural bile duct

Fig. 2: Biliary obstruction secondary to biliary carcinoma of the common bile duct in a cat.

Minor pancreatic papilla

Major duodenal papilla

Pancreas

Fig. 1: Normal canine biliary anatomy (redrawn from Miller’s guide to the dissection of the dog; third Ed).

CLINICAL PRESENTATIONS The extrahepatic biliary tract of dogs and cats can be affected by a variety of diseases, either due to primary pathology of the biliary system or as a result of disease in another organ causing secondary dysfunction of the biliary tree. Although a wide range of causes of extrahepatic biliary dysfunction exist, these all result in either obstruction to bile flow or to leakage of bile into the peritoneal cavity. G Intraluminal causes of biliary obstruction include inspissation of biliary secretion, cholelithiasis and mucinous debris resulting from gallbladder mucocoeles. G Intramural causes of biliary obstruction include biliary neoplasia (Fig. 2) and cholangitis.

Fig. 3: Cat with obstructive jaundice secondary to pancreatitis.

Fig. 4: Biliary peritonitis in a dog secondary to blunt abdominal trauma.

UK Vet - Vol 12 No 1 January 2007

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7: Retrograde cannulation of the canine common bile duct via a duodenal incision. 2 SMALL ANIMAL G SURGERY ### UK Vet . predisposes the patient to post-operative hypotension and subsequent acute renal failure. Cholecystotomy is only indicated when the gallbladder wall remains healthy. The commonest causes of biliary tract obstruction in the dog are pancreatitis and neoplasia whilst in the cat. These perforations were usually a result of NSAID toxicity and the biliary tract itself was normal.VII. 3. PREOPERATIVE CONSIDERATIONS Haemorrhagic diathesis in dogs and cats with liver disease is seldom a clinical problem.secondary to necrotising cholecystitis (Fig. Ultrasonography provides the best. Fine synthetic monofilament suture material is used. There is also strong evidence that chronic obstructive jaundice. readily available. trauma. is more difficult owing to the acute angle between the cystic and the common bile ducts. 1. via a duodenal incision (Fig. modality to image the biliary tract. Cases of Fig. Laparotomy swabs are used to pack off the gallbladder to minimise the risk of abdominal contamination from gallbladder contents. Cats also regularly present with biliary obstruction secondary to neoplasia. biliary peritonitis may be suspected following accumulation of fluid within the peritoneal cavity and recovery of bile-containing fluid on abdominocentesis (Fig. 4). It is imperative that patency of the cystic duct and common bile duct is confirmed before the gallbladder is closed. A stay suture is placed. a combination of inflammatory conditions such as cholangitis. IX and X. This decompression will reduce the risk of spillage of luminal contents during incision of the gallbladder. subcutaneous administration of vitamin K1 (at 1-2 mg/kg) is usually sufficient to normalise coagulation within 3 to 12 hours of administration. although it can be difficult in some cases to distinguish between current and recent but resolved biliary obstruction. along with an increased tortuosity of the biliary tract (Fig. usually affecting the biliary ducts or. 5: Biliary peritonitis and adhesions following gallbladder rupture secondary to necrotising cholecystitis. Clinical cases of biliary obstruction in dogs and cats are usually encountered before this situation develops. Biliary tree cannulation is most readily achieved in a retrograde fashion. DIAGNOSIS A full discussion of the diagnosis of biliary obstruction in dogs and cats is beyond the scope of this article. 2. rarely. CHOLECYSTOTOMY Primary indications for cholecystotomy include removal of inspissated biliary ‘sludge’ or choleliths from the gallbladder. into the fundus of the gallbladder to facilitate atraumatic manipulation during the procedure. in dogs and in humans. 6) is suggestive of biliary obstruction. 5). in contrast to the situation in humans. secondary to biliary obstruction. Fig.Vol 12 No 1 January 2007 .Vitamin K deficiency can occur secondarily to chronic biliary obstruction and this can lead to lowered levels of clotting factors II. cholangiohepatitis. Anterograde cannulation. Fig. It may be possible to aspirate some of the gallbladder contents. pancreatitis and inflammatory bowel disease frequently co-exist. but should these deficiencies be suspected. via the cholecystotomy incision. Note: the authors have seen several cases of biliary peritonitis that resulted from bile leaking through a proximal duodenal perforation. 6: Biliary tract dilation and increased tortuosity in a cat following fibrosis of the common bile duct. into the peritoneal cavity. 7). using a 16G needle. Dilation of the gallbladder and biliary ducts.

