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Mullins RA, Escribano Carrera A, Anderson DM, Billet JP, Brissot H, Broome C, de Rooster H, Kirby BM, Pratschke KM, Tivers MS, White RN, Yool DA, Youmans KR. Postattenuation neurologic signs after surgical attenuation of congenital portosystemic shunts in dogs: A review. Vet Surg 2021; 51:23-33. [PMID: 34585759 DOI: 10.1111/vsu.13729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/26/2021] [Accepted: 03/18/2021] [Indexed: 11/27/2022]
Abstract
The development of postattenuation neurologic signs (PANS) is a poorly understood and potentially devastating complication after surgical attenuation of congenital portosystemic shunts in dogs. Postattenuation neurologic signs include seizures but also more subtle neurologic signs such as depression, behavioral changes, tremors, and twitching. They most commonly occur within 7 days postoperatively and are typically unrelated to hyperammonemia, hypoglycemia, or electrolyte disturbances. This narrative review summarizes the findings of 50 publications from 1988-2020 that report occurrence of PANS. While most published reports included only dogs affected by postattenuation seizures (PAS), others included dogs with any form of PANS. Overall, PANS (including PAS) affected 1.6%-27.3% of dogs, whereas incidence of PAS ranged from 0%-18.2%. The etiology of PANS remains unknown; however, several theories have been proposed. Risk factors include preoperative hepatic encephalopathy, increasing age, and possibly certain breeds and extrahepatic shunt morphology. There is increasing evidence that prophylactic antiepileptic drugs do not prevent PANS. Treatment is centered around controlling neurologic signs with antiepileptic drugs and providing supportive intensive care. The 30-day survival rate in studies that included a minimum of four dogs affected by PANS was 0%-100% (median, 50.0%) and 0%-75.0% (median, 37.5%) for those with PAS. Mortality associated with PANS was typically related to occurrence of generalized seizure activity. Prognostic factors positively associated with short-term survival included having a history of preoperative seizures and development of focal seizures only. If affected dogs survived to discharge, survival for several years was possible, and the majority of neurologic signs manifested as part of the phenomenon of PANS appeared to resolve.
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Affiliation(s)
- Ronan A Mullins
- Section of Small Animal Clinical Sciences, University College Dublin, Dublin, Ireland
| | | | | | | | | | - Cameron Broome
- Veterinary Referral Hospital, Melbourne, Victoria, Australia
| | - Hilde de Rooster
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Barbara M Kirby
- Section of Small Animal Clinical Sciences, University College Dublin, Dublin, Ireland
| | - Kathryn M Pratschke
- Veterinary Clinical Services, The Royal (Dick) School of Veterinary Studies and The Roslin Institute, Easter Bush Campus, Midlothian EH25 9RG, UK
| | - Michael S Tivers
- Paragon Veterinary Referrals, Paragon Business Village, Red Hall Crescent, Wakefield, UK
| | - Robert N White
- School of Veterinary Medicine & Science, University of Nottingham, Sutton Bonington Campus, Loughborough, UK
| | - Donald A Yool
- University of Glasgow, School of Veterinary Medicine, Glasgow, UK
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Serrano G, Charalambous M, Devriendt N, de Rooster H, Mortier F, Paepe D. Treatment of congenital extrahepatic portosystemic shunts in dogs: A systematic review and meta-analysis. J Vet Intern Med 2019; 33:1865-1879. [PMID: 31471995 PMCID: PMC6766526 DOI: 10.1111/jvim.15607] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 08/20/2019] [Indexed: 11/27/2022] Open
Abstract
Background Several options have been proposed for the treatment of congenital extrahepatic portosystemic shunts (cEHPSS) in dogs, but formal comparisons among different treatment options are currently unavailable. A previous evidence‐based review (2012) found low quality of evidence for papers assessing the treatment of cEHPSS in dogs. Objectives To assess the quality of evidence available in the treatment of cEHPSS, summarize the current state of knowledge with respect to outcome after cEHPSS management, and compare different treatment techniques. Animals Not used. Methods A bibliographic search was performed without date or language restrictions. Studies were assessed for quality of evidence (study design, study group sizes, subject enrollment quality, and overall risk of bias) and outcome measures reported (perioperative outcome, clinical outcome, and surgical or interventional outcome), all reported with 95% confidence intervals. A network meta‐analysis was performed. Results Forty‐eight studies were included. Six retrospective studies (grade 4b) compared 2 techniques and 7 were abstracts (grade 5). The quality of evidence was low and risk of bias high. Regarding surgical outcome, statistically significant superiority of ameroid constrictor over thin film band was observed (P = .003). No other comparisons were statistically significant. Conclusions and Clinical Importance The evidence base of choice of treatment of cEHPSS in dogs remains weak despite recent publications on the subject. Ameroid is superior to thin film band in causing EHPSS closure. Blinded randomized studies comparing different treatment modalities, which routinely include postoperative imaging to assess cEHPSS closure and acquired portosystemic shunt development are essential.
