Introduction

A 9-year-old 6.8-kg castrated male domestic shorthair cat (cat 1) was presented for recurrent obstructive feline lower urinary tract disease (FLUTD), which had been treated by the referring veterinarian on an outpatient basis over 3 visits during the preceding 5 days. The cat was treated with meloxicam and amoxicillin–clavulanic acid by the referring veterinarian; however, it was unknown during which visit these medications were prescribed or the dosages thereof. The owner did report administration of the last dose of meloxicam (0.05 mg/kg, PO, q 24 h) the day before the referral examination.

For cat 1, physical examination and abdominal radiographic findings were within reference limits. Hematologic and plasma biochemical analyses revealed a WBC count of 9.12 X 10⁹ cells/L (reference range, 6.5 X 10⁹ to 15.4 X 10⁹ cells/L) and a neutrophil count of 5.22 X 10⁹ cells/L (reference range, 2.5 X 10⁹ to 12.5 X 10⁹ cells/L) with a mild left shift (0.64 X 10⁹ band neutrophils /L; reference range, 0 X 10⁹ to 0.3 X 10⁹ band neutrophils/L) and moderately high serum amyloid A concentration (40.7 μg/mL; reference range, < 8 μg/mL). The cat was administered meloxicam (0.05 mg/kg, IV, once) and ampicillin-sulbactam (30 mg/kg, IV, q 8 h) as well as buprenorphine hydrochloride (15 μg/kg, IV, q 8 h) and prazosin (0.5 mg, PO, q 12 h) because clinical signs were considered related to FLUTD. The day after hospital admission, cat 1 underwent abdominal ultrasonography, which revealed moderate pneumoperitoneum, mild corpuscular peritoneal effusion, and reactive mesenteric fat. Cytologic analysis of a peritoneal fluid sample obtained by abdominocentesis revealed intracellular bacteria consistent with septic peritonitis. Some of the collected fluid was also submitted for bacterial culture. An exploratory celiotomy was planned, and the cat received ampicillin-sulbactam (30 mg/kg, IV) at induction of anesthesia and every 90 minutes during surgery. Exploratory celiotomy identified a mild to moderate amount of free peritoneal fluid, local peritonitis in the cranial portion of the abdomen, a 2-cm-diameter full-thickness duodenal perforation aborad to the pyloric sphincter with a large ulcer extending from the perforation into the pyloric canal, and presence of 8 worms free within the abdominal cavity. Omental adhesions were removed, and the stomach and small intestine were isolated by use of moistened laparotomy sponges. Consideration was given to resection and performance of a gastroduodenostomy (Billroth I procedure); however, there was concern over excessive tension on the anastomosis, and a gastrojejunostomy (Billroth II procedure) was considered more appropriate. Enterectomy of the perforated region of duodenum and partial gastrectomy were performed. The duodenal incision was performed approximately 8 mm orad to the major duodenal papilla, whereas the gastric resection included 360° excision of the pyloric sphincter and canal as well as approximately half of the gastric antrum. Branches of the right gastric, right gastroepiploic, and cranial pancreaticoduodenal arteries were isolated and sealed by bipolar electrosurgery. Resection of the lesion with approximately 2- to 3-mm lateral margins of grossly normal tissue was performed by use of a scalpel blade and curved iris scissors; the presence of grossly normal mucosa was confirmed at each cut surface. The duodenum was closed in a single layer, and the stomach was closed with 4-0 polydioxanone suture material in a 2-layer simple continuous pattern. A freely movable proximal to midjejunal segment was positioned against an avascular region of the greater curvature of stomach (Figure 1). A 4-cm-long full-thickness incision was made in the antimesenteric border of the jejunum between stay sutures, and a corresponding incision was made in the adjacent stomach. The side-to-side gastrojejunostomy was closed with 4-0 polydioxanone suture material in a single-layer simple continuous suture pattern. Following copious lavage, omentum was wrapped around all gastrointestinal incisions. The abdomen was routinely closed.

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Schematic representation of a cat’s stomach before and after the Billroth II procedure. A—Dashed lines indicate the margins of excision. B—Following pylorectomy, partial gastrectomy, and gastrojejunostomy (arrow), the jejunal loop undergoes anastomosis in this manner to prevent kinking. The afferent loop of the duodenum with the major duodenal papilla and the common bile duct (asterisk) and the efferent loop of the proximal portion of the jejunum (star) are identified.

