Partial Pancreatectomy and Splenectomy Using a Bipolar Vessel Sealing Device in a Cat with an Anaplastic Pancreatic Carcinoma

Zurich Open Repository and Archive University of Zurich Main Library Strickhofstrasse 39 CH-8057 Zurich www.zora.uzh.ch

Year: 2012

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

Knell, Sebastian Christoph ; Venzin, C

Abstract: 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.

DOI: https://doi.org/10.1024/0036-7281/a

Other titles: Partielle Pankreatektomie und Splenektomie mittels Ligasure bei der Katze mit einem pankreatischen anaplastischen Karzinom

Posted at the Zurich Open Repository and Archive, University of Zurich ZORA URL: https://doi.org/10.5167/uzh-64420 Journal Article Accepted Version

Originally published at: Knell, Sebastian Christoph; Venzin, C (2012). Partial pancreatectomy and splenectomy using a bipolar vessel sealing device in a cat with an anaplastic pancreatic carcinoma. Schweizer Archiv für Tierheilkunde, 154(7):298-301. DOI: https://doi.org/10.1024/0036-7281/a 1

1 Partial pancreatectomy and splenectomy using a bipolar vessel 2 sealing device in a cat with an anaplastic pancreatic carcinoma 3 4 5 S. C. Knell

6 C. Venzin

8 Summary

9 A fourteen year old domestic shorthair cat was presented because of vomiting, 10 anorexia and an abdominal mass. A diagnosis could not be made pre operative and 11 in surgery the mass was assigned to the gastric part of the pancreas. A partial 12 pancreatectomy and splenectomy was performed using a Ligasure® vessel sealing 13 device. No surgery related complications occurred. Histological examination revealed 14 an anaplastic carcinoma of the pancreas. The cat was in a good clinical condition 14 15 days after surgery. After two months the private vet euthanized the cat with the 16 suspicion of a pathologic fracture. Review of the xray suggested a bone tumor but 17 histology was not performed to confirm that. Findings in this case indicated that 18 pancreatic carcinoma in cats has a poor prognosis a previously described, but 19 pancreatectomy can be performed as known in dogs and humans using a bipolar 20 vessel sealing device as a safer and faster alternative to standard surgical 21 techniques. 22 23 24 25

26 Keywords: cat, vessel sealing device, partial pancreatectomy, splenectomy, 27 anaplastic pancreatic carcinoma 28 29

31 2

32 Partielle Pankrektomie und Splenektomie mittels Ligasure bei der 33 Katze mit einem pankreatischen anaplastischen Karzinom 34

36 Zusammenfassung

37 Im Notdienst wurde eine 14 jährige europäisch Kurzhaarkatze mit vorberichtlichem 38 Erbrechen und Anorexie vorgestellt. In der klinischen Untersuchung und im 39 Ultraschall wurde eine abdominale Masse palpiert bzw. dargestellt, die präoperativ 40 nicht näher spezifiziert werden konnte und intraoperativ dem Pankreas zugeordnet 41 wurde. Eine partielle Pankrektomie mittels einem bipolaren 42 Gefässversiegelungsgerät (Ligasure ®) verlief ohne Komplikationen und die Katze 43 zeigte ein gutes Allgemeinbefinden 14 Tage nach der Operation. Histologisch konnte 44 ein Pankreaskarzinom diagnostiziert werden. Weitere 2 Monate später wurde die 45 Katze mit Verdacht auf eine pathologische Fraktur eingeschläfert, ohne dass dies 46 histologisch untersucht wurde. Dieser Fallbericht unterstreicht die schlechte 47 Prognose von Pankreaskarzinomen bei Katzen und zeigt die partielle Pankrektomie 48 mittels Ligasure® als schnelle und sichere Alternative zu konventionellen Techniken 49 bei der Katze. 50 51

63 3

65 Introduction

66 Cancer of the exocrine pancreas is very rare in dogs and uncommon in cats

67 (Davenport, 1985). Most pancreas cancer in cats are adenocarcinomas of ductular or

68 acinar origin (Withrow, 2007). The prognosis for these animals is considered poor

69 and metastases, usually to liver, lymph nodes or the lungs, are often widespread at

