Laparoscopic omentalization of a pancreatic cyst in a cat

Michael Brückner 1Blå Stjärnans Djursjukhus Göteborg AB, Gjutjärnsgatan 4, 417 07 Göteborg, Sweden.
1Blå Stjärnans Djursjukhus Göteborg AB, Gjutjärnsgatan 4, 417 07 Göteborg, Sweden.

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Abstract

CASE DESCRIPTION A 15-year-old spayed female domestic shorthair cat was examined because of a 1-year history of daily vomiting, which was not associated with food intake.

CLINICAL FINDINGS Initial physical examination findings and serial hematologic and serum biochemical results were unremarkable except for the presence of a grade 2/6 left-sided heart murmur and persistent mild azotemia. A well-defined multilobulated cystic structure located between the spleen and left kidney was identified by abdominal ultrasonography.

TREATMENT AND OUTCOME Laparoscopic exploration revealed that the cystic structure originated from the left pancreatic limb. With laparoscopic guidance, the structure was percutaneously drained and underwent omentalization. Then, a partial cystectomy was performed to obtain a tissue specimen for histologic evaluation. The vomiting resolved for a short period immediately after surgery and then gradually resumed over 6 months, albeit with less frequency than prior to surgery. The histologic diagnosis was pancreatic cyst. Abdominal ultrasonography performed 6 months after surgery revealed that the original cyst had completely resolved but multiple smaller cysts had developed. The serum feline pancreas-specific lipase activity was not measured before surgery but remained increased from the reference limit following surgery, and chronic pancreatitis was considered the most likely cause of pancreatic cyst formation.

CLINICAL RELEVANCE Laparoscopic-guided drainage and omentalization of a large pancreatic cyst resulted in a satisfactory outcome for the cat of this report and can be considered an alternative to percutaneous ultrasound-guided cyst drainage and the more invasive laparotomy approach for pancreatic cystectomy with or without omentalization.

Abstract

CASE DESCRIPTION A 15-year-old spayed female domestic shorthair cat was examined because of a 1-year history of daily vomiting, which was not associated with food intake.

CLINICAL FINDINGS Initial physical examination findings and serial hematologic and serum biochemical results were unremarkable except for the presence of a grade 2/6 left-sided heart murmur and persistent mild azotemia. A well-defined multilobulated cystic structure located between the spleen and left kidney was identified by abdominal ultrasonography.

TREATMENT AND OUTCOME Laparoscopic exploration revealed that the cystic structure originated from the left pancreatic limb. With laparoscopic guidance, the structure was percutaneously drained and underwent omentalization. Then, a partial cystectomy was performed to obtain a tissue specimen for histologic evaluation. The vomiting resolved for a short period immediately after surgery and then gradually resumed over 6 months, albeit with less frequency than prior to surgery. The histologic diagnosis was pancreatic cyst. Abdominal ultrasonography performed 6 months after surgery revealed that the original cyst had completely resolved but multiple smaller cysts had developed. The serum feline pancreas-specific lipase activity was not measured before surgery but remained increased from the reference limit following surgery, and chronic pancreatitis was considered the most likely cause of pancreatic cyst formation.

CLINICAL RELEVANCE Laparoscopic-guided drainage and omentalization of a large pancreatic cyst resulted in a satisfactory outcome for the cat of this report and can be considered an alternative to percutaneous ultrasound-guided cyst drainage and the more invasive laparotomy approach for pancreatic cystectomy with or without omentalization.

A 15-year-old 3.1-kg (6.8-lb) spayed female domestic shorthair cat was examined because of chronic vomiting and persistent mild azotemia. One year previously, an abdominal ultrasonographic examination revealed the presence of a multilobulated cystic structure in the region of the left kidney and along the greater curvature of the stomach. The cystic areas varied in size from a few millimeters to 2 cm. During the previous year, the cat had a dental cleaning performed at the referring veterinary clinic, and several different diets were fed. However, the cat continued to vomit at least once daily, and the vomiting was unrelated to food intake. Hematologic and serum biochemical analyses were performed periodically, and indices of renal function had increased slightly over time, with the creatinine concentration peaking at 180 μmol/L (reference range, 70 to 160 μmol/L) and BUN concentration peaking at 13.3 mmol/L (reference range, 2 to 10 mmol/L) prior to referral to a specialty hospital (Table 1). Because of the persistent, albeit mild, azotemia, the cat's diet was changed to a prescription cat fooda formulated to support renal function, but it continued to vomit daily.

Table 1—

Results of serial serum biochemical and hematologic analyses for a 15-year-old spayed female domestic shorthair cat that was examined because of a 1-year history of daily vomiting, which was not associated with food intake.