Citation: Journal of the American Veterinary Medical Association 259, 11; 10.2460/javma.20.04.0241

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Cat 1 received a constant rate infusion of fentanyl hydrochloride (2 to 5 μg/kg/h) during recovery from anesthesia, and treatment with omeprazole (1 mg/kg, IV, q 12 h), sucralfate (0.6 g, PO, q 8 h), misoprostol (25 μg, PO, q 12 h), and maropitant citrate (1 mg/kg, IV, q 24 h) was commenced. Administration of fentanyl was gradually tapered over a 24-hour period and then substituted with buprenorphine hydrochloride (10 to 20 μg/kg, IV, q 8 h). The cat was maintained on ampicillin-sulbactam (30 mg/kg, IV) until results of the bacterial culture and antimicrobial susceptibility testing of the peritoneal fluid sample were available. A nasoesophageal feeding tube was placed after unsuccessful appetite stimulation with mirtazapine (3.75 mg, PO, once).

The free intra-abdominal worms were identified as adult forms of Toxocara cati, and cat 1 was treated with a single oral dose of milbemycin oxime (12.5 mg) and praziquantel (125 mg). Bacterial culture of the peritoneal fluid sample obtained prior to surgery yielded pure growth of Escherichia coli, which was susceptible to marbofloxacin. Ampicillin-sulbactam was substituted with marbofloxacin. Histologic examination of specimens of the excised duodenal wall revealed marked necrosis with multifocal acute hemorrhage, neutrophilic infiltration of the lamina propria, multifocal shortening and fusion of villi, and marked dystrophic mineralization of the adjacent mucosa with no evidence of neoplasia or other identifiable cause. Additionally, the serosa was thickened and had deposits of degenerated neutrophils, cellular debris, and fibrin exudation. The cat commenced eating voluntarily 6 days after surgery and was discharged from the hospital the following day. The owner was instructed to administer marbofloxacin (15 mg, PO, q 24 h) for 21 days, prazosin (0.5 mg, PO, q 12 h) for 5 days, omeprazole (10 mg, PO, q 12 h) for 21 days, and sucralfate (0.6 g, PO, q 8 h) for 14 days and to adjust the cat’s diet by providing frequent small meals of highly digestive food.

Eight days after discharge from the hospital, cat 1 was presented because of anorexia and vomiting. On physical examination, mild dehydration (approx 5%) was identified, and IV administration of a balanced crystalloid solution was started. The next morning, abdominal ultrasonography revealed mildly decreased peristalsis of all small intestinal loops, a small amount of free peritoneal fluid, and diffusely heterogeneous and hyperechoic (likely reactive) mesenteric fat. The stomach contained a small amount of food after 12 hours without food intake and hypomotility or delayed gastric emptying was suspected, despite ultrasonographic evidence of 4 or 5 gastric contractions/min. The cat was hospitalized, and treatment with metoclopramide hydrochloride (0.3 mg/kg, IV, q 8 h) and maropitant citrate (1 mg/kg, IV, q 24 h) was instituted. After 4 days, the cat had a good appetite and was discharged from the hospital. Administration of maropitant citrate (1 mg/kg, PO) was continued for 5 days along with metoclopramide hydrochloride (0.3 mg/kg, PO, q 8 h) for 7 days.

During telephone follow-up conversations with the owner at 8 and 13 months after the Billroth II procedure, cat 1 was reported healthy and in good general condition with stable body weight but had occasional episodes of anorexia. The owner had changed the cat’s diet to ad libitum feeding 2 months after surgery.

