[00:00:05] Speaker A: Welcome to All Cats Considered, a new podcast from the American Association of Feline Practitioners, where we interview professionals from across the veterinary world and take deep dives into the latest evidence based research developments, studies and guidelines that improve feline health and well being. My name is Dr. Kira of Ramdis, President of the AAFP, and I'm proud to introduce this new podcast. We are the home for veterinary professionals seeking to improve the care of cats through high standards of practice, continuing education and evidence based medicine. In each podcast, you will hear interviews from a variety of experts throughout our field, covering a wide range of topics and recent developments in the practice of feline health, sharing the key points you need to know to improve your patient's care. Let's dive in and take a listen with this week's experts.
[00:00:59] Speaker B: So, welcome everybody. I'm Natalie Dalgrey, head of ISFM and for our JFMS Clinical Spotlight article interview. This month, I am speaking with Daniel Lowe and Daniel is the author of our latest article in JFMS on the surgical management of feline biliary tract disease. So, just to get started, Daniel, I wondered if you'd be able to tell us a little bit more about your career and how you came to be co authoring this article with John Williams.
[00:01:28] Speaker C: Thank you, Natalie. Thank you for having me on today. So, my name is Daniel. I am a veterinary surgeon in practice in the UK. Currently, I graduated from the Royal Veterinary College 2019. I spent two years in general practice in Lincolnshire before moving on to rotating internship working with John Williams. Currently, I'm working as a surgical intern in Yorkshire and have completed this article on biliary tract disease and cats co authored with him.
[00:02:00] Speaker B: What prompted the two of you to choose that topic for the article?
[00:02:05] Speaker C: We thought that it was a topic that's not very commonly seen in general practice and something that general practitioners are not very familiar with and are just hoping to get more information out to the veterinary community to be able to help them to make decisions when managing this disease.
[00:02:23] Speaker B: Brilliant. And I found it a really interesting article because, as you've just said, it's something that we're perhaps as GP vets, not as familiar with, especially the surgical options available to us. I was wondering if you had sort of a preferred diagnostic approach to deciding if surgery is indicated in cases of especially extra hepatic biliary obstruction.
[00:02:48] Speaker C: Yes. So, first off, every case is unique and should be approached on an individual basis, although a general approach can be discussed. So first you'd suspect hepatobiliary disease on the basis of the patient sigma and it's presenting clinical signs. You'd narrow down your differential list after doing hematology and biochemistry. Certain abnormalities on your routine clinical pathology will lead you to suspect biliary tract disease in a cat. Then you normally proceed to imaging to diagnose extraepathic biliary tract obstruction. Abbreviate this as ehbo, from now on for imaging. Most likely this will be abdominal ultrasonography. Most practices should have access to this imaging modality. But it has to be said that you need an experienced operator to be able to look at the biliary tract. Once you've performed all that and you've diagnosed extra hepatic biliary tract obstruction, you should be diagnosing the underlying cause and further decisions will be made on this basis. For example, inflammatory and neoplastic biliary tract disease will be approached very differently. But broadly speaking, the practitioner after diagnosis would need to decide whether to proceed with medical or surgical management. Surgery would be indicated if you have tried medical management and it has failed, or if you think that medical management is very likely to fail, but this goes back to the underlying cause. And finally, the surgeon is not the sole decision maker in these cases, as usually, collaboration with other colleagues from other services would be required. So you wouldn't necessarily be working by.
[00:04:30] Speaker B: Yourself, just sort of following on from that. When you feel that surgery probably is indicated and you're working with that sort of wider team, are you always really confident when you go in about what procedure you're likely to be performing in these cases? Or is there a lot of adapting to individual patient circumstance during the surgery?
[00:04:50] Speaker C: Yes, so you are correct, there is some interoperative decision making that may have to be made in some cases. In some cases it may be fairly straightforward. And you, for example, may be going in to do a colystectomy on a cat who has had recurrent biliary well, inflammation of the gallbladder. In that case you probably end up doing the planned procedure. But in other cases of Ehbo, you may need to assess the biliary tract. And one example I can think of is colidopolyps. If you visualize their gallstone within the common bowel duct that's causing an obstruction, your plan may be to go into retropulse it into the gallbladder to perform a colystectomy. However, if you're not able to do so, you may end up performing an alternative procedure such as colidocotomy or colysysto enterostomy. So that changes the plan quite markedly. If you go in and you're not able to do what you plan to.