70 the time of diagnosis (Bennett, 1997; Thomson, 2003). The use of bipolar

71 electrosurgical vessel sealing devices is becoming more and more common both in

72 human and veterinary medicine for a variety of surgical procedures. These include

73 partial pancreatectomy in dogs and humans (Hartwig et al., 2010; Wouters et al.,

74 2011), laparoscopic ovariectomy in dogs and horses (Hand et al., 2002; Mayhew and

75 Brown, 2007; Dupré et al., 2009), splenectomy in dogs (River and Monnet, 2010),

76 resection of elongated soft palate (Bredecka et al., 2008) and partial hepatectomy in

77 dogs (Risselada et al., 2010). To the authors’ knowledge, their use in cats has thus

78 far not been described. The present report documents the successful removal of a

79 pancreatic carcinoma with partial pancreatectomy and total splenectomy using a

80 bipolar vessel sealing device in a cat.

82 Clinical examination and diagnosis

83 A 14-year-old female spayed domestic shorthair cat was referred to the veterinary

84 hospital with a two-day history of vomiting, apathy and anorexia. The cat was

85 diagnosed with diabetes mellitus four years prior to presentation and had been in

86 remission until one month ago when insulin therapy was reinstituted.

87 The cat was in a lethargic condition and the abdominal palpation revealed

88 discomfort and a cranial abdominal mass of approximately 4cm diameter. The

89 remaining was unremarkable. A complete blood count, serum biochemistry, 4

90 fructosamin and urinalysis revealed leukopenia (leukocytes 3.8 x109/l; reference

91 range 4.6-12.8 x109/l), hyperglycemia (glucose 25.6 mmol/l; RR 4.0-9.0 mmol/l),

92 hypoproteinemia (total protein 58 g/l; RR 64-80 g/l), a mildly elevated serum lipase

93 (116 U/l; RR 8-26 U/l), elevated serum fructosamin (481 µmol/l; RR 202-299 µmol/l),

94 and glucosuria. Serum fructosamin was elevated. Abdominal ultrasound revealed a

95 hypoechoic space-occupying mass (3.5cm x 3cm) in contact to the hilus of the

96 spleen and moderately enlarged lymph nodes in the iliocaecal region (Fig 1). The

97 liver appeared hypoechoic. Cytology of the mass and the lymph nodes, collected by

98 ultrasound-guided fine-needle aspiration were not diagnostic and exploratory surgery

99 was performed.

100 Surgical Procedure

101 A standard midline exploratory coeliotomy was performed and a mass close to

102 the hilus of the spleen, originating from the left pancreatic lobe, was encountered. A

103 partial pancreatectomy including removal of the spleen was accomplished using a

104 bipolar vessel sealing device (Ligasure® 5mm controlled by ForceTriad® Energy

105 Platform, Covidien, Bolder, CO, USA). Vascularisation of the remaining pancreas

106 was spared (Fig. 2) and a margin to the mass of approximately 3 cm was respected.

107 The Ligasure® was applied without any previous dissection by sealing the short

108 gastric vessels, the splenic artery and vein and the gastroepiploic artery and vein

109 including partial removal of the omentum. Biopsies were taken from gastric and

110 iliocaecal lymph nodes and the liver.

111 The abdomen was subsequently lavaged with warmed lactated Ringer’s

112 solution before routine abdominal closure following a total surgical time of 65

113 minutes. Histological examination of the resected pancreatic segment revealed a

114 poorly-differentiated carcinoma that was completely excised with clean margins.

115 Hepatic and lymph node biopsies did not show any evidence of metastasis. 5

116

117 Recovery and further examination

118 The cat made a satisfactory recovery from the surgery and was discharged 7

119 days postoperatively. Follow-up examination performed 2 weeks after surgery was

120 unremarkable and no evidence of abdominal effusion was found either on palpation

121 or ultrasonographically. Further bloodwork to assure diabetes control and

122 chemotherapy using gemcitabine (cytostatic cytidine analogue leading to apoptosis)

123 were declined by the owner. Two months after surgery, the cat was presented to the

124 referring veterinarian with acute hindlimb lameness. Radiographs of the left femur

125 revealed a supracondylar short oblique simple femur fracture with a moth-eaten

126 appearance of the bone. Thoracic laterolateral and ventrodorsal radiographs did not

127 show evidence of pulmonary metastasis at that time. A pathologic fracture was

128 suspected and the cat was euthanized at the owner’s request. Post-mortem

129 examination was declined by the owner.