 Date     
VariableJune 2016November 2016April 2017June 2017*January 2018Reference range
T3 (nmol/L)10.50.60.4–2.0
T4 (nmol/L)33.730.433.110.0–60.0
Cholesterol (mmol/L)3.243.33.79< 3.4
Sodium (mmol/L)158152155154154147–156
Potassium (mmol/L)4.84.14.13.94.13.5–4.7
Glucose (mmol/L)6.713.843.3–9.7
Alanine aminotransferase (μkat/L)1.050.8710.70.940.0–1.20
Alkaline phosphatase (μkat/L)0.30.40.40.49< 4.2
Bile acids (μmol/L)2.31.61.10.5< 20.0
BUN (mmol/L)11.311.213.39.610.32.0–10.0
Creatinine (μmol/L)17318013819917170–160
Phosphate (mmol/L)1.241.071.4111.40–2.60
Calcium (mmol/L)2.322.222.462.391.50–3.00
Creatine kinase (μkat/L)4.73.33.5< 6.0
Protein (g/L)67636255.854–78
Albumin (g/L)3133333329.625–40
Amyloid A (mg/L)54.24< 10
WBC count (X 109 cells/L)74.54.65.25.5–19.5
RBC count (X 109 cells/L)8.48.88.69.15.0–10.0
Hemoglobin (g/L)11911111010980–150
Hct (%)35.935.138.532.924.0–45.0
MCV (fL)42.539.94936.239.0–55.0
MCHC (g/L)331316287330260–360
Platelets (X 109 platelets/L)478426359Clumps180–600
Neutrophils (%)72.953.255.135.0–78.0
Lymphocytes (%)14.430.124.120.0–55.0
Monocytes (%)43.32.4< 7.0
Eosinophils (%)8.41318.21.0–12.0
Basophils (%)0.30.40.2≤ 1.0

Initial examination at the referral hospital prior to laparoscopic surgery to identify, drain, and omentalize a pancreatic cyst.

Recheck examination 6 months after laparoscopic surgery.

— = Not determined. MCHC = Mean corpuscular hemoglobin concentration. MCV = Mean corpuscular volume.

The cat had a body condition score of 5 on a scale of 1 to 9. The only remarkable finding during the initial physical examination at the specialty hospital was a grade 2/6 left-sided heart murmur; no abnormalities were detected during a subsequent echocardiographic examination. An abdominal ultrasonographic examination revealed a well-defined multilobulated cystic structure cranial and medial to the left kidney (Figure 1). The anechoic (cystic) areas measured up to 2.8 cm in diameter. No other ultrasonographic abnormalities were observed. The only remarkable serum biochemical result was a slightly increased creatinine concentration (199 μmol/L; Table 1).

Figure 1—
Figure 1—

Ultrasonographic image of a multilobulated cystic structure located cranial and medial to the left kidney of a 15-year-old spayed female domestic shorthair cat that was examined because of a 1-year history of daily vomiting, which was not associated with food intake. The image was obtained along the longitudinal axis of the cystic structure. The fluid within the structure was anechoic, and the largest cavity measured approximately 2.8 cm in diameter.

Citation: Journal of the American Veterinary Medical Association 255, 2; 10.2460/javma.255.2.213

