ABSTRACT Objectives: Biopsy quality is an essential factor for successful diagnosis of canine liver disease. Several minimally invasive methods to obtain diagnostic liver biopsies have been described. The aim of this study was to compare weight and volume of the samples, surgical time required, possible complications and histological quality between liver biopsies obtained laparoscopically with a pre- tied ligating loop (PLL) and cup biopsy forceps (CBF). Materials and Methods: Fifteen client owned dogs underwent laparoscopic liver biopsies for diagnosis of liver disease. Biopsies were obtained from the same liver lobe using a PLL and CBF. The resulting biopsies were evaluated for; weight, volume, histological value and the surgical time required and compared. Any surgical complications were recorded. Results Samples obtained with the PLL were significantly heavier and larger in volume than those obtained with CBF. Samples obtained with the PLL contained significantly more portal tracts and less crush and fragmentation artefact than the ones obtained with CBF. The duration required to obtain a liver biopsy with the PLL was approximately double of that of the CBF. Clinical significance 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
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University of Edinburgh€¦ · Web viewSoft Tissue-General, Laparoscopy, Pre-tied ligating loop, Liver biopsy, Hepatic biopsy. INTRODUCTION Liver biopsy is integral in the diagnosis,
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ABSTRACT
Objectives: Biopsy quality is an essential factor for successful diagnosis of canine liver disease.
Several minimally invasive methods to obtain diagnostic liver biopsies have been described. The aim
of this study was to compare weight and volume of the samples, surgical time required, possible
complications and histological quality between liver biopsies obtained laparoscopically with a pre-tied
ligating loop (PLL) and cup biopsy forceps (CBF).
Materials and Methods: Fifteen client owned dogs underwent laparoscopic liver biopsies for
diagnosis of liver disease. Biopsies were obtained from the same liver lobe using a PLL and CBF. The
resulting biopsies were evaluated for; weight, volume, histological value and the surgical time
required and compared. Any surgical complications were recorded.
Results
Samples obtained with the PLL were significantly heavier and larger in volume than those obtained
with CBF. Samples obtained with the PLL contained significantly more portal tracts and less crush
and fragmentation artefact than the ones obtained with CBF. The duration required to obtain a liver
biopsy with the PLL was approximately double of that of the CBF.
Clinical significance
The use of a PLL is a good alternative technique to the CBF when performing laparoscopic liver
(n=1), fibrosis and biliary hyperplasia (n=1), chronic cholestasis and biliary hyperplasia (n=1),
hepatocellular swelling (n=1) and normal liver (n=1).
Complications and follow-up
Eight dogs were presented to the scheduled recheck appointment 10-14 days after surgery. Three of
the eight dogs had minor wound complications. Two cases showed dehiscence of the 6 mm side
wound and one case showed dehiscence of the wounds on both sides (11 mm and 6 mm wounds).
None of the dogs that developed wound complications wore the Elizabethan collar given to the owner
at discharge. Bacterial culture was performed in two of the three cases which developed wound
complications. One yielded a mixed growth of E. coli and Pasteurella sp and no growth was reported
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in the second one. Both cases received oral co-amoxiclav (15-20 mg/kg, q 12h) for 10 days. All three
cases were also managed with wound dressings.
Of the five remaining dogs, which were not presented to the scheduled recheck appointment, no
wound complication was reported by the owners on follow-up by telephone contact or on routine
recheck appointment with the Internal Medicine Service.
In total, four dogs (26.6%) were euthanased during the study period due to disease progression.
Follow-up time for the rest of the dogs was 26-254 days.
DISCUSSION
The results of the present study confirm that using a PLL is a feasible and safe method to obtain
laparoscopic liver biopsies. In addition, the hepatic sample obtained is significantly larger and
contains significantly more portal tracts and less artefacts than those obtained with CBF from the
same liver lobe.
The size of the sample obtained by traditional open coeliotomy is the largest of any of the methods
described in the literature, providing more than adequate tissue for histopathology, copper analysis
and culture (Rothuizen and Twedt 2009). The sample obtained with the PLL via laparoscopy shows
similar characteristics to biopsies obtained in open surgery with the guillotine technique with a sample
significantly larger than that obtained with CBF and enough tissue to perform histopathology,
bacterial culture and copper analysis for comprehensive evaluation of liver disease. Conversely, the
total amount of tissue obtained with CBF in this study would have not been enough to perform all the
tests required (i.e. quantitative copper analysis). However, for ethical reasons, a smaller number of
hepatic biopsies were obtained with CBF as the aim was not to remove more liver tissue than required
between the two methods.
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The PLL technique for laparoscopic hepatic biopsies has been described previously in a surgical
textbook and in a review on diagnostic laparoscopic techniques in cats (Robertson et al. 2014a,
Robertson et al. 2014b). In both, its use is recommended for animals with increased risk of
haemorrhage such as advance hepatic failure, focal or highly vascular lesions and coagulopathies.