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Affiliation(s)
- Gonçalo Serrano
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
| | - Marios Charalambous
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
| | - Nausikaa Devriendt
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
| | - Hilde de Rooster
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
| | - Femke Mortier
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
| | - Dominique Paepe
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
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Bristow P, Lipscomb V, Kummeling A, Packer R, Gerrits H, Homan K, Ortiz V, Newson K, Tivers M. Health-related quality of life following surgical attenuation of congenital portosystemic shunts versus healthy controls. J Small Anim Pract 2018; 60:21-26. [PMID: 30251431 DOI: 10.1111/jsap.12927] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 08/09/2018] [Accepted: 08/13/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To design a health-related quality of life questionnaire for dogs with congenital portosystemic shunts, use it in a cohort of dogs treated with suture attenuation and compare results with those obtained from a healthy control cohort. MATERIALS AND METHODS Data were collected from the hospital records of dogs treated with suture ligation of an intrahepatic or extrahepatic congenital portosystemic shunt at two referral centres. Owners were asked to complete a questionnaire assessing their dog's health-related quality of life preoperatively (retrospectively) and at the time of follow-up. Owners of control dogs also completed the questionnaire. RESULTS One hundred and twenty-eight dogs with congenital portosystemic shunts and 131 control dogs were recruited. Median follow-up time was 64 months (range 19.7 to 157.2). The median long-term health-related quality of life score was excellent for both intrahepatic and extrahpatic shunt cases and similar to that of control dogs. The long-term portosystemic shunt clinical sign scores for both intrahepatic and extrahepatic congenital portosystemic shunt dogs were significantly worse than the those of the control group. CLINICAL SIGNIFICANCE Suture attenuation of congenitial portosystemic shunts is associated with an excellent health-related quality of life score at long-term follow-up.
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Affiliation(s)
- P Bristow
- Department of Veterinary Clinical Sciences, Royal Veterinary College, Hatfield, Herts, AL9 7TA, UK
| | - V Lipscomb
- Department of Veterinary Clinical Sciences, Royal Veterinary College, Hatfield, Herts, AL9 7TA, UK
| | - A Kummeling
- Faculty of Veterinary Medicine, Clinical Sciences of Companion Animals, Utrecht University, Utrecht, 3508, The Netherlands
| | - R Packer
- Department of Veterinary Clinical Sciences, Royal Veterinary College, Hatfield, Herts, AL9 7TA, UK
| | - H Gerrits
- Faculty of Veterinary Medicine, Clinical Sciences of Companion Animals, Utrecht University, Utrecht, 3508, The Netherlands
| | - K Homan
- Faculty of Veterinary Medicine, Clinical Sciences of Companion Animals, Utrecht University, Utrecht, 3508, The Netherlands
| | - V Ortiz
- Department of Veterinary Clinical Sciences, Royal Veterinary College, Hatfield, Herts, AL9 7TA, UK
| | - K Newson
- Department of Veterinary Clinical Sciences, Royal Veterinary College, Hatfield, Herts, AL9 7TA, UK
| | - M Tivers
- Department of Veterinary Clinical Sciences, Royal Veterinary College, Hatfield, Herts, AL9 7TA, UK
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Strickland R, Tivers MS, Adamantos SE, Harcourt-Brown TR, Fowkes RC, Lipscomb VJ. Incidence and risk factors for neurological signs after attenuation of single congenital portosystemic shunts in 253 dogs. Vet Surg 2018; 47:745-755. [DOI: 10.1111/vsu.12925] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 01/10/2018] [Accepted: 03/02/2018] [Indexed: 01/15/2023]
Affiliation(s)
- Rhiannon Strickland
- Department of Clinical Science and Services; Royal Veterinary College, University of London; London United Kingdom
| | - Michael S. Tivers
- School of Veterinary Sciences; University of Bristol; Bristol United Kingdom
| | | | | | - Robert C. Fowkes
- Department of Comparative Biomedical Sciences; Royal Veterinary College, University of London; London United Kingdom
| | - Victoria J. Lipscomb
- Department of Clinical Science and Services; Royal Veterinary College, University of London; London United Kingdom
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Tivers MS, Lipscomb VJ, Bristow P, Brockman DJ. Intrahepatic congenital portosystemic shunts in dogs: short- and long-term outcome of suture attenuation. J Small Anim Pract 2017; 59:201-210. [DOI: 10.1111/jsap.12788] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 09/29/2017] [Accepted: 10/06/2017] [Indexed: 10/18/2022]
Affiliation(s)
- M. S. Tivers
- Department of Clinical Sciences and Services; Royal Veterinary College; Hatfield Hertfordshire AL9 7TA UK
- Bristol Veterinary School; University of Bristol; Langford Bristol BS40 5DU UK
| | - V. J. Lipscomb
- Department of Clinical Sciences and Services; Royal Veterinary College; Hatfield Hertfordshire AL9 7TA UK
| | - P. Bristow
- Department of Clinical Sciences and Services; Royal Veterinary College; Hatfield Hertfordshire AL9 7TA UK
| | - D. J. Brockman
- Department of Clinical Sciences and Services; Royal Veterinary College; Hatfield Hertfordshire AL9 7TA UK
