Successful surgical management of pancreatic torsion in a 3-month-old Bernese Mountain dog without evidence of long-term pancreatic dysfunction.

To describe the clinical presentation, diagnosis, perioperative management and the short- and long-term outcomes of a dog diagnosed with pancreatic torsion. A 3-month-old female intact Bernese Mountain dog presented for an acute onset of vomiting, anorexia and abdominal pain. Abdominal ultrasonography showed a hypoechoic mass effect cranial to the stomach. A pancreatic torsion was diagnosed during exploratory laparotomy and treated with partial pancreatectomy. Histopathology confirmed pancreatic torsion. The patient recovered uneventfully and pancreatic function and inflammation testing that was performed 14 months postoperatively showed no evidence of ongoing dysfunction. This is the first report that demonstrates long-term follow-up with pancreatic function testing in a patient who had a partial pancreatectomy due to pancreatic torsion. There was no evidence of long-term pancreatic dysfunction due to partial pancreatectomy secondary to pancreatic torsion. Additionally, this is the youngest patient with pancreatic torsion to be described in the veterinary literature.

Pancreatic adenocarcinoma treated with surgical resection, toceranib phosphate and firocoxib in a dog: a case report.

Exocrine pancreatic carcinomas are rarely reported in dogs. A ductal pancreatic adenocarcinoma in a 10-year-old intact beagle is described in this report. The diagnosis was made based on clinical signs, imaging (abdominal ultrasound and CT scan) and histopathology. Treatment consisted of partial right lobe pancreatectomy followed by adjuvant therapy with toceranib phosphate (Palladia®) and firocoxib (Previcox®) for six months. The treatment was well tolerated, and the survival time was 445 days. To our knowledge, this is the longest survival reported in the literature for a dog diagnosed with exocrine pancreatic adenocarcinoma. The results described here may contribute to provide a better understanding about this neoplasia and potential treatment options.

Nesidioblastosis and Subsequent Diabetes Mellitus in a Dog with Hyperinsulinemic Hypoglycemia Treated with Partial Pancreatectomy.

A 6.5 yr old castrated male mixed-breed dog was presented for clinical signs associated with hypoglycemia. Hyperinsulinemic hypoglycemia was diagnosed as the cause of the persistent hypoglycemia. No obvious pancreatic mass was seen on abdominal computed tomography and exploratory laparotomy. A partial pancreatectomy was performed with the suspicion of an insulinoma-causing hyperinsulinemic hypoglycemia. Nesidioblastosis was diagnosed based clinical, biochemical, and histopathologic findings. There was beta cell hyperplasia and no evidence of neoplasia. The dog was euglycemic postoperatively after a partial pancreatectomy. Long-term follow-up after 2 yr revealed that the dog was diagnosed with diabetes mellitus.

Laparoscopic partial pancreatectomy of the left limb using a harmonic scalpel in nine cats.

OBJECTIVE: To describe a laparoscopic technique and outcome for partial pancreatectomy in cats. STUDY DESIGN: Prospective cohort study. ANIMALS: Nine cats. METHODS: Laparoscopic pancreatectomy was performed using a single incision laparoscopic surgery port and an additional 5.5 mm port. The left pancreatic limb was dissected, sealed and divided at the level of the splenic vein insertion to the portal vein using a harmonic device. Surgical time and complications were recorded. The weight and length of the resected pancreatic limb was recorded. Pre- and postoperative trypsin-like immunoreactivity (TLI), pancreatic lipase immunoreactivity (PLI), and hemoglobin A1C were documented. RESULTS: Laparoscopic partial pancreatectomy was performed successfully in all cats. One grade 1 intraoperative complication occurred (1/9; 11%) resulting in minor hemorrhage from a caudal splenic vein branch. A grade 2 postoperative complication occurred within 3 days after surgery in one cat (1/9; 11%), involving localized, sterile peritonitis in the region of the pancreatic angle. Signs resolved with conservative management. No cats exhibited signs of pancreatitis postoperatively. Long-term, mean TLI decreased by 37% ± 38% (p = .03) following partial pancreatectomy, while PLI and A1C were unchanged. All cats were alive and clinically well at last follow-up 250 to 446 days following surgery. CONCLUSIONS: Laparoscopic partial pancreatectomy using a harmonic device is effective in cats, and offers a minimally-invasive alternative to open surgical pancreatectomy techniques. Laparoscopic pancreatectomy of the left limb results in adequate exocrine and endocrine function in the long-term.

A true congenital pancreatic cyst in a dog.