approximately 5 cm apart. NB It is easier to achieve a tension free UK Vet . a generous incision is made from the fundus towards the neck of the gall bladder. and also when the gallbladder is suspected to be the source of recurrent biliary disease (e. Cholelithiasis and cholecystitis (including the necrotizing form. Luminal contents are removed using tissue forceps and/or lavage and suction. 8: Excised gall bladder from a cat. If an obstructive biliary disease is suspected. 7. A biopsy of the gallbladder wall may be taken first. If a biliary tract obstruction is suspected then the patency of the common bile duct must be verified. Duodenal contents are suctioned and the major duodenal papilla is identified. An antimesenteric duodenal incision is made (centred approximately 4 cm distal to the pylorus in a medium sized dog). 3. Choice of stay suture material is of little consequence. Fig. The patency of the common bile duct and cystic ducts is checked. The cystic duct and cystic artery are then ligated with a single ligature using synthetic absorbable suture material.Vol 12 No 1 January 2007 SMALL ANIMAL G SURGERY ### 3 . This visceral peritoneal incision is progressively extended around the entire liver-gallbladder junction in order that a clean plane of dissection can be subsequently maintained.4. at their junction with the cystic duct. before being sectioned proximal to the ligature. Minor haemorrhage from the liver surface is controlled by gentle pressure with a swab.The gallbladder should be submitted for histological and microbiological analysis (Fig. 1. Whilst an assistant applies traction to the stay sutures. as previously described. gallbladder mucocoeles). 5. Mobilisation of the gallbladder and proximal cystic duct is effected and then the cystic duct is cross clamped. It is also used for management of extrahepatic biliary tract rupture. 1. Complete mobilisation of the gallbladder up to its junction with the cystic duct is crucial to permit a tension-free anastamosis to the duodenum. Bacteriological culture and sensitivity testing are performed on the bile. CHOLECYSTECTOMY Cholecystectomy is indicated when the gallbladder is traumatised or diseased. The cholecystotomy incision is closed using a monofilament absorbable suture material.g. A stay suture is placed into a non-friable area of the apex of the gallbladder to facilitate manipulation of the organ during dissection. It is widely considered to be the most useful procedure for biliary diversion in dogs and cats. CHOLECYSTODUODENOSTOMY Cholecystoduodenostomy is indicated to bypass sites of obstruction or trauma affecting the extrahepatic biliary tree. using Metzenbaum scissors. as for cholecystectomy. 4. 3. An assistant’s fingers are employed to occlude the duodenum either side of the proposed duodenal incision site. 6. The suture line is begun at the gallbladder neck and the initial knot’s short end is retained as a stay suture.The gallbladder and proximal cystic duct are removed. The duodenal incision is closed using a full thickness simple continuous suture pattern with a synthetic absorbable suture material. The region around the gallbladder is packed off as for cholecystotomy. and so minimise the risks of biliary leakage. Stay sutures are also placed in the antimesenteric border of the proximal duodenum. A 4 Fr catheter is passed and the biliary system flushed. 5. then before the cystic duct is clamped. a rounded suction tip or by finger dissection. Blunt dissection between the gallbladder and the hepatic fossa is continued. Cholecystocentesis is not necessary and it is easier to follow an appropriate plane of dissection around a turgid gallbladder. via the duodenum (see cholecystotomy). 8). but the authors recommend avoiding cholecystotomy where mural disease is suspected. Traction is applied using the stay suture and a pair of Metzenbaum scissors are used to incise the visceral peritoneum between the gallbladder and its hepatic fossa. A distal cystic duct ‘stump’ is left so that the hepatic ducts from the central division of the liver are not ‘pinched’ by the clamp. wound dehiscence and stoma stricture post-operatively. together with ligation of the common bile duct. The gallbladder is packed off using laparotomy swabs. 2. It is used when the gallbladder is not directly involved in the disease process. Care is taken not to traumatise the gallbladder wall or the cystic artery as it courses with the cystic duct to invest the gallbladder wall. A stay suture is placed in the gallbladder. an incision is made into the gallbladder to permit retrograde flushing of the biliary tract. which may present with perforation) can often be successfully treated by performing a cholecystectomy. The gallbladder is mobilised away from the hepatic fossa. 2. as previously described for cholecystotomy. to ensure the patency of the common bile duct.

