Devastating pancreatitis and duodenal necrosis in a dog<br />Case advisors: Dr K Murphy, Dr J Brown<br />Program advisor: ...
Signalment and history<br />‘Kita’ 6 y.o NF Husky<br />Idiopathic epilepsy since 1 y.o, on phenobarb<br />Got into garbage...
Physical exam<br />Generalised weakness, mentally dull<br />Pyrexic at 40.1°C<br />HR=200bpm, normotensive<br />Abdominal ...
Lab findings<br />Abdominal fluid cytology- degenerate neutrophils +++, no bacteria<br />Severe mixed metabolic and respir...
Lab findings<br />Coagulopathic- PT and aPTT 2X high normal<br />Platelet count 154,000<br />Albumin=26g/L<br />Creatinine...
Imaging<br />
Imaging<br />
Assessment<br />Severe acute pancreatitis+SIRS+/- DIC<br />Global perfusion compromise, acute renal insult, at risk for AR...
Mechanisms of renal insult in acute pancreatitis<br />
Stabilisation plan<br />Crystalloids 50ml/kg+ pentastarch 5ml/kg to achieve adequate volume status- HR↓ 124bpm<br />U-cath...
Surgical plan<br />‘Seek and destroy’ FB<br />View pancreas- biopsy for histo+ culture<br />Visualise biliary system<br />...
Blood supply<br />Exocrine ducts <br /><ul><li>68% dogs have pancreatic duct and accessory pancreatic duct
Accessory duct >>pancreatic duct
32% have accessory duct alone, or 3 ducts</li></ul>Biliary ducts<br />
Options?<br />Duodenum necrotic from pylorus to 20cm distally<br />Entire right limb of the pancreas necrotic<br />Common ...
Literature review<br />No case series or formal case reports x<br />Technique of canine total pancreatectomy for generatin...
Human literature review<br />Sakorafas GHExperience with duodenal necrosis- A rare complication of acute necrotizing pancr...
Pancreatic surgery in acute pancreatitis<br />Indications in humans...<br />Bacteria on cytology or culture from aspirates...
Key points...<br />Anticipate staged approach and need for 		several procedures<br />Conservative technique<br />Retain al...
Insulin<br />Hormone of energy storage<br />Insulin dependency likely post pancreatectomy > 50% (pancreatitis) >80% neopla...
Pancreatectomy- impact on exocrine function<br />EPI inevitable in TP or if pancreatic duct and accessory pancreatic ducts...
Duodenectomy and partial pancreatectomy<br />Advantages<br />Lower risk of insulin dependency vs TP (30-50% vs 100%)<br />...
Partial pancreatectomy , choleduodenostomy and pancreaticojejunostomy<br />
Total pancreatectomy<br />Insulin dependency, ‘brittle’ diabetes inevitable<br />EPI inevitable<br />Biliary re-routing re...
High complication rate<br />20-40% mortality with severe				 pancreatic necrosis<br />80-100% mortality with infected panc...
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Pacreatitis grand rounds

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  • Doppler evaluation failed to identify blood flow in large areas of the pancreas
  • Sagittal view
  • Improve comfortReduce risk of aspiration under ga/ during recoveryImprove surgical visibility
  • Smelt bad, black and green
  • Serosa separating from muscularis
  • No-one involved had ever dealt with anything like this before, so pause to phone a friend.
  • of duodenectomy + partial/total pancreatectomy on canine clinical cases in the literature
  • Hypoglycemia biggest cause of long term complications/ mortality
  • Exocrine duct ligation- combination of polymer infiltration of duct and ligation needed
  • Pacreatitis grand rounds

    1. 1. Devastating pancreatitis and duodenal necrosis in a dog<br />Case advisors: Dr K Murphy, Dr J Brown<br />Program advisor: Dr K Mathews<br />
    2. 2. Signalment and history<br />‘Kita’ 6 y.o NF Husky<br />Idiopathic epilepsy since 1 y.o, on phenobarb<br />Got into garbage 5 days prior to admission<br />Vomiting 48 hours later<br />Generalised seizures X 2<br />Hospitalised on IV fluids for last 2 days, no improvement<br />
    3. 3. Physical exam<br />Generalised weakness, mentally dull<br />Pyrexic at 40.1°C<br />HR=200bpm, normotensive<br />Abdominal pain, abdominal free fluid<br />Injectedm.membs<br />Assessment:Hypovolemic +/- distributive shock<br />DDx- severe acute pancreatitis vs septic peritonitis<br /> Treatment: IV fluid bolus 20ml/kg PLA<br />Hydromorphone<br />
    4. 4. Lab findings<br />Abdominal fluid cytology- degenerate neutrophils +++, no bacteria<br />Severe mixed metabolic and respiratory acidosis<br />PvCO2=30mmHg (27.9 )<br />BE=-13.3<br />Hyperchloremic (-9 of BE)<br />Lactate=2.7<br />
    5. 5. Lab findings<br />Coagulopathic- PT and aPTT 2X high normal<br />Platelet count 154,000<br />Albumin=26g/L<br />Creatinine=297umol/l<br />TBIL=68umol/l<br />Lipase=11,620<br />Leukocytosis + left shift<br />9% bands<br />Assessment<br />?early DIC<br />renal insult<br />suspect biliary obstruction<br />
    6. 6. Imaging<br />
    7. 7. Imaging<br />
    8. 8. Assessment<br />Severe acute pancreatitis+SIRS+/- DIC<br />Global perfusion compromise, acute renal insult, at risk for ARF<br />Suspect common bile duct obstruction<br />?? Sepsis<br />Suspect duodenal FB<br />
    9. 9. Mechanisms of renal insult in acute pancreatitis<br />
    10. 10.