BACKGROUND: True congenital pancreatic cysts are a rare pathological process reported within feline and human literature. To date there has been no documented case of a true congenital cyst affecting a canine patient. The objective of this case report is to document the clinical findings, diagnostic investigations, surgical treatment, histopathological diagnosis and long-term outcome of a dog with a true pancreatic cyst. CASE PRESENTATION: A 5-month-old crossbreed dog was presented with a six-week history of abdominal pain, apparent bilateral pelvic limb weakness, reluctance to walk and intermittent vomiting and diarrhoea. An abdominal ultrasound examination performed by the dog's primary care veterinarian identified a large intra-abdominal structure of unclear origin. A computed tomographic examination identified a large ovoid structure measuring 156 mm in length, 95 mm in height and 89 mm in width and apparently originating from the left limb of the pancreas. An exploratory coeliotomy was performed and a partial pancreatectomy was performed to allow complete removal of the cystic structure. Histopathological analysis of sections of the wall of the large fluid-filled cyst identified a thick fibromuscular wall lined by a well regimented hyperplastic tall columnar epithelium with basally located round to ovoid nuclei featuring fine chromatin stippling and abundant apically located and surface mucin, concurrent with a true congenital pancreatic cyst. A long-term follow-up of twenty-nine months identified no clinical signs of recurrence. CONCLUSION: A partial pancreatectomy and en bloc excision of a true pancreatic cyst provided an excellent long-term outcome in a dog.

Intrapancreatic accessory spleen mimicking pancreatic insulinoma with intrapancreatic metastasis in a cat.

An 11-year-old neutered male Domestic Shorthair cat presented with a 3-month history of hypoglycemia, two episodes of seizure, and intermittent tick-like signs. Serum biochemistry revealed severe hypoglycemia associated with high insulin concentrations. Dynamic abdominal computed tomography (CT) indicated two pancreatic masses, which were enhanced most during the late arterial phase but had different degrees and variations of attenuation. Partial pancreatectomy was performed. Histopathology and immunohistochemistry confirmed that one mass was an insulinoma and the other was an ectopic splenic tissue, consistent with the differences in imaging findings. When an intrapancreatic lesion with hyper-attenuation on dynamic abdominal CT is detected, not only insulinoma or metastasis of malignancies but also intrapancreatic accessory spleen (IPAS) should be considered as differential diagnoses.

Pancreatic adenosquamous carcinoma with invasion to the spleen in a cat.

A four-and-a-half-year-old female Scottish Fold cat underwent partial pancreatectomy with en-bloc splenectomy. The resected specimen was a biphasic tumor that was diagnosed histologically and immunohistochemically as pancreatic adenosquamous carcinoma (ASC), a ductal carcinoma variant according to the WHO classification of tumors in humans. There was a gradual transition between the adenocarcinoma component and the squamous cell carcinoma component. The squamous cell carcinoma component comprised approximately 30-40% of the tumor. A pancreatic tumor infiltrated into the gastrosplenic ligament and spleen with regional lymph node and mesenteric metastases. Pancreatic ASC has not been reported in animals. This is a case report of feline pancreatic ASC with splenic involvement.

Technological Advances in Surgical Equipment in Exotic Pet Medicine.

Surgery can be challenging in exotic pets owing to their small size and blood volume, and their increased anesthetic risk compared with small animals. Various devices are available to facilitate suturing, cutting, and hemostasis in the human and veterinary fields. These surgical equipment improve the simplicity, rapidity, and effectiveness of surgery. Vessel-sealing devices, radiosurgery, lasers, and ultrasound devices are commonly used because of their ease of use and increase in surgical efficiency. Other surgical devices are available (eg, stapling devices) but are not discussed in this article.

Long-Term Survival and Glycemic Control with Toceranib Phosphate and Prednisone for a Metastatic Canine Insulinoma.

Canine insulinoma is a highly metastatic neoplasm that is associated with a guarded to poor prognosis in dogs with distant metastases. A median survival of 6 mo has been reported for dogs with metastatic insulinoma. The dog in this report, diagnosed with stage III pancreatic insulinoma, had long-term glycemic control with survival of over 24 mo while receiving prednisone and toceranib phosphate after partial pancreatectomy. Toceranib phosphate has been shown to be an efficacious therapy for canine mast cell tumors with increasing evidence that it may be beneficial in the medical management of neuroendocrine tumors.

Resolution of hyperinsulinemic hypoglycemia following partial pancreatectomy in a dog with nesidioblastosis.