A 10-year-old 6.9-kg castrated male Maine Coon cat (cat 2) was presented for evaluation of poor general health after outpatient care for obstructive FLUTD. The treatment of FLUTD provided by the referring veterinarian had involved urinary bladder catheterization and administration of marbofloxacin and meloxicam (dosages and treatment durations unknown). Physical examination findings included mild hypothermia (36.8 °C), approximately 5% dehydration, and tachypnea (48 breaths/min). Venous blood gas analysis identified moderate hyperlactatemia (9.02 mmol/L; reference range,¹ 0.61 to 5.86 mmol/L). Because of the cat’s worsening clinical condition, abdominal radiography was performed 8 hours after the initial presentation, and pneumoperitoneum and abdominal effusion were identified. Cytologic analysis of a sample of aspirated abdominal fluid revealed intracellular bacteria consistent with septic peritonitis; however, a fluid sample was not submitted for bacterial culture. An exploratory celiotomy was planned, and the cat received ampicillin-sulbactam (30 mg/kg, IV) at the induction of anesthesia and every 90 minutes during surgery. During exploratory celiotomy, generalized peritonitis and a 3-cm-diameter full-thickness pyloric perforation located at the lesser omentum insertion were identified. Similar to the situation for cat 1, consideration was given to resection of the lesion and performance of a gastroduodenostomy; however, there was concern over excessive tension on the anastomosis, and a gastrojejunostomy (Billroth II procedure) was considered more appropriate. The Billroth II procedure was performed by the same surgeon with the same technique as described for cat 1. For cat 2, resection was performed with approximately 2- to 3-mm lateral margins of grossly normal tissue; the presence of grossly normal healthy mucosa at the cut surface of the duodenum was confirmed. The distance from the cut surface of the duodenum to the major duodenal papilla was approximately 15 mm, and the pyloric sphincter and canal and approximately half of the pyloric antrum underwent 360° resection. Following copious lavage, omentum was wrapped around all surgical incisions. A Jackson-Pratt drain was placed, and the abdomen closed routinely. An esophageal feeding tube was placed.

Cat 2 recovered from anesthesia and received a constant rate infusion of fentanyl hydrochloride (2 to 5 μg/kg/h) as well as omeprazole (1 mg/kg, IV, q 12 h), sucralfate (0.6 g, PO, q 8 h), and maropitant citrate (1 mg/kg, IV, q 24 h). The cat was treated with ampicillin-sulbactam (30 mg/kg, IV, q 8 h) until the time of hospital discharge. After surgery, hematologic and plasma biochemical analyses revealed that cat 2 had a marked left shift (3.58 X 10⁹ band neutrophils/L, reference range, 0 X 10⁹ to 0.3 X 10⁹ band neutrophils/L), marked hypoalbuminemia (not measurable; reference range, 3.0 to 4.2 g/dL), hypoproteinemia (3.9 g/dL; reference range, 6.3 to 8.0 g/dL), and hyperbilirubinemia (30.7 μmol/L; reference range, 0 to 6.2 μmol/L). The cat received 40 g of 20% human albumin over a 24-hour period, which normalized its serum albumin concentration (2.9 g/dL). Esophageal tube feeding with a liquid recovery diet was initiated 8 hours after surgery and was gradually increased over 3 days to provide the cat’s full resting energy requirement. Four days after surgery, there was minimal intra-abdominal production of serosanguineous fluid, and the abdominal drain was removed; cytologic analysis of drain fluid revealed an absence of intracellular bacteria. Microbial culture of aspirated abdominal fluid samples collected during surgery had not been undertaken, and the previously initiated antimicrobial treatment was continued. Histologic examination of the excised perforated tissue revealed transmural perforating pyloric ulceration with severe infiltration of neutrophils, early granulation tissue formation, and multifocal dystrophic mineralization with no evidence of neoplasia or other identifiable cause. Seven days after the Billroth II procedure, cat 2 had improved general health with normalization of hematologic and biochemical abnormalities and was discharged from the hospital. Esophageal tube feeding was continued at home. The cat was returned to the hospital 2 days later with profuse diarrhea and ongoing anorexia. Abdominal ultrasonography identified minimal free peritoneal fluid, hyperechoic mesentery, gallbladder distention with sludge, and normal gastrointestinal tract motility. Following administration of probiotics, the cat commenced eating and passing normal formed feces at 11 days after surgery; the next day, the cat was discharged from the hospital. The owner was instructed to administer omeprazole (5 mg, PO, q 12 h) for 21 days, amoxicillin–clavulanic acid (94 mg, PO, q 12 h) for 5 days, and ursodeoxycholic acid (75 mg, PO, q 24 h) for 10 days and adjust the cat’s diet by providing frequent small meals of highly digestive food.

Seven weeks after the Billroth II procedure, cat 2 was presented because of anorexia. Abdominal ultrasonography identified a small amount of gastric content and minimal free peritoneal fluid. Gastroscopy identified a large trichobezoar, which was causing gastrojejunostomy obstruction. Endoscopic removal of the trichobezoar was unsuccessful. The trichobezoar was retrieved successfully by gastrotomy (Figure 2). On inspection of the gastrojejunostomy site through the incision, no abnormalities were evident and its size was similar to that at the time of the Billroth II procedure. The gastrotomy was closed with 4-0 polydioxanone suture in a 2-layer simple continuous pattern. Cat 2 had a good appetite 5 days after removal of the trichobezoar and was discharged from the hospital. The owner was instructed to treat the cat with omeprazole (5 mg, PO, q 12 h) for 14 days.