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Tivers MS, Handel I, Gow AG, Lipscomb VJ, Jalan R, Mellanby RJ. Attenuation of congenital portosystemic shunt reduces inflammation in dogs. PLoS One 2015; 10:e0117557. [PMID: 25658922 PMCID: PMC4320035 DOI: 10.1371/journal.pone.0117557] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 12/29/2014] [Indexed: 12/15/2022] Open
Abstract
Liver disease is a major cause of morbidity and mortality. One of the most significant complications in patients with liver disease is the development of neurological disturbances, termed hepatic encephalopathy. The pathogenesis of hepatic encephalopathy is incompletely understood, which has resulted in the development of a wide range of experimental models. Congenital portosystemic shunt is one of the most common congenital disorders diagnosed in client owned dogs. Our recent studies have demonstrated that the pathophysiology of canine hepatic encephalopathy is very similar to human hepatic encephalopathy, which provides strong support for the use of dogs with a congenital portosystemic shunt as a naturally occurring model of human hepatic encephalopathy. Specifically, we have demonstrated an important role for ammonia and inflammation in the development of hepatic encephalopathy in dogs with a congenital portosystemic shunt. Despite the apparent importance of inflammation in driving hepatic encephalopathy in dogs, it is unclear whether inflammation resolves following the successful treatment of liver disease. We hypothesized that haematological and biochemical evidence of inflammation, as gauged by neutrophil, lymphocyte and monocyte concentrations together with C-reactive protein concentrations, would decrease following successful treatment of congenital portosystemic shunts in dogs. One hundred and forty dogs with a congenital portosystemic shunt were enrolled into the study. We found that the proportion of dogs with a monocyte concentration above the reference range was significantly greater in dogs with hepatic encephalopathy at time of initial diagnosis. Importantly, neutrophil and monocyte concentrations significantly decreased following surgical congenital portosystemic shunt attenuation. We also found a significant decrease in C-reactive protein concentrations following surgical attenuation of congenital portosystemic shunts. Our study demonstrates that haematological and biochemical indices of inflammation reduce following successful treatment of the underlying liver disorder.
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Affiliation(s)
- Michael S. Tivers
- Department of Veterinary Clinical Sciences, Royal Veterinary College, Hatfield, Hertfordshire, United Kingdom
- * E-mail:
| | - Ian Handel
- Royal (Dick) School of Veterinary Studies and The Roslin Institute, The University of Edinburgh, Roslin, Midlothian, United Kingdom
| | - Adam G. Gow
- Royal (Dick) School of Veterinary Studies and The Roslin Institute, The University of Edinburgh, Roslin, Midlothian, United Kingdom
| | - Victoria J. Lipscomb
- Department of Veterinary Clinical Sciences, Royal Veterinary College, Hatfield, Hertfordshire, United Kingdom
| | - Rajiv Jalan
- UCL Institute for Liver and Digestive Health, UCL Medical School, London, United Kingdom
| | - Richard J. Mellanby
- Royal (Dick) School of Veterinary Studies and The Roslin Institute, The University of Edinburgh, Roslin, Midlothian, United Kingdom
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom
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Tivers MS, Upjohn MM, House AK, Brockman DJ, Lipscomb VJ. Treatment of extrahepatic congenital portosystemic shunts in dogs - what is the evidence base? J Small Anim Pract 2011; 53:3-11. [PMID: 22098116 DOI: 10.1111/j.1748-5827.2011.01144.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A variety of surgical treatments and medical therapies are recommended for dogs with extrahepatic congenital portosystemic shunts (CPSS). The objective of this review was to assess the evidence base for the management of extrahepatic CPSS in dogs. An online bibliographic search was performed in November 2010 to identify articles relating to the question "Which of the treatment options for extrahepatic CPSS in dogs offers the best short- and long-term outcomes?" Articles were assigned a level of evidence based on a modified grading system. Thirty-eight articles were included in the review. Thirty-six articles were classified as grade 4 and two as grade 5. The timings and methods of assessment of short- and long-term outcomes varied widely between studies. One prospective study (grade 4a) showed that surgically treated dogs survived significantly longer than medically treated dogs. Four retrospective studies (grade 4b) compared the outcome of two surgical techniques but there were no statistically significant differences between treatment groups in terms of complications or outcome. The review found that the evidence base for the treatment of extrahepatic CPSS is weak. There is a lack of evidence of short- and long-term outcomes to recommend one treatment over another.
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Affiliation(s)
- M S Tivers
- Department of Veterinary Clinical Sciences, Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Hertfordshire, United Kingdom
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