A laparoscopic abdominal exploratory surgery was performed. The cat was premedicated with midazolamb (0.2 mg/kg [0.09 mg/lb], IM) and methadonec (0.5 mg/kg [0.23 mg/lb], IM). Anesthesia was induced with propofold (3.0 mg/kg [1.36 mg/lb], IV to effect). Following tracheal intubation, anesthesia was maintained with a 1:1 mixture of oxygen and sevoflurane. The cat was connected to a mechanical ventilator and received crystalloid fluidse (6 mL/kg/h [2.7 mL/lb/h]), IV) for the duration of anesthesia. The ventral portion of the abdomen was clipped and prepared for surgery in a routine manner. The cat was positioned in dorsal recumbency on a circulating warm-water blanket and draped for surgery. A modified Hasson approach was used to insert a 6-mm blunt-tipped canula with a multifunction valvef at the umbilicus. The abdomen was insufflated with carbon dioxide to achieve a pressure of 6 mm Hg. Laparoscopic exploration of the abdomen revealed a cystic structure that was approximately 7 cm in length and located between the spleen and left kidney. No other abnormalities were identified. A second port was created just cranial to the bladder with visual laparoscopic guidance and a second 6-mm blunt-tipped cannula with multifunction valve. An endoscopic palpation probef was inserted through that port and used to manipulate the spleen to facilitate further examination of the cystic structure. The cystic structure appeared to originate from the left pancreatic limb (Figure 2). An 18-gauge spinal needleg was inserted percutaneously into the cystic structure, and 15 mL of brown fluid was removed, which caused the structure to collapse. Then a monofilament suture–needle combination was inserted into the abdominal cavity and grasped with an endoscopic needle holder.f A transabdominal suspension suture was placed through the wall of the cystic structure with the ends brought back outside of the abdominal cavity and manually restrained to suspend the cystic structure from the abdominal wall for further manipulation. Endoscopic scissorsf were inserted through the caudalmost port and used to open the cyst. The scissors were then replaced with a 5-mm laparoscopic vessel sealer-divider device,h which was used to extend the incision in the cystic structure to a length of approximately 3 cm and to perform careful blunt dissection to break down as many tissue septa as possible within the structure. The remaining fluid within the cystic structure was removed with a laparoscopic suction device.f Then, the vessel sealer-divider device was replaced with endoscopic grasping forceps,i which were used to grasp the omentum majus. A portion of the omentum majus was packed into the cystic structure and fixed to the margins of the structure with 4 endoclips (2 on each side of the structure wall), which were applied with an endoclip applier.j In a final step, a partial cystectomy was performed with the aid of the vessel sealer-divider device. The resected tissue was pulled into the cannula in the caudalmost portal, and the resected tissue and cannula were removed together. The resected tissue was submitted for histologic examination. The abdominal cavity was deflated, and both portals were routinely closed in 3 layers with 4–0 monofilament suture. Surgical duration was 25 minutes. The cat recovered from anesthesia uneventfully and was discharged from the hospital the same day with instructions for administration of buprenorphinek (15 μg/kg [6.8 μg/lb], PO, q 8 h) for 3 days for analgesia.

Figure 2—
Figure 2—

Laparoscopic images of the cystic structure (Cy) of the cat of Figure 1 obtained during a procedure to identify, drain, and omentalize the structure. A—The cystic structure originated from the left limb of the pancreas (P) and was located between the spleen (S) and left kidney. In this image, a laparoscopic palpation probe was used to manipulate the spleen and improve visibility of the cystic structure. B—An 18-gauge spinal needle (black arrow) was used to drain the cystic structure, and a transdermal suspension suture (white arrow) was placed to temporarily suspend the structure from the abdominal body wall to facilitate further manipulation. C—Endoscopic scissors were used to open the cyst; the transdermal suspension suture (white arrow) is also visible. D—A 5-mm vessel sealer-divider device was used to extend the incision to a length of approximately 3 cm and to bluntly dissect and break down as many tissue septa within the structure as possible and to perform a partial cystectomy to obtain a tissue specimen for histologic analysis. The spinal needle (black arrow) used to drain the cystic structure is also visible. E—A portion of the omentum majus (Om) was packed into the cystic structure and fixed to the margin of the structure with 2 endoclips (asterisks) on each side. In this image, an endoclip applier (white arrow) is about to place the second endoclip on the left side of the cyst.

Citation: Journal of the American Veterinary Medical Association 255, 2; 10.2460/javma.255.2.213

Serum amylase A and lipase activities determined immediately prior to surgery were compared with those in the fluid removed from the cystic structure. The serum amylase A activity was 19.1 μkat/L (reference range unavailable for cats), and the serum lipase activity was 30 U/L (reference range, < 72 U/L). The cystic fluid amylase A activity was 21,650 μkat/L, and the cystic fluid lipase activity was 4,787 U/L. The cystic fluid total protein concentration was 0 g/L, and the total cell count was 4.9 × 109 cells/L. Cytologic evaluation of the cystic fluid revealed a background with a considerable quantity of gray-blue material; most of the cells present in the fluid were mononuclear cells with gray-blue foamy cytoplasm. No bacteria were observed.

Histologic examination of the resected tissue from the cystic structure revealed an irregular wall that consisted of cuboid epithelium with apical secretory vesicles (Figure 3). In some areas, cells had a tubulopapillary shape and appeared to be growing into the lumen. The cells did not disrupt the papillar membrane, were homogeneous, and did not have any evidence of mitotic activity. Phagocytic macrophages with foamy cytoplasm were observed along the outer wall of the cyst, along with multifocal to diffuse infiltrates of lymphoplasmacytic cells and occasional neutrophils. The specimen did not have any signs of malignancy, and the histologic diagnosis was pancreatic cyst.