[00:05:53] Speaker B: Do and do you have a sort of general approach that you take in the offset of these cases.
[00:06:01] Speaker C: So generally you go in, you perform your exploratory laparotomy and explore the abdomen. I generally prefer to do this before evaluating the biliary tract to make sure that the rest of the abdominal organs are grossly normal. And then we proceed to evaluate the biliary tract by palpation as well as observation. And usually with Ehbo, some form of cannulation of the biliary tract is needed. Door denotomy followed by retrograde cannulization of the biliary tract would be the first place to start to assess its patency.
[00:06:41] Speaker B: Actually, that was one of the things I was keen to ask you, because the paper obviously mentioned that importance of doing the full exploratory survey of the abdomen, but it sort of say it could be pre or post based on the surgeon's preference. So you definitely would prefer that first full assessment of the abdomen?
[00:06:58] Speaker C: Yes. And generally with other abdominal surgeries as well, it just makes me feel confident that I'm not missing something major before I PROCEED to do the planned procedure.
[00:07:09] Speaker B: Brilliant. Yeah. I have to say I've been caught out on that before. So my role for abdominal surgery is already here, but always have a good look at everything first. And then within that, you mentioned sort of placing a cannula, and I was quite interested in the paper in reading about the sort of stenting procedure as well. And in a case where you're having to place a stent, how long does that stent generally remain in place? In reading the paper, I sort of was assuming that especially when we're dealing with an inflammatory cause, it might sort of loosen and fall out as that inflammation decreases. But I was interested in learning a little bit more about that stenting process.
[00:07:50] Speaker C: Right. So biliary stenting is not the same as cannulization of the biliary tract. So cannulization is performed intraoperatively. You remove the cannula once you've confirmed the patency. Stenting provides temporary relief of Ehbo. A stent is placed with the intent to maintain a lumen within the common bowel duct on a temporary basis until the swelling and obstruction resolves. So the stent is placed and anchored with monofilament absorbable suture material, PDS or monochrome, for example. And what this does is, as it's absorbed by the body, the stent will pass into the gastrointestinal tract once the suture has lost its tensile strength. I'm unaware of any experimental studies investigating how quickly suture material is absorbed in bowel, and I'm not sure you can extrapolate the duration of strength retention in tissue, for example, to this use. But PDS would probably last longer than monochrome. So the choice of suture material would be at the discretion of the surgeon, depending on how aggressive you think disease is and how long you think you need to maintain that stent in place.
Interestingly, in people, they have described the use of biodegradable stents, so you don't need to worry about it being passed, being stuck there. And they will, like suture material, dissolve in the body, but I'm not aware of that being used in cathodocs cannulas.
[00:09:23] Speaker B: We'Re placing to make sure there's patency. And that's really just a test scentings. If there is a blockage and you're wanting that temporary passage of bile until it falls out. And then the other thing that was mentioned, because there are a lot of things, when I was reading this article, I was trying very hard to remember aspects of my anatomy and I don't think I was getting it always right. But the article also mentioned collysystotomy tube placement. So would you be able to tell us a little bit more about what they are and what the indications for their placement are.
[00:09:55] Speaker C: A colystostomy tube would be a tube that's placed into the gallbladder and exiting the body, creating an exit for bowel. This works similarly to a biliary stent in that it provides a temporary biliary diversion and it is not a treatment, a definitive treatment for any disease, but just provides temporary relief for whatever the underlying cause is. So this can be either placed surgically at open surgery or minimally invasive. Techniques have been described in dogs, but I think cats are limited by their size. Briefly, a stab incision is created in the gallbladder and you place a pigtail catheter around a purse string suture and then you exit it through the body wall. So it's very much like a gastrostomy feeding tube just in a different luminal organ. And what you do is you can use this tube to remove bowel from the gallbladder so that you don't have any further progression of the Ehbo while you are treating the underlying disease by another means. And these tubes are normally poured after three to four weeks and you can remove them just like any other ostomy tube, an esophag ostomy tube or gastrostomy tube. You cut external suture, you pull the tube and you allow the stoma to heal by second intention when you pull them. It either depends on the underlying disease, you don't want to pull them too early, but equally you don't want to leave them in forever and ever. So you would thus not place them if you do not expect a reasonably quick resolution of the underlying disease. And finally, if you do use them, you need to make sure you have the facilities and expertise to maintain it and that your client also knows what they have to do at home as the animal is likely to be discharged with a tube in place.