    11. 11. Stabilisation plan<br />Crystalloids 50ml/kg+ pentastarch 5ml/kg to achieve adequate volume status- HR↓ 124bpm<br />U-cath- monitor urine output as @ risk for ARF<br />Fentanyl analgesia<br />FFP 10ml/kg vscoagulopathy<br />NG tube passed, aspirated 1500mls gastric fluid<br />Ampicillin22mg/kg Q6 pending cultures<br />
    12. 12. Surgical plan<br />‘Seek and destroy’ FB<br />View pancreas- biopsy for histo+ culture<br />Visualise biliary system<br />Lavage abdomen and place abdominal drains<br />Place e-tube<br />Place central line<br />
    13. 13.
    14. 14.
    15. 15. Blood supply<br />Exocrine ducts <br /><ul><li>68% dogs have pancreatic duct and accessory pancreatic duct
    16. 16. Accessory duct >>pancreatic duct
    17. 17. 32% have accessory duct alone, or 3 ducts</li></ul>Biliary ducts<br />
    18. 18. Options?<br />Duodenum necrotic from pylorus to 20cm distally<br />Entire right limb of the pancreas necrotic<br />Common bile duct occluded<br />Left limb of the pancreas inflamed <br />
    19. 19. Literature review<br />No case series or formal case reports x<br />Technique of canine total pancreatectomy for generating a human diabetes research model<br />Anecdotal reports- EPI+DM<br />
    20. 20. Human literature review<br />Sakorafas GHExperience with duodenal necrosis- A rare complication of acute necrotizing pancreatitis International J Pancreatology 1999<br />Kingham TPManagement and spectrum of complications in patients undergoing surgical debridement for pancreatic necrosis The American Surgeon 2008<br />Heidt DG Total and partial pancreatectomy: Indications, Operative technique, Postoperative sequelaeJ GastrointestSurg 2007<br />Kahl S Exocrine and endocrine pancreatic insufficiency after pancreatic surgery Clinical Gastroenterology 2004<br />
    21. 21. Pancreatic surgery in acute pancreatitis<br />Indications in humans...<br />Bacteria on cytology or culture from aspirates of peripancreatic fluid - manifests late<br />CT signs of abscess or wide area failing to enhance->necrosis<br />Persistent sepsis manifesting as hemodynamic instability without identifiable source<br />Failure to improve after> 14 days<br />
    22. 22. Key points...<br />Anticipate staged approach and need for several procedures<br />Conservative technique<br />Retain all tissues/ structures until inflammation ↓<br />Place drains to<br />Remove local fluid collections<br />Achieve temporary biliary bypass- flank cystostomy tubes<br />Evacuate intraluminal duodenal /gastric secretions<br />Manage small duodenal perforations with local drainage until later definitive repair<br />Achieve enteral feeding<br />
    23. 23. Insulin<br />Hormone of energy storage<br />Insulin dependency likely post pancreatectomy > 50% (pancreatitis) >80% neoplasia<br />‘Brittle’ diabetes<br />Glargine insulin of choice<br />Glucagon<br />Hormone of energy release<br />Deficit results in<br />↑insulin sensitivity<br />↑hypoglycemic crises<br />↓ketosis<br />↓catecholamine response to hypoglycemia<br />hepatic lipidosis<br />Dog has some enteric sources of glucagon<br />Pancreatectomy- impact on endocrine function<br />
    24. 24. Pancreatectomy- impact on exocrine function<br />EPI inevitable in TP or if pancreatic duct and accessory pancreatic ducts lost<br />↓ HCO3 in GI-> chronic ulcers<br />Malabsorbtion compounded by concurrent gastrectomy<br />Long term therapy with<br />Pancreatic enzymes<br />Proton pump inhibitors<br />Multivitamins<br />Surgical re-routing of exocrine secretions possible<br />
    25. 25. Duodenectomy and partial pancreatectomy<br />Advantages<br />Lower risk of insulin dependency vs TP (30-50% vs 100%)<br />Some glucagon secretion maintained ->↓hepatic lipidosis<br />Disadvantages<br />Exocrine duct ligation -> EPI+ acute/ chronic pancreatitis in pancreatic remnant<br />Pancreaticojejunostomy?<br />
    26. 26. Partial pancreatectomy , choleduodenostomy and pancreaticojejunostomy<br />
    27. 27. Total pancreatectomy<br />Insulin dependency, ‘brittle’ diabetes inevitable<br />EPI inevitable<br />Biliary re-routing required<br />Splenectomy may be required<br />Pancreatic pain reduced<br />Inflammatory focus removed<br />
    28. 28. High complication rate<br />20-40% mortality with severe pancreatic necrosis<br />80-100% mortality with infected pancreatic necrosis managed non-surgically<br />Median ICU stay 20 days<br />15-20% incidence of ARF<br />40-60% incidence ARDS requiring mechanical ventilation<br />20% incidence significant intra-abdominal hemorrhage<br />
    29. 29. Outcome for Kita...... euthanasia in surgery<br />
    30. 30. Questions?<br />
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