130

131 Discussion

132 The presented case documents the successful removal of a pancreatic mass

133 and the spleen using a bipolar vessel sealing device in a cat. No surgical

134 complications were encountered and the cat recovered uneventfully from surgery. It

135 has been shown in pigs that postoperative markers for pancreatitis were lower using

136 the bipolar vessel sealing device (Hartwig et al., 2010). The seal of the pancreatic

137 tissue, the less handling necessary for separation of the pancreatic tissue, the

138 reduced surgical time and the decreased thermal damage compared to conventional

139 devices results in less risk of postoperative complications (Kennedy et al., 1999;

140 Stranahan et al., 1999; Goldstein et al., 2002; Wouters et al., 2011). 6

141 Surgical alternatives to the use of this device include partial pancreatectomy

142 performed by suture fracture technique or dissection ligation (Allen et al.,1989).

143 Complete removal of the spleen was performed because adhesions between the

144 tumour and the spleen were present. Preservation of the spleen was considered

145 impossible without risking damage of the splenic artery and vein and was considered

146 necessary to achieve clean margins for the resection of the tumor. Little is known

147 about the outcome in splenectomies performed in cats. One study found preoperative

148 weight loss to be associated with outcome (3 vs 293 days median survival time) in

149 feline patients with splenectomy. Even though all of these had splenic masses,

150 mostly Mastocytoma, and survival is most likely to be associated with the splenic

151 mass rather than with the splenectomy itself. In the presented case the primary tumor

152 was pancreatic and the splnectomy was performed because of adhesions so direct

153 comparison may be difficult (Gordonet al., 2010).

154 Two to three separated sealing procedures next to each other for artery and

155 vein are recommended for splenectomy in dogs weighing up to 66 kg using the

156 Ligasure® to achieve a secure seal (Rivier and Monnet, 2010). In the cat as reported

157 here, only one seal and dissecting step was performed without evidence of intra- or

158 postoperative hemorrhage. It was considered safe and time saving. However,

159 general recommendations for splenectomy in cats using this device cannot be made

160 based on a single case. In humans, recommendations regarding the use of

161 Ligasure® for splenectomy do not include the separation of vein and artery and

162 multiple sealing steps (Romano et al., 2002; Romano et al., 2007).

163 Considering the smaller size of the patient, the total operative time of 65

164 minutes in the present report is comparable to a mean of 78 minutes reported for

165 splenectomies in dogs (Rivier and Monnet, 2010) and 107 minutes for partial

166 pancreatectomy in dogs (Wouters et al., 2011). In the presented case the decrease 7

167 in surgery time might also be due to the direct seal of artery and vein and the

168 dissection to separate these two vessels. In humans, decreased operative time is

169 reported with the use of Ligasure over stapling devices for splenectomy without a

170 seal of artery and vein (Romano et al., 2007).

171 The bipolar vessel sealing device used seals vessels with a different

172 technique than the commonly used conventional bipolar systems using lower voltage

173 and higher currents. Compression of the jaws and the heat generated induce fusion

174 of collagen and elastin in vessel walls and subsequent tissue reformation with

175 creation of a permanent seal zone (Kennedy et al., 1999; Heniford et al., 2001;

176 Shamiyeh et al., 2002). The tissue damage is limited because the heat created

177 reaches only 50-80°C compared to up to 600°C with the electric scalpel. This results

178 in reduced healing time and lowers the risk for scar tissue formation (Stranahan et

179 al., 1999). The collateral spread of 0.5-2 mm is achieved by using tissue impedance

180 measurement, reduced fusing cycle time and tissue desiccation (Kennedy et

181 al.,1999; Stranahan et al., 1999; Heniford et al., 2001; Goldstein et al., 2002). The

182 seal created resists three times the normal blood pressure and arteries up to 7mm in