None of the dogs in the current study had a clinically significant coagulopathy and comparing the
degree of haemorrhage between the two methods in dogs with and without coagulopathy in detail was
beyond the scope of the study. However, less haemorrhage was noted when using the PLL in
comparison to the CBF.
In this study, both techniques were used in dogs of a wide range of body sizes and different
histological diagnoses. The PLL was easier to use in dogs with fibrosis as the tissues were more
resilient to handling. On the contrary, the technique was slightly more challenging in dogs with a
friable liver or those with rounded liver edges.
A recent study concluded that the likelihood of obtaining a sample that represents the predominant
histological diagnosis is increased when multiple liver lobes were biopsied. (Kemp et al. 2015a). They
reported that when one liver lobe was sampled, the sample would reflect the prevalent histologic
diagnosis in 92% of the cases, whereas when two liver lobes were sampled, the percentage increased
to 98%. The previous study was published after all the data collection had completed for the current
study with only one liver lobe sampled with the two different techniques. Therefore, we have not
included this circumstance in our experimental design.
Despite all samples being considered of diagnostic value, 33% of the biopsies obtained with the cup
forceps contained less than eleven portal tracts as recommended in the human literature (Rockey et al.
2009). Conversely, all the biopsies obtained with the PLL had more than 18 portal tracts and showed a
significantly less crush and fragmentation artefact making the PLL method a superior method to the
CBF in terms of histologic sample quality. Furthermore, the PLL method provided a total sample 3.23
times heavier and 4.33 times larger in volume than those obtained with CBF. Both weight and volume
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were measured as different hepatopathies may affect weight and volume independently and they may
not increase or decrease together in a proportional fashion.
PLL sampling consistently required more surgical time than cup forceps biopsy. The PLL technique
requires more advanced laparoscopic skills when compared to the CBF and the learning curve is
probably steeper. All the procedures were performed by a resident in training as the primary surgeon
who had previous experience using CBF but had minimal experience with the PLL. This study is
likely to represent part of the learning curve for this procedure and this surgeon. All these reasons
may explain the longer duration required to obtain the necessary biopsies. Additionally, the PLL
method required a third port being placed for triangulation which also added a mean time of 2.8
minutes to the total surgical time.
An assistant was required in all the procedures included in this study. When an assistant is used, the
primary surgeon and the assistant should be able to coordinate their movements and therefore, the
assistant should also have previous laparoscopic experience. Following the study, the procedure has
been performed without a trained assistant, with them only stabilising the camera whilst the surgeon
was positioned at the caudal aspect of the dog between the hind limbs rather than on the side of the
dog.
In the case in which the PLL was cut inadvertently, a collagen sponge was used first to stop the
haemorrhage. However, this was not enough to control the haemorrhage and a second PLL was placed
around the liver parenchyma which immediately controlled the haemorrhage. This could provide an
additional use of the PLL in controlling haemorrhage in laparoscopic surgery.
None of the cases in this study required conversion to an open approach during surgery due to
uncontrolled haemorrhage or laceration of abdominal viscera. In a previous retrospective study
including 80 cases undergoing laparoscopic liver biopsies, the spleen was lacerated in one (1,3%) of
the cases and necessitated conversion to an open approach (Petre et al. 2012). In human laparoscopy,
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the incidence of iatrogenic trauma to abdominal organs and vessels by trocars or Veress needle has
been reported to be as low as 0.18% (Schafer et al. 2001).
A total of 13 of 15 (86.6%) survived to hospital discharge. The two dogs that died or were euthanased
during the study period had a histologic diagnosis of chronic hepatitis with cirrhosis. Cirrhosis is a
poor prognosis indicator in canine liver disease associated to a median survival time of 1.3 months
(Favier et al. 2013).
Only four cases developed postoperative complications. One dog needed rescue analgesia 24 hours
after discharge and three dogs had wound related complications. Tramadol is considered an
unpredictable analgesic and oral tramadol alone provided an inadequate level of analgesia in a
significant number of dogs undergoing an orthopaedic procedure (Davila et al. 2013). Postoperative
wound complications was reported in 16% in a study on dogs undergoing laparoscopic ovariectomy
(Pope and Knowles 2014). In that study, they could not find a statistically significant difference in
wound complications between the wound of 6 mm ports and 11 mm ports. In the present study, three
(20%) cases developed wound related complications which is a similar to previously reported and
only one of the three showed a wound complication in the 10 mm wound.
The goal of this study was to describe the use of a PLL to perform laparoscopic liver biopsies and
compare it to the traditional cup biopsy forceps. The limitations of the present study include the
limited number of cases, the use of single liver lobe for histological diagnosis and the experience of
the primary surgeon. The number of cases that developed complications was too low to allow
meaningful comparison with previous studies. The mean total surgery time was 78 minutes and this
included cases in which gallbladder bile aspiration was performed. Given the steep learning curve for
performing laparoscopy, it