[00:11:45] Speaker B: In terms of their sort of postoperative management and care, is there a high risk of complications with them or are they tolerated reasonably well?
[00:11:55] Speaker C: Are you referring to the cholesteromy tubes?
[00:11:59] Speaker B: Yeah, the cholestostomy tubes. I'm just thinking some of the other ostomy tubes we place can have a risk of sort of breakdown and infection and things. Is there a greater risk with these type of tubes?
[00:12:11] Speaker C: So to my knowledge, not any more than the other ostomy tubes. The same complications will be faced in that there is a risk of infection at the stomach site and also a risk of premature tube removal causing peritonitis. The other additional complication that has been described is if used for weeks by removing too much bowel, it causes mild digestion. So bowel has to be replaced by another means, otherwise you get complications such as vomiting and diarrhea as a result.
[00:12:43] Speaker B: Brilliant. I then just had a few questions around antibiotic usage as well because I think we can't discuss a surgery paper without discussing antibiotics. In what sort of situations would you consider the use of prophylactic antibiotics to be essential, and what situations would you be maybe happy to wait for the culture result?
[00:13:03] Speaker C: Biliary tract surgery in the cat is classified as clean, contaminated surgery, and surgery is usually of an extended duration, at least 90 to 120 minutes if you're quick. And both of these are reasons for perioperative prophylactic antibiotics.
If you're going to collect any samples intraoperatively, for example, bowel or tissue or cole lifts for culture, then this would be collected with antibiotics on board, and you would have to interpret the culture results with this in mind. The only time that you may be able to get your result without antibiotics is if you collected a sample of bowel preoperatively during the time of workup, and this might be a little bit more useful once you've completed your surgery. Generally, antibiotics do not need to be continued postoperatively if there hasn't been any gross spillage during surgery or if there's no ongoing infection such as a peritonitis. The only other reason you'd continue it postoperatively are in cases of neutrophilic cholangitis where there may be a bacterial etiology, but this would not necessarily be the decision of the surgeon, and it would be a decision with the other services.
[00:14:24] Speaker B: And in some of those cases, such as were you having some indications for carrying on with the antibiotics? So biliary tract rupture or peritonitis in terms of the length of time that you'd carry on with the antibiotics post surgery, again, is that something you'd be involved in the discussion with, or is that something that the medics would normally be talking about?
[00:14:46] Speaker C: Yeah, so I don't think there's any good evidence to say how long the cat needs to be on antibiotics postoperatively for each of these conditions, and it will be a collective decision. So generally for these cases, four weeks of antibiotics, but this may be shorter or longer, depending on the individual case. Additionally, once you've received the culture results, if you've got negative culture or if you've got positive culture with a sensitivity, then you may want to de escalate your antibiotics if appropriate.
[00:15:18] Speaker B: Great. And I did have another sort of surgical well, another two surgical management questions, actually. The paper obviously talked about Hepatic disease as being a risk factor for coagulopathies. When you guys are performing these types of surgery, do you like to have blood products available for use during this sort of surgery on an emergency basis or on a precautionary basis?
[00:15:41] Speaker C: So you are correct that Hepatic disease is a risk factor, so preoperative hemostatic testing should be performed, although it has to be said that the hemostatic disturbances in Hepatic disease are complex, and you do not always pick it up on in vitro tests. So whether or not you have any abnormalities, the referral centers that John and I have worked in always have pack red blood cells and fresh frozen plasma available.
So this is always kept on hand should we need it. For whatever reason, I recognize that this may not always be possible in smaller practices. So this in itself may be a reason for referral. If you're worried about perioperative management of the catalyst with biliary tract disease now.
[00:16:29] Speaker B: That'S good to know. It definitely was part of the discussion that I was like, oh, actually that's something I hadn't really thought about and a potential massive complication risk. The other question I had around sort of surgical management as well was around placing feeding tubes. Would you always place a feeding tube if one wasn't in place? If you're giving them an anesthetic for this type of surgery, yes.
