1. Devastating pancreatitis and duodenal necrosis in a dog Case advisors: Dr K Murphy, Dr J Brown Program advisor: Dr K Mathews

2. Signalment and history ‘Kita’ 6 y.o NF Husky Idiopathic epilepsy since 1 y.o, on phenobarb Got into garbage 5 days prior to admission Vomiting 48 hours later Generalised seizures X 2 Hospitalised on IV fluids for last 2 days, no improvement

3. Physical exam Generalised weakness, mentally dull Pyrexic at 40.1°C HR=200bpm, normotensive Abdominal pain, abdominal free fluid Injectedm.membs Assessment:Hypovolemic +/- distributive shock DDx- severe acute pancreatitis vs septic peritonitis Treatment: IV fluid bolus 20ml/kg PLA Hydromorphone

4. Lab findings Abdominal fluid cytology- degenerate neutrophils +++, no bacteria Severe mixed metabolic and respiratory acidosis PvCO2=30mmHg (27.9 ) BE=-13.3 Hyperchloremic (-9 of BE) Lactate=2.7

5. Lab findings Coagulopathic- PT and aPTT 2X high normal Platelet count 154,000 Albumin=26g/L Creatinine=297umol/l TBIL=68umol/l Lipase=11,620 Leukocytosis + left shift 9% bands Assessment ?early DIC renal insult suspect biliary obstruction

6. Imaging

7. Imaging

8. Assessment Severe acute pancreatitis+SIRS+/- DIC Global perfusion compromise, acute renal insult, at risk for ARF Suspect common bile duct obstruction ?? Sepsis Suspect duodenal FB

9. Mechanisms of renal insult in acute pancreatitis

11. Stabilisation plan Crystalloids 50ml/kg+ pentastarch 5ml/kg to achieve adequate volume status- HR↓ 124bpm U-cath- monitor urine output as @ risk for ARF Fentanyl analgesia FFP 10ml/kg vscoagulopathy NG tube passed, aspirated 1500mls gastric fluid Ampicillin22mg/kg Q6 pending cultures

12. Surgical plan ‘Seek and destroy’ FB View pancreas- biopsy for histo+ culture Visualise biliary system Lavage abdomen and place abdominal drains Place e-tube Place central line

16. Accessory duct >>pancreatic duct

17. 32% have accessory duct alone, or 3 ductsBiliary ducts

18. Options? Duodenum necrotic from pylorus to 20cm distally Entire right limb of the pancreas necrotic Common bile duct occluded Left limb of the pancreas inflamed

19. Literature review No case series or formal case reports x Technique of canine total pancreatectomy for generating a human diabetes research model Anecdotal reports- EPI+DM

20. Human literature review Sakorafas GHExperience with duodenal necrosis- A rare complication of acute necrotizing pancreatitis International J Pancreatology 1999 Kingham TPManagement and spectrum of complications in patients undergoing surgical debridement for pancreatic necrosis The American Surgeon 2008 Heidt DG Total and partial pancreatectomy: Indications, Operative technique, Postoperative sequelaeJ GastrointestSurg 2007 Kahl S Exocrine and endocrine pancreatic insufficiency after pancreatic surgery Clinical Gastroenterology 2004

21. Pancreatic surgery in acute pancreatitis Indications in humans... Bacteria on cytology or culture from aspirates of peripancreatic fluid - manifests late CT signs of abscess or wide area failing to enhance->necrosis Persistent sepsis manifesting as hemodynamic instability without identifiable source Failure to improve after> 14 days

22. Key points... Anticipate staged approach and need for several procedures Conservative technique Retain all tissues/ structures until inflammation ↓ Place drains to Remove local fluid collections Achieve temporary biliary bypass- flank cystostomy tubes Evacuate intraluminal duodenal /gastric secretions Manage small duodenal perforations with local drainage until later definitive repair Achieve enteral feeding

23. Insulin Hormone of energy storage Insulin dependency likely post pancreatectomy > 50% (pancreatitis) >80% neoplasia ‘Brittle’ diabetes Glargine insulin of choice Glucagon Hormone of energy release Deficit results in ↑insulin sensitivity ↑hypoglycemic crises ↓ketosis ↓catecholamine response to hypoglycemia hepatic lipidosis Dog has some enteric sources of glucagon Pancreatectomy- impact on endocrine function

24. Pancreatectomy- impact on exocrine function EPI inevitable in TP or if pancreatic duct and accessory pancreatic ducts lost ↓ HCO3 in GI-> chronic ulcers Malabsorbtion compounded by concurrent gastrectomy Long term therapy with Pancreatic enzymes Proton pump inhibitors Multivitamins Surgical re-routing of exocrine secretions possible

25. Duodenectomy and partial pancreatectomy Advantages Lower risk of insulin dependency vs TP (30-50% vs 100%) Some glucagon secretion maintained ->↓hepatic lipidosis Disadvantages Exocrine duct ligation -> EPI+ acute/ chronic pancreatitis in pancreatic remnant Pancreaticojejunostomy?

26. Partial pancreatectomy , choleduodenostomy and pancreaticojejunostomy

27. Total pancreatectomy Insulin dependency, ‘brittle’ diabetes inevitable EPI inevitable Biliary re-routing required Splenectomy may be required Pancreatic pain reduced Inflammatory focus removed

28. High complication rate 20-40% mortality with severe pancreatic necrosis 80-100% mortality with infected pancreatic necrosis managed non-surgically Median ICU stay 20 days 15-20% incidence of ARF 40-60% incidence ARDS requiring mechanical ventilation 20% incidence significant intra-abdominal hemorrhage

29. Outcome for Kita...... euthanasia in surgery

30. Questions?