Care is taken not to twist the cystic duct during this manoeuvre. ensuring a complete seal around the stoma (Fig. A full thickness incision. adjacent and parallel to the duodenal incision. It is not necessary to dissect free the cystic duct itself to achieve an adequately mobilised gallbladder. The comparatively narrow extrahepatic biliary tract of our patients renders the risks both of post-operative biliary leakage from the repair site and of stenosis/stricture of the repair site. A full thickness incision is made. Furthermore. adjacent and parallel to the simple continuous suture line.Techniques of primary repair of the biliary tract are less applicable to dogs and cats than to humans. pancreatitis) may benefit from biliary tract decompression via cholecystocentesis under ultrasonographic guidance. and such a dissection exposes the cystic artery to the risk of iatrogenic trauma as it accompanies the cystic duct in its course.anastomosis between the gallbladder and the jejunum but this is a less physiological technique and predisposes the patient to duodenal ulceration. is made at the antimesenteric border of the proximal duodenum. effective and secure cholecystoduodenostomy. there is a significant risk of leakage from the needle hole if the cause of obstruction persists. 10). suture line. 5). usually pancreatic or biliary adeno- 4 SMALL ANIMAL G SURGERY ### UK Vet . The time interval elapsing between rupture and surgical intervention may therefore be sufficient to permit adhesion formation between the biliary tract and adjacent tissues. 4.g. Cases of biliary tract obstruction or rupture secondary to a neoplastic process. The presence of bile in the duodenum is. 6. A second. COMPLICATIONS/PROGNOSIS The prognosis for a patient following biliary tract surgery is very much influenced by the underlying pathology that is present.This incision should be as long as possible to limit the risk of post-operative stoma stricture. An assistant applies traction to both the gallbladder and duodenal stay sutures. full thickness suture (Fig. integral to the neuroendocrine mechanisms responsible for inhibiting gastric acid secretion. Fig. clinical signs following biliary tract rupture often have an insidious onset. simple continuous suture is placed to appose the near edges of the gallbladder and duodenal incisions. of the same length as the gallbladder incision. Biliary and duodenal contents are aspirated from the vicinity of the incisions. cholecystectomy. A simple continuous. full thickness. However. they can then be tied to the respective ends of the second TREATMENT There is a plethora of surgical techniques described for treatment of biliary tract disease and trauma. much higher. Fig. in order to appose the gallbladder’s longitudinal axis and the antimesenteric aspect of the proximal duodenum. the EndoGIA. thus rendering primary repair more difficult (Fig. in fact. Stenting techniques are also popular in human medicine but are often inappropriate in dogs and cats because of the higher risks of stent occlusion and because of difficulties with regard to patient compliance.g. 10: Completed cholecystoduodenostomy. Cases of biliary obstruction secondary to transient. whilst the primary condition resolves. non-biliary disease (e. 9) is placed to appose the duodenum and gallbladder. Laparoscopic stapling devices (e. along the longitudinal axis of the gallbladder.Vol 12 No 1 January 2007 . 5. the vast majority of situations can be addressed by performing cholecystotomy. If the ends of the first suture line are tied but not cut. The end of the short limb of the initial knot can be clamped and employed as a further stay suture whilst the suture line is being constructed. or by effecting biliary diversion via cholecystoduodenostomy. Synthetic absorbable suture material is used. Tyco) can also be employed to create a swift. 9: Cholecystoduodenostomy in a dog. The first suture line has been completed. In veterinary medicine.

UK Vet . Holt. The prognosis for patients with biliary peritonitis is very much dependent on the presence of bacteria within the peritoneal effusion. (2003) JSAP 44[5]:231-235 Extrahepatic biliary tract surgery in the cat: a case series and review. A. correct choice of instrumentation and suture material and finally. and WHITE R. The creation of a large stoma when performing cholecystoduodenostomy will decrease both the risks of post-operative stoma stenosis and of reflux cholangiohepatitis.Vol 12 No 1 January 2007 SMALL ANIMAL G SURGERY ### 5 . careful attention to surgical technique. MAYHEW et al (2002) JSAP 43[6]:247-253 Pathogenesis and outcome of extrahepatic biliary obstruction in cats. Cats are generally recognized as representing a greater challenge than dogs. FURTHER READING FAHIE et al (1995) JAAHA 31[6]:478-482 Extrahepatic biliary tract obstruction : a retrospective study of 45 cases (1983-1993). E. PIKE et al (2004) JAVMA 224[10]:1615-1622 Gallbladder mucocoele in dogs: 30 cases (2000-2002). the selection of an appropriate procedure performed on viable tissue are all major factors in the success of surgery in addressing biliary tract problems. merit an extremely guarded prognosis. in achieving a successful outcome following biliary surgery. J.Atraumatic tissue handling. Alasdair Hotston Moore and Ivan Doran. © Photographs courtesy of Professor P. HERMAN et al (2005) JAVMA 227[11]:1782-1786 Therapeutic percutaneous ultrasound-guided cholecystocentesis in three dogs with extrahepatic biliary obstruction and pancreatitis. LUDWIG et al (1997) Vet Surg 26[2]:90-98 Surgical treatment of bile peritonitis in 24 dogs and 2 cats : a retrospective study (1987-1994) BACON N. Animals with a septic biliary peritonitis carry a considerably worse prognosis than animals with a sterile biliary peritonitis.carcinoma. MEHLER et al (2004) Vet Surg 33 [6]:644-649 Variables associated with outcome in dogs undergoing extrahepatic biliary surgery : 60 cases (1988-2002).