183 diameter can be securely sealed in humans (Kennedy et al., 1999; Shamiyeh et al.,

184 2002). Another advantage is the feedback control of the Ligasure® that indicates a

185 complete seal of the vessel by a tone. This is determined by measuring the

186 impedance of the sealed tissue. In contrast, an incomplete seal is documented by an

187 alarm tone giving the surgeon the opportunity to apply the jaws properly and avoiding

188 severe bleeding due to an incomplete seal. The use of Ligasure® has improved

189 several procedures in human medicine by creating faster healing time, shorter

190 hospitalisation periods, less pain and overall lower complication rates (Chiappa et al.,

191 2008; Remzi et al., 2008; Kovacs et al., 2009). In some veterinary procedures, it has 8

192 also been stated to result in faster operating time, less morbidity and shorter

193 hospitalisation time (Wouters et al., 2011; Rivier and Monnet, 2010).

194 Next to the advantages listed above the Ligasure® is an expensive

195 investment. The control unit is offered for approximately 30.000 SFr and each

196 instrument is another 500-600 SFr. The instruments are sold as single use devices

197 but they can be reused after gas sterilization several times.

198 The use of the Ligasure® appears as a safe and quick technique for splenectomy in

199 cats. As only one case was presented a prospective comparative study is warranted

200 to make conclusions generally applicable and to further evaluate the need for

201 separately sealing artery and vein because this report and the human literature are

202 contradictionary to the veterinary literature.

203

204

205 Acknowledgements

206 The authors wish to thank Dr. J. Howard for her writing assistance.

207 9

207

208 Figures

209 Figure 1: Abdominal ultrasound showing the mass adjacent to the otherwise normal

210 appearing spleen.

211

212

213

214

215

216

217

218

219

220 10

221 Figure 2: Dissection of the pancreas with the Ligasure® bipolar vessel sealing

222 device.

223

224

225

226

227 11

227 References

228 Allen S.W., Cornelius L.M., Mahaffey E.A.: A comparison of two methods of partial 229 pancreatectomy in the dog. Vet. Surg. 1989, 18:274-278. 230 231 232 Bennett P.F.: Clinical and diagnostic features in 17 dogs and 5 cats with exocrine 233 pancreatic tumors: 1979-1997. Proceedings in Veterinary Cancer Society. 1997, 109. 234 235 236 Brdecka D.J., Rawlings C.A., Perry A.C., Anderson J.R.: Use of an electrothermal, 237 feedback-controlled, bipolar sealing device for resection of the elongated portion of 238 the soft palate in dogs with obstructive upper airway disease. J. Am. Vet. Med. 239 Assoc. 2008, 15:1265-1269. 240 241 Chiappa A., Bertani E., Biffi R., Zbar A.P., Viale G., Pruneri G., Bellomi M., Andreoni 242 B.: Effectiveness of LigaSure diathermy coagulation in liver surgery. Surg. Technol. 243 Int. 2008, 17:33-38. 244 245 246 Davenport D.: Pancreatic carcinoma in twenty dogs and five cats. Vet. Cancer Soc. 247 Mtg. 1985. 248 249 250 Dupré G., Fiorbianco V., Skalicky M., Gultiken N., Ay S.S., Findik M.: Laparoscopic 251 ovariectomy in dogs: comparison between single portal and two-portal access. Vet. 252 Surg. 2009, 38:818-824. 253 254 255 Gordon S.S., McClaran J.K., Bergman P.J., Liu S.M.:Outcome following splenectomy 256 in cats. J Fel Med Surg. 2010, 12:256-261 257 258 259 Goldstein SL, Harold KL, Lentzner A, Matthews BD, Kercher KW, Sing RF, Pratt B., 260 Lipford E.H., Heniford T.: Comparison of thermal spread after ureteral ligation with 261 the Laparo-Sonic ultrasonic shears and the Ligasure system. J. Laparoendosc. Adv. 262 Surg. Tech. A. 2002, 12:61-63. 263 264 265 Hand R., Rakestraw P., Taylor T.: Evaluation of a vessel-sealing device for use in 266 laparoscopic ovariectomy in mares. Vet. Surg. 2002, 31:240-244. 267 268 269 Hartwig W., Duckheim M., Strobel O., Dovzhanskiy D., Bergmann F., Hackert T., 270 Büchler M.W., Werner J.: LigaSure for pancreatic sealing during distal 271 pancreatectomy. World J. Surg. 2010, 34:1066-1070. 272 273 274 Heniford B.T., Matthews B.D., Sing R.F., Backus C., Pratt B., Greene F.L.: Initial 275 results with an electrothermal bipolar vessel sealer. Surg. Endosc. 2001, 15:799-801. 276 12