CASE DESCRIPTION A 6-year-old castrated male Australian Shepherd was evaluated because of a recent onset of persistent hypoglycemia. CLINICAL FINDINGS Physical examination results were generally unremarkable. No abnormalities were detected on thoracic radiographs, and abdominal ultrasonography revealed no obvious pancreatic lesion. Hematologic analysis revealed hypoglycemia with a high serum insulin-to-glucose concentration ratio. TREATMENT AND OUTCOME Insulinoma was suspected; medical treatment with prednisone was initiated, and exploratory laparotomy was performed. No pancreatic lesions or masses were observed. Partial left pancreatectomy and hepatic and local lymph node biopsies were performed. Histologic examination revealed islet cell hypertrophy and hyperplasia, with no evidence of neoplasia. Results of a PCR assay of the pancreatic tissue for Bartonella infection were negative. Clinical, biochemical, and histopathologic findings were compatible with nesidioblastosis. The clinical signs, including hypoglycemia, resolved after surgery. On follow-up examination 8 months later, the dog was apparently healthy and results of a CBC and serum biochemical analysis, including blood glucose concentration, were within respective reference ranges. CLINICAL RELEVANCE To our knowledge, this is the first report of nesidioblastosis in a dog for which clinical signs and clinicopathologic abnormalities resolved after partial pancreatectomy. Although extremely rare, nesidioblastosis should be considered a differential diagnosis in dogs with signs suggestive of insulinoma.

Laparoscopic Resection of a Pancreatic ß Cell Tumor in a Dog.

Laparoscopic partial pancreatectomy has been performed in experimental canine studies and has been evaluated in human medicine but has not been reported in a clinical veterinary case. The authors present a 9 yr old field spaniel with weakness and hypoglycemia with insulin levels and Amended Insulin: Glucose Ratio results equivocal for a pancreatic insulinoma. Multiple abdominal ultrasounds did not detect the tumor, yet dual-phase computed tomographic angiography revealed the presence of a focal hypoattenuating nodule in the left lobe of the pancreas. A 3-port laparoscopic approach to the abdomen confirmed a 1.5-cm mass in the mid-left limb of the pancreas, and resection of the mass was performed with a bipolar vessel-sealing device. The surgery was performed without complication, and the dog became normoglycemic within 4 hr following surgery. Final histopathology results revealed pancreatic neuroendocrine carcinoma of the ß cells. Recurrence of hypoglycemia was noted 18 mo postoperatively; however, repeat computed tomographic angiography did not reveal pancreatic abnormalities and fine needle aspirates of liver nodules did not suggest metastatic disease. Medical management was elected and the patient was euthanized 28 mo after surgery due to refractory hypoglycemic seizures.

Lymphocytic mural folliculitis and pancreatic carcinoma in a cat.

A 9-year-old castrated domestic shorthair cat was presented with a 6 week history of progressive non-pruritic alopecia, polyphagia and weight loss. A diagnosis of lymphocytic mural folliculitis was made and the cat was treated with a combination of prednisolone and ciclosporin; this produced an improvement in the alopecia but no resolution. Sixteen months after the initial assessment and diagnosis, the cat was re-evaluated for intermittent vomiting and weight loss with normal appetite. On examination the dermatopathy was still evident and a mass involving the duodenum and pancreas was present, which was diagnosed as a pancreatic carcinoma. From this case it would appear that lymphocytic mural folliculitis might be an early dermatological manifestation of pancreatic neoplasia.

Contrast-enhanced ultrasonographic findings in three dogs with pancreatic insulinoma.

Abdominal ultrasonography is one of the most common diagnostic imaging modalities used for dogs with suspected insulinoma; however, pancreatic masses are clearly identified in fewer than half of affected dogs and benign pancreatic nodules can be difficult to differentiate from malignant ones. The purpose of this prospective study was to describe contrast-enhanced ultrasonography (CEUS) characteristics of confirmed pancreatic insulinoma in a group of dogs. Inclusion criteria were as follows: (1) repeated hypoglycemia (blood glucose levels <60 mg/dl, twice or more); (2) elevated blood insulin levels with hypoglycemia; (3) pancreatic nodules detected with conventional ultrasonography; and (4) histological confirmation of pancreatic islet cell carcinoma. Immediately following conventional ultrasonography of the entire abdomen, CEUS of the pancreatic nodule and adjacent parenchyma was performed using contrast-specific technology pulse inversion imaging and perflubutane microbubble contrast agent. Three dogs met inclusion criteria. Pancreatic nodules in all the three dogs became more clearly demarcated after injection of the contrast agent. Each nodule showed different enhancement patterns: markedly hyperechoic for 5 s, slightly hyperechoic for 1 s, and clearly hypoechoic for over 30 s. These results were not in complete agreement with previously reported CEUS findings in human patients with insulinoma. All nodules were surgically resected and histopathologically confirmed as malignant insulinomas. Findings from the current study indicated that contrast-enhanced ultrasound may help to increase conspicuity of pancreatic insulinomas in dogs and that enhancement characteristics may be more variable in dogs than in humans.