Figure 3—
Figure 3—

Photomicrographs of a section of the tissue resected from the cystic structure of the cat of Figure 1. A—The wall of the structure was irregular and consisted of cuboid epithelium with apical secretory vesicles. In some areas, cells had a tubulopapillary shape and appeared to be growing into the lumen. H&E stain; bar = 100 μm. B—Higher magnification of the specimen in panel A. Notice that the cells did not disrupt the papillar membrane, were homogeneous, and did not have any evidence of mitotic activity. Phagocytic macrophages with foamy cytoplasm were observed along the outer wall of the structure, along with multifocal to diffuse infiltrates of lymphoplasmacytic cells and occasional neutrophils. These findings were consistent with a pancreatic cyst. H&E stain; bar = 100 μm.

Citation: Journal of the American Veterinary Medical Association 255, 2; 10.2460/javma.255.2.213

A recheck examination was performed 3 days after surgery. The owner reported that the cat had not vomited since the surgery and had a good appetite. A blood sample was obtained for quantification of fPL activity, which was 11.2 μg/L (reference range, < 3.5 μg/L). The cat was examined again 10 days after surgery. The owner reported that the cat had vomited once since the previous recheck examination. The portal sites had healed well, and the sutures were removed. The fPL activity had increased to 18.5 μg/L.

The owner was contacted by telephone intermittently for 3 months after surgery and continued to report that, although the cat vomited occasionally, it had a good appetite and did not have any other clinical signs of pancreatitis. Another recheck examination was performed 6 months after surgery, at which time the owner reported that the cat vomited almost every other day but otherwise appeared to be doing well. Abdominal ultrasonography revealed that the original large cyst had resolved, but multiple smaller cysts with diameters up to 10 mm had developed throughout the pancreas. The fPL activity was 12.3 μg/L at that time.

Discussion

Cystic changes in the pancreas of cats have been infrequently reported. In fact, prior to the present report, the veterinary literature contained only 2 case reports1,2 of cats with true pancreatic cysts. Pancreatic pseudocysts have been reported in a total of 3 cats,3,4 and there is 1 report5 of a cat with a pancreatic abscess concomitant with diabetes mellitus. Pancreatic pseudocysts and abscesses are more frequently reported in dogs.4,6–9 In both cats and dogs, the most common clinical sign associated with pancreatic cysts, pseudocysts, and abscesses is vomiting, with or without anorexia; and pancreatic cysts, pseudocysts, and abscesses are often associated with acute or chronic pancreatitis and diabetes mellitus.1–5,7–9

Ultrasonography or CT is often used to definitively diagnose cystic lesions within the pancreas.1–4,7–9 Ultrasonography is also useful to guide aspiration of cystic structures to collapse them and to collect fluid for cytologic examination, bacterial culture, and determination of amylase and lipase activities, which help facilitate diagnosis.4,8,9 In human medicine, aspirated fluid from pancreatic cyst-like structures with high amylase and lipase activities is most consistent with pseudocysts.10 Specifically, a cystic fluid amylase activity > 5,000 U/L (83.3 μkat/L) has a diagnostic sensitivity of 94% and specificity of 74% for differentiation of pancreatic pseudocysts from true pancreatic cysts.11 Results of a human study10 suggest that surgical treatment is indicated in patients with pancreatic pseudocysts and high cystic fluid amylase activity because those findings are suggestive of persistent communication of the pseudocyst with one of the pancreatic ducts. For the cat of the present report, ultrasound-guided aspiration of the cystic structure was not attempted because of its multilobulated nature and concerns about possible fluid leakage and contamination of the abdominal cavity. Additionally, in a previous case series4 of dogs and cats with pancreatic pseudocysts, both cats in which percutaneous drainage of the pseudocyst was attempted died soon after the procedure.

The color of aspirated pancreatic fluid can vary from red to greenish brown to colorless. Fluid contained in pancreatic pseudocysts generally has low cellularity, although the protein concentration may be slightly increased.4 Those characteristics were fairly consistent with the cytologic findings for the aspirated pancreatic cyst fluid for the cat of this report. The fluid was brown, had a low total cell count (4.9 × 109 cells/L), and had an unmeasurable protein concentration. The predominant cell population consisted of macrophages. Bacterial culture of the fluid was not performed because there were no cytologic signs of inflammation or any evidence of bacterial infection. A review of the veterinary literature failed to yield any descriptions of the cytologic characteristics of fluid retrieved from true pancreatic cysts in cats. It is possible that the cytologic characteristics of fluid from pancreatic cysts may be indistinguishable from those for fluid from pancreatic pseudocysts.