277 278 Kennedy J.S., Buysse S.P., Lawes K.R.: Recent innovations in bipolar 279 electrosurgery. Minimally invasive Therapy and Allied Technologies. 1999, 8:95-99. 280 281 282 Kovacs O., Szanto Z., Krasznai G., Herr G.: Comparing bipolar electrothermal device 283 and endostapler in endoscopic lung wedge resection. Interact. Cardiovasc. Thorac. 284 Surg. 2009, 9:11-14. 285 286 287 Mayhew P.D., Brown D.C.: Comparison of three techniques for ovarian pedicle 288 hemostasis during laparoscopic-assisted ovariohysterectomy. Vet. Surg. 2007, 289 36:541-547. 290 291 292 Remzi F.H., Kirat H.T., Kaouk J.H., Geisler D.P.: Single-port laparoscopy in 293 colorectal surgery. Colorectal. Dis. 2008, 10(8):823-6. 294 295 296 Rivier P., Monnet E.: Use of a vessel sealant device for splenectomy in dogs. Vet. 297 Surg. 2010, 40:102-105. 298 299 300 Risselada M., Ellison G.W., Bacon N.J., Polyak M.M., van Gilder J., Kirkby K., Kim 301 S.E.: Comparison of 5 surgical techniques for partial liver lobectomy in the dog for 302 intraoperative blood loss and surgical time. Vet. Surg. 2010, 39:856-862. 303 304 305 Romano F., Caprotti R., Franciosi C., De Fina S., Colombo G., Uggeri F.: 306 Laparoscopic splenectomy using Ligasure. Preliminary experience. Surg. Endosc. 307 2002, 16:1608-1611. 308 309 310 Romano F., Gelmini R., Caprotti R., Andreotti A., Guaglio M., Franzoni C., Uggeri F. 311 Saviano M.: Laparoscopic splenectomy: ligasure versus EndoGIA: a comparative 312 study. J. Laparoendosc. Adv. Surg. Tech. A. 2007, 17:763-767. 313 314 315 Shamiyeh A., Schrenk P., Tulipan L., Vattay P., Bogner S., Wayand W.: A new 316 bipolar feedback-controlled sealing system for closure of the cystic duct and artery. 317 Surg. Endosc. 2002, 16:812-813. 318 319 320 Stranahan P.L., Buysse S.P., Ryan T.P., Pearce J.A., Thomson S., Sieve V.D.: 321 Healing process and histologic evaluation following use of bipolar energy for vessel 322 sealing. Valleylab, a Division of Tyco Healthcare Group. Boulder, Colorado, 323 USA1999. 324 325 326 Thomson M.: Oncology - Alimentary tract, Liver and Pancreas. In: Kuntz C, editor. 327 Textbook of small animal oncology. 2003, 2368-78. 13

328 329 330 Withrow S.J.: Exocrine Pancreatic Cancer. In: Withrow S.J., Vail DM, editors. 331 Withrows and Macewens Small Animal Clinical Oncology. 4th ed. St. Louis, Missouri: 332 Saunders, 2007, 479-480. 333 334 335 Wouters E.G., Buishand F.O., Kik M., Kirpensteijn J.: Use of a bipolar vessel-sealing 336 device in resection of canine insulinoma. J. Small Animal Pract. 2011, 52:139-145. 337 338 339 340 341 Corresponding author

342 Claudio Venzin 343 Department of Small Animal Surgery 344 Vetsuisse Faculty University of Zurich 345 Winterthurerstrasse 260 346 8057 Zurich 347 Switzerland 348 [email protected] 349

350