Prolonged survival in an aged Labrador retriever with a metastatic insulinoma.

This case report highlights an unusually prolonged, asymptomatic, disease-free interval in an aged male Labrador retriever that underwent partial pancreatectomy for a functionally active pancreatic insulinoma with histologically confirmed hepatic metastasis. The patient developed pancreatitis and nonseptic suppurative peritonitis 24 hr after surgical resection of the insulinoma and was managed medically until discharge. Three mo after surgery, the dog was diagnosed with exocrine pancreatic insufficiency (EPI) that was effectively managed with parenteral pancreatic enzymes. Due to normal glucose levels 3 mo postsurgically, liver samples from the initial surgery were resubmitted for immunohistochemistry. Results confirmed insulinoma metastasis with insulin expression. Ten mo postsurgically, the blood glucose was normal and serum insulin levels were slightly above the upper reference limit. The first hypoglycemic episode was documented 23 mo postoperatively, which was effectively managed with prednisone. The cause for the prolonged disease remission and survival was unknown, but was possibly a result of pancreatitis and peritonitis, partial spontaneous regression of metastatic lesions, or idiopathic. Despite life-threatening postoperative complications, this patient enjoyed a profoundly longer than expected survival. This case highlights the importance of removing the primary tumor (insulinoma) despite the presence of metastatic disease.

Partial pancreatectomy and splenectomy using a bipolar vessel sealing device in a cat with an anaplastic pancreatic carcinoma.

A 14-year old domestic shorthair cat was presented because of vomiting, anorexia and an abdominal mass. A diagnosis could not be made preoperative and during surgery the mass was assigned to the gastric part of the pancreas. A partial pancreatectomy and splenectomy was performed using a Ligasure® vessel sealing device. No surgery related complications occurred. Histological examination revealed an anaplastic carcinoma of the pancreas. The cat was in a good clinical condition 14 days after surgery. After 2 months the cat was euthanized with the suspicion of a bone tumor. Findings of this case demonstrate that pancreatic carcinoma in cats has a poor prognosis but pancreatectomy can be performed using a bipolar vessel sealing device as a safe and fast alternative to standard surgical techniques.

Use of a bipolar vessel-sealing device in resection of canine insulinoma.

OBJECTIVES: To describe partial pancreatectomy using a bipolar vessel-sealing device (BVSD) and compare this novel technique to the conventional suture-fracture (SF) method for canine insulinoma. METHODS: Pre-, intra- and postoperative data of eight dogs with insulinoma, which underwent resection using the BVSD (LigaSure V), were prospectively collected and compared with those of eight randomly selected case-matched patients that underwent resection using the conventional SF technique. RESULTS: Mean surgical time was significantly (P=0·022) shorter in the BVSD (107 ± 9 minutes) than in the SF (135 ± 22 minutes) group. The BVSD technique was negatively associated with surgical time and duration of the hospitalisation period. Neither technique caused intraoperative complications, such as bleeding, collateral damage to adjacent tissues or problems with sealing or suturing the pancreatic tissue. Three dogs in the SF group and none in the BVSD group developed postoperative clinical signs associated with pancreatitis. CLINICAL SIGNIFICANCE: BVSD is a safe and viable alternative to conventional methods of pancreatectomy for canine insulinoma. It provides the possibility to remove insulinomas in the pancreatic limbs and corpus with relative ease. BVSD pancreatectomy in dogs with insulinoma significantly decreases operative and hospitalisation times and is not associated with more clinical complications than SF pancreatectomy.