Various medical and surgical treatment options have been described for dogs and cats with pancreatic pseudocysts and cysts, and the outcomes for those options vary. Clinical signs resolved following surgical resection of a true pancreatic cyst in one cat,2 but another cat had recurrent cysts and pancreatic atrophy following surgical resection of a pancreatic cyst.1 In another report,9 percutaneous ultrasound-guided drainage of a pancreatic pseudocyst in a dog was associated with a successful outcome. In yet another s t u d y,4 percutaneous drainage of pancreatic pseudocysts resulted in a successful outcome for 3 of 4 dogs but was not successful in 2 cats, which died or were euthanized within 2 months after the procedure. A dog developed fatal hypotensive shock following ethanol ablation of a suspected pancreatic pseudocyst.8 Omentalization was used to successfully treat a Labrador Retriever with a pancreatic pseudocyst.12 After reviewing the reported outcomes for cats with pancreatic cysts or pseudocysts, it was deemed that surgery was the best treatment option for the cat of the present report. Other reasons surgery was elected for the cat of this report included the severity of the clinical signs (daily vomiting), the large size and multilobulated nature of the cystic structure, and the fact that surgery would allow for a tissue specimen to be obtained for histologic examination. Because of the location of the cystic structure and the important anatomic structures surrounding it, complete resection of the structure was considered too risky. A laparoscopic approach was considered an excellent alternative because the procedure could be performed without aggressive manipulation of the pancreas, which minimized the risk of inducing acute pancreatitis.

Chronic or acute pancreatitis is one of the suspected underlying causes of pancreatic pseudocysts. Unfortunately, for the cat of the present report, the serum fPL activity was not measured before surgery; thus, it was impossible to definitively determine whether pancreatitis was the underlying cause of the pancreatic cyst. Interestingly, the serum fPL activity (11.2 μg/L) for the cat of this report was increased from the reference range (< 3.5 μg/L) 3 days after surgery and continued to increase through 10 days after surgery (18.5 μg/L), even in the absence of any clinical signs of pancreatitis. At the recheck examination 6 months after surgery, the cat's serum fPL activity (12.3 μg/L) remained increased from the reference range. Therefore, it was suspected that chronic pancreatitis incited or contributed to the chronic vomiting and development of the pancreatic cyst.

The age, clinical signs, location of the cystic structure, ultrasonographic findings (ie, multilobular cystic structure and absence of signs of pancreatic duct obstruction), and clinicopathological and cytologic results for the cat of the present report were most consistent with a diagnosis of pancreatic pseudocyst. However, histologically the structure had a clear epithelial lining with secretory cells, which was most consistent with a pancreatic cyst rather than a pseudocyst. Therefore, pancreatic cyst was the final diagnosis for this cat.

The present report was the first to describe a good medium-term outcome following laparoscopic omentalization of a large pancreatic cyst in a cat. The procedure was performed fairly quickly and on an outpatient basis. Six months after surgery, the original cyst had completely resolved, but the cat had developed multiple smaller pancreatic cysts and still had clinical signs, albeit less severe than before surgery, of chronic pancreatitis. For cats with pancreatic cysts, laparoscopic omentalization can be considered a viable alternative to percutaneous ultrasound-guided drainage of the cyst and the more invasive pancreatic cystectomy with or without omentalization.

Acknowledgments

At the time of the study the author was working at the Blå Stjärnans Djursjukhus in Göteborg (Sweden), where the patient was evaluated and treated. The histopathologic examination was performed at the Statens Veterinärmediciniska Anstalt (SVA) in Uppsala, Sweden.

ABBREVIATIONS

fPL

Feline pancreas-specific lipase

Footnotes

a.

Katt Renal, Royal Canin, Aimargues, France.

b.

Midazolam (5 mg/mL), Hameln Pharma Plus GmbH, Hameln, Germany.

c.

Semfortan Vet (10 mg/mL), Eurovet Animal Health, Bladel, Netherlands.

d.

Propolipid (10 mg/mL), Fresenius Kabi AB, Uppsala, Sweden.

e.

Ringer-Acetate, Baxter Medical AB, Kista, Sweden.

f.

Karl Storz, Skärholmen, Sweden.

g.

Spinocan, B. Braun Melsungen AG, Melsungen, Germany.

h.

Dolphine tip, Covidien Sverige AB, Solna, Sweden.

i.

KLICKline Dissecting and Grasping Forceps, Karl Storz, Skärholmen, Sweden.

j.

Endo Clip (5 mm), Medtronic AB, Kista, Sweden.

k.

Bupaq Vet (0.3 mg/mL), Richter Pharma AG, Wels, Austria.

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