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Photograph of the healed gastrojejunostomy in cat 2 during exploration for trichobezoar removal. Cat 2 underwent the Billroth II procedure for treatment of generalized peritonitis and a 3-cm-diameter full-thickness pyloric perforation located at the lesser omentum insertion. The site of anastomosis of the stomach and jejunum (arrow), the afferent loop (asterisk), and the efferent loop (star) of the jejunum are identified. The dashed line indicates the gastrotomy site.

Citation: Journal of the American Veterinary Medical Association 259, 11; 10.2460/javma.20.04.0241

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During telephone follow-up conversations with the owner at 3, 7, and 8 months after the Billroth II procedure, the cat was reported to be in good general health but had occasional episodes of anorexia. Its body weight had returned to the preoperative value, and at 4 months after the Billroth II procedure, the owner was providing food to the cat 3 to 4 times daily. The cat received regular grooming to prevent further trichobezoar formation.

Nine months after the Billroth II procedure, cat 2 was evaluated because of occasional vomiting and mild weight loss in the preceding 2 weeks. Results of hematologic and plasma biochemical analyses and abdominal ultrasonography were within reference limits. Upper gastrointestinal endoscopy revealed an appropriately sized anastomosis with both efferent and afferent jejunal limbs visible and grossly normal gastric and intestinal mucosa (Figure 3); endoscopic biopsy specimens of the stomach and jejunum were collected. The next day, the cat had a good appetite and was discharged from the hospital. Histologic examination of the endoscopic biopsy specimens revealed mild to moderate lymphocytic plasmacytic enteritis and mild erosive gastritis. Two weeks later, the owner was contacted by telephone; the cat was reported to be in good general health and had no further vomiting. Feeding the cat a hypoallergenic diet was proposed to the owner.

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Endoscopic views of the gastrojejunostomy site in cat 2 obtained 9 months after the Billroth II procedure. A—In this view, notice the stoma with the efferent loop of the jejunum (asterisk). B—In a close-up view, the stoma and the efferent (asterisk) and afferent loops (star) of the jejunum are apparent.

Citation: Journal of the American Veterinary Medical Association 259, 11; 10.2460/javma.20.04.0241

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Discussion

The 2 cats of the present report had pyloroduodenal ulceration and perforation and were successfully managed with a Billroth II procedure. To our knowledge, the application of this technique in cats has not been previously described. However, on the basis of our limited experience, the Billroth II procedure is feasible and relatively straightforward to perform in cats and appears to be associated with a full recovery and good medium- to long-term outcome. However, the Billroth II procedure is rarely indicated, and it is invasive and technically demanding. Similar to previously reported cases,^2,3,4 both cats of the present report were critically ill prior to surgery and required intensive postoperative care.

Full-thickness excision and appositional closure is the recommended treatment for gastric perforations in cats, but such treatment is dependent on the cause, location, and size of the perforation.³ In a small case series,³ ulcers were resected with 1-cm lateral full-thickness stomach wall margins, and primary closure was performed. Importantly, lesions in those 3 cats were located in areas of the stomach more amenable to that surgical treatment (namely, in the fundus adjacent to the greater curvature [n = 1], in the gastric body [1], and in the pyloric antrum in the region of the lesser curvature [1]).³ Numerous other techniques have been described to treat perforations in the pyloric region and proximal portion of the duodenum,⁵ including resection and Heineke-Mikulicz pyloroplasty, application of serosal patch, variation of the Y-U pyloroplasty (full-thickness gastric wall advancement), and partial gastrectomy (pylorectomy) and gastroduodenostomy (Billroth I procedure).^6,7 Prior to performing definitive Billroth II procedures in the cats of the present report, consideration was given to other surgical techniques. Resection and Heineke-Mikulicz pyloroplasty or application of a serosal patch was not considered appropriate because of the size and extent of the lesions and involvement from the proximal aspect of the duodenum through to the pyloric antrum. In people, duodenal perforation with mural defects ≤ 2 cm are treated with direct (primary) closure without resection; for larger lesions, Heineke-Mikulicz pyloroplasty or Finney pyloroplasty would typically be performed before considering gastrectomy.^8,9 The Y-to-U pyloroplasty (full-thickness gastric wall advancement) was similarly considered unsuitable for the cats of the present report because each cat’s lesion involved the pyloric canal and advancement from the pyloric antrum to the distal extent of resection in the duodenum would have been required. Thus, there would have been concern over the length of the flap required and possible necrosis of the distal portion of the flap. Both the Heineke-Mikulicz and Y-to-U pyloroplasty are indicated when partial circumferential resections are performed. A vascularized jejunal patch graft in a dog has also been described, and possibly such a graft could have been performed in the cats of the present report; however, we were concerned about the size of the defects that the grafts would have had to span.¹⁰