Cirugía endoscópica transluminal NOTES: resultados experimentales iniciales / Natural orifice transluminal endoscopic surgery (NOTES): initial experimental results

Introducción: La aparición de la cirugía endoscópica transorificial (NOTES) y de nuevos prototipos para su realización nos llevó a diseñar un programa de cirugía experimental. Material y métodos: Se ha realizado durante 1 año cirugía de NOTES en cerdas, cumpliendo la normativa europea de experimentación animal. Se han practicado 90 intervenciones sin supervivencia animal. En este estudio se ha evaluado: a) complejidad de las vías de acceso (transgástrica, transvaginal, transesofágica y transumbilical); b) técnicas de ayuda para la orientación temporoespacial, y c) posibilidades técnicas de cierre de los orificios viscerales (clips, t-bars®, clips de Obesco® y sutura por endoscopia). Las intervenciones practicadas mediante uno o dos endoscopios han sido: anexectomía, colecistectomía, biopsia de adenopatías mediastínicas, pancreatectomía distal y gastroyeyunostomía. Resultados: Esta experiencia nos ha permitido conocer una serie de aspectos técnicos imprescindibles para el desarrollo del NOTES: a) el neumoperitoneo con CO2 es más seguro para la entrada; b) el tamaño del orificio es importante para limitar la contaminación; c) la entrada con punción y dilatación con guía es más segura; d) la buena localización de la salida gástrica facilita el abordaje de las vísceras a disecar; e) la hemorragia intrabdominal es de difícil control; f) el cierre con garantías absolutas de fuga no existe, los clips no lo garantizan, los t-bars® y clips de Obesco® y la sutura endoscópica pueden funcionar, y g) la posibilidad de utilizar endoscopios que triangulan facilita la disección. Conclusiones: La NOTES requiere de un equipo multidisciplinario con cirujanos laparoscopistas y endoscopistas. La realización de NOTES pura es compleja; posiblemente las formas híbridas o la vía transumbilical sean fases intermedias (AU)

Introduction: The advent of natural orifice endoscopic surgery (NOTES) and new prototypes for performing this surgical procedure led us to design an experimental animal surgical programme. Material and method: NOTES was performed over a period of one year, in sows, following the European guidelines on the use of experimental animals. Ninety operations were performed with no animals surviving. The following aspects were assessed: 1. Access route complexity (transgastric, transvaginal, transesophageal and transumbilical). 2. Support measures for temporal/spatial orientation. 3. Technical possibilities for visceral orifice closure (clips, T-bars®, Obesco® clips and endoscopic suture). Resections of fallopian tubes, ovaries, gallbladder, mediastinal lymph nodes, tail of the pancreas and gastrojejunal derivations were performed with one or two endoscopes. Results: This experience enabled us to highlight a series of technical aspects essential for these techniques: 1. Pneumoperitoneum with CO2 is safer for entry. 2. Orifice size is important to limit contamination. 3. Puncture entry and guided dilation is safer. 4. Good gastric exit location makes it easier to approach viscera to be resected. 5. Intra-abdominal haemorrhage is difficult to control. 6. Leak-free closure cannot be guaranteed with clips, but t-bars® and Obesco® clips may be effective. 7. Endoscopes that permit triangulation may facilitate the dissection and endoscopic suture. Conclusions: NOTES requires a multidisciplinary team comprising laparoscopic and endoscopic surgeons. Pure NOTES is complex and hybrid forms or transumbilical route could be intermediate steps (AU)

Induction of diabetes in rhesus monkeys and establishment of insulin administration strategy.

OBJECTIVES: The diabetic rhesus monkey seems to be a useful model for preclinical investigations of islet transplantation and new drug treatments for type 1 diabetes mellitus (T1DM). Information is limited regarding a standard technique to induce and assess diabetes in rhesus monkeys as well as the strategy to apply insulin administration. Herein, we have established and characterized a model of diabetic rhesus macaques. METHODS: Four monkeys were divided into 2 groups of 2 each: group 1, total pancreatectomy; and group 2, partial pancreatectomy (75%) with low-dose streptozotocin (STZ) administration. Pancreatic function was measured using intravenous glucose tolerance tests before the operation. Spiral computed tomography (CT) scans of the pancreas were obtained before and after pancreatectomy. Fasting blood glucose and postprandial blood glucose levels were monitored twice daily using blood samples from the fingers or toes. Various types and doses of insulin were administered twice daily. We performed regular assessments of hematological and serum biochemical parameters, insulin, and C-peptide. RESULTS: Both total pancreatectomy and partial pancreatectomy (75%) with STZ administration induced T1DM in rhesus monkeys; there was interindividual variation in the STZ dose. Excluding C-peptide and insulin, the hematological and serum biochemical parameters did not differ significantly from normal values postoperatively. The various insulin treatment strategies are achieved stable blood glucose (BG) levels. CONCLUSIONS: STZ injection after partial pancreatectomy may be a safe, reproducible method to induce T1DM. Porcine insulin administration was a safe, economical method to control BG levels in a diabetic rhesus monkey before islet transplantation.