[00:16:51] Speaker C: The reason being these patients are almost always very ill and are going to require many days in hospital postoperatively. So placing a feeding tube would be a very good idea. And esophagostomy tube is generally the best option, although you can use nasogastric, nasal, esophageal or gastrostomy tube in certain cases. Sometimes feeding tube may have already in place like may have already been placed, like you've mentioned, during the workup of the patient, as it's not with straightforward diagnosis and the cat may have been in hospital for a few days prior to surgery anyway.
[00:17:31] Speaker B: That's brilliant.
The other thing I just wanted to touch on briefly as well is that laparoscopic approaches were very mentioned quite briefly, unsurprisingly, because this was a surgical article. But is that something that you've had any experience with and do you think it's a field that's probably going to grow with this type of surgery?
[00:17:50] Speaker C: So probably in dogs, but not in cats. As cat size cats more size limits the utility of laparoscopic surgery. The most feasible laparoscopic procedure in cats is the colystectomy, and only if it's a straightforward case. If you anticipate that eggjunctive procedures may be required, or if you do need the cannulate ability tract, then open surgery would be preferable.
[00:18:19] Speaker B: Okay, no, that makes sense. And we always forget that size factor. I think sometimes with cats that often it requires equipment to be a lot smaller than what it can be for some dog.
One of the final questions I sort of had around this and I asked this very much as a GP vet who is probably an adequate soft tissue surgeon, but that's about it. Should this type of balloon track surgery really always be left to the specialists or are there some procedures that you think could be suitable for potentially more advanced or experienced general practitioner vets?
[00:18:55] Speaker C: I think cholecystectomy and treatment of bowel peritonitis may be performed by advanced practitioners who are familiar with the procedures and with prior experience of soft tissue surgery, as a lot of the soft tissue surgical principles can be extrapolated to these procedures. Other procedures such as biliary diversion or coldocotomies are much more advanced and should only be performed if you have prior training or mentoring in these procedures. If that's not something that you have any experience with, then it's probably best to refer these cases. It's also useful to refer because these cases always require a multidisciplinary approach and the surgeon is not the one working in isolation and you are going to need intensive perioperative care and if your facilities aren't adequate, then best to refer again.
[00:19:49] Speaker B: Brilliant. And sort of as we wrap up this sort of discussion, what's next for you? Do you have any further publication plans or research projects?
[00:19:59] Speaker C: Yes, so currently I'm working on a project investigating the weekend effect in veterinary medicine. You may have heard of the weekend effect in healthcare in humans in that humans admitted to hospital on the weekends have been shown to have a poorer outcome than those emitted on a weekday. And I'm investigating this in surgical patients currently and hope to publish my results very soon.
[00:20:25] Speaker B: That sounds very interesting. We'll look forward to hearing that. My gut response when you said that is yes there is. So it'd be very interesting to see what your findings are. And finally, would you recommend publishing in JFMS to your colleagues?
[00:20:38] Speaker C: Yes, I would. So JFMS it's an open access journal, so publishing in JFMS increases the visibility of your research or your article. So I do recommend publishing in JFMS. Whether it be a review, case report or original research, it is indeed a place to consider.
[00:21:00] Speaker B: Brilliant. Well, thank you very much for your time today, Daniel, and I'm glad you had a good experience in publishing in the journal and I've definitely enjoyed reading the article. I think for most of us in general practice, there's some really useful bits of information in there. So thank you so much.
[00:21:16] Speaker C: Yes, and thank you for having me. And if listeners have any further questions or wondering about biliary tract surgery, then please do take a look at the article.
[00:21:26] Speaker B: Brilliant, thank you. And it will be available in the show notes for the podcast, the link to, as Daniel said, the open access article, so it's available for everyone to read. Thank you very much.
[00:21:37] Speaker C: Thank you.
[00:21:38] Speaker A: Thank you for listening to this episode of All Cats Considered. We hope you enjoyed this interview. For more information on the topics discussed during the episode, please be sure to head over to Catvets.com and explore the links in the podcast description. And please be sure to subscribe to this podcast and your platform of choice so that you don't miss any episodes as we release them. Have thoughts or ideas about the interview you heard today? Share them with us. Leave us a comment on our Facebook page or or shoot us an email at
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