After assessing the size of the lesion in each of the 2 cats of the present report, the Billroth I procedure was not performed owing to concerns of the primary surgeon that tension-free anastomosis could not be achieved. Further mobilization of tissues by dissection of the hepatoduodenal ligament could have been undertaken, but this was not performed. Our primary goal was to create a tension-free anastomosis with minimal risk of dehiscence. During a Billroth I procedure, the dorsal aspect of distal extent of gastric incision is difficult to observe, and meticulous surgical technique is required. For dogs undergoing a Billroth I procedure, it has been recommended that 5 to 10 mm of normal tissue is maintained between the cut surface and the major duodenal papilla to prevent inadvertent damage or obstruction of the bile duct or its opening.¹¹ In both cats of the present report, an 8- to 15-mm circumferential cuff of duodenum was maintained between the duodenal blind end and the major duodenal papilla, and there was no evidence of subsequent postoperative biliary leakage or obstruction.

In people, the Billroth I and II procedures have similar complication rates.¹² However, compared with one another, shorter duration of hospitalization and faster recovery appear to be associated with the Billroth II procedure,¹³ whereas some surgeons favor the Billroth I procedure because of its reduced morbidity rate and shorter duration of surgery.¹⁴ In humans, Braun anastomosis is often combined with the Billroth II procedure and involves creation of a side-to-side anastomosis between the afferent (duodenum) and efferent (jejunum) limbs to reduce gastric bile reflux.⁸ In the cases described in the present report, inclusion of Braun anastomosis would have added an additional level of complexity and a site of potential dehiscence given the cats’ septic peritonitis. Furthermore, there are no reports concerning the purported benefit of this technique in the veterinary medical literature, to our knowledge.

The Roux-en-Y technique (gastrojejunostomy with end-to-side anastomosis of the distal portion of the duodenum to the jejunum) is considered standard of care for gastric resection and bariatric surgery in humans because of few associated complications (especially bile reflux) and fast recovery times, despite the procedure’s high technical demand and long surgery times.^12,14 Because of the complexity of that technique and limited information available regarding its use in the veterinary medical literature, it was not considered an advisable treatment choice for the 2 cats of the present report.

Gastrointestinal perforation is a life-threatening condition resulting in septic peritonitis and possible death. Spontaneous gastrointestinal perforation is rare in cats and denotes perforation in the absence of a foreign body, gastric dilatation volvulus, external trauma, or leakage at a previous surgical site and is most often associated with gastric ulceration or neoplasia.^2,15 Previously reported causes include neoplasia (mast cell tumor,¹⁶ gastrinoma,¹⁷ and alimentary lymphoma and adenocarcinoma¹⁸), administration of NSAIDs^2,3,19 or corticosteroids,⁴ inflammatory bowel disease,²⁰ parasitic disease,²¹ decreased gastric perfusion,²² and Dieffenbachia plant toxicosis.²³ However, in most cases of gastrointestinal perforation, an underlying cause is not identified, and the condition is deemed idiopathic.²

In both cases described in the present report, lesions were located in the proximal portion of the duodenum and the pyloric region, and both cats had previously received NSAIDs. This location is consistent with previous descriptions of nonneoplastic gastrointestinal perforations, most of which are located in the pyloroantral region or proximal portion of the duodenum.^2,4,19 It remains unclear whether stress induced by FLUTD in combination with NSAID treatment in the face of anorexia led to perforation in the cats of the present report. In Cat 1, T cati was found, and although this parasite has been reported as a possible cause of perforation, we suspected that the presence of the worms free in the peritoneal cavity was likely a result rather than the cause of the perforation.²¹ The Billroth II procedure has been described for treatment of peptic ulcers,²⁴ gastric neoplasia,²⁵ obesity, and type 2 diabetes mellitus^26,27 in humans, and dogs have been used in investigations of this technique for treatment of human conditions.^28,29 In people, complications associated with the Billroth II procedure include those related to the anastomosis (leakage, stricture, obstruction, afferent and efferent loop syndrome, jejunal intussusception, internal hernia, and marginal ulcers) and those related to gastrointestinal motility (rapid transit or diarrhea, dumping syndrome, postvagotomy diarrhea, slow transit, gastric stasis, alkaline gastritis, and reflux esophagitis).^30,31 In dogs, complications associated with the Billroth II procedure include anorexia, vomiting, diarrhea, gastric distention, weight loss, and anastomotic jejunal ulcers.^32,33,34,35 However, data are limited to findings of an experimental study involving 17 dogs³² and a few canine case reports,^33,34,35 and there are no such reports involving cats. Peptic ulcers, remnant cancer, and nutritional deficiencies are additional long-term complications in humans,³⁶ although not described for dogs that have undergone a Billroth II procedure. The intermittent anorexia in the cases described in the present report may have been related to dumping syndrome, in which undigested or partially digested food moves directly into the small intestine and causes osmotic gradients across the digestive tract. In people, this leads to discomfort, nausea, vomiting, cramps, and diarrhea as well as diaphoresis, palpitations, and flushing.³¹ For cat 2, endoscopy performed 9 months after the Billroth II procedure confirmed the absence of anastomotic stenosis and revealed no other abnormalities. Feeding cat 2 several small meals each day did not seem to influence its anorexia, and worsening signs were not observed after discontinuation of that feeding regimen.

Prognosis for veterinary patients following a Billroth II procedure is generally regarded as poor.⁷ However, both the Billroth I and Billroth II procedures are most commonly performed in patients with major pyloroduodenal pathological changes and poor general health status. Additionally, biliary diversion procedures are necessary when there is compromise or involvement of the major duodenal papilla or bile duct; the 2 cats of the present report did not have such problems, which likely reduced morbidity and improved outcomes. Bearing in mind that the major duodenal papilla is the common opening of the common bile duct and the pancreatic duct in cats, with only 20% of cats reported to have an accessory pancreatic duct opening at the minor duodenal papilla,³⁷ postoperative pancreatitis may be a possible complication of the Billroth II procedure when there is involvement of the major duodenal papilla. With regard to human surgery, researchers have used dogs in investigations of the effect of the Billroth II procedure on gastrointestinal motility²⁸ and for minimally invasive surgical technique advancements.²⁹ In contrast with the perceived poor prognosis associated with this technique in veterinary patients, experimental Billroth II procedures performed by human surgeons in experimental dogs were considered associated with low short- to medium-term risk of complications. Additionally, human patients undergoing gastrectomy (Billroth I or II or Roux-en-Y procedure) for various reasons have postoperative mortality rates < 1%.⁸ Good medium- to long-term outcomes were reported for a limited number of dogs undergoing the Billroth II procedure for gastrointestinal pythiosis and gastrojejunostomy without gastrectomy for pyloric stenosis.^33,35 However, the outcomes for the cats in the present report are difficult to put into perspective given the lack of similar published reports. Both cat 1 and cat 2 had mild postoperative complications but returned to a normal quality of life. Cat 2 developed obstruction of the gastrojejunostomy site because of a trichobezoar that required surgical removal, but development of that problem was unlikely to have been related to the surgical technique, and the anastomosis seemed appropriate in size at the time. Longhair cats are predisposed to trichobezoar formation and subsequent gastrointestinal obstruction,³⁸ and cat 2 was prevented from completing its normal grooming routine after the Billroth II procedure by placement of an Elizabethan collar.

As illustrated by the 2 cases described in the present report, the Billroth II procedure in cats appears to be a feasible and relatively straightforward surgery when the major duodenal papilla can be preserved, and the procedure was associated with good medium- to long-term outcomes for these 2 cats. Although evaluation of a larger cohort of cats is required to determine complication rates and longer-term outcomes, we consider the Billroth II procedure to be a viable option for treatment of large mural defects in the pyloric and proximal duodenal regions of cats for which performance of the Billroth I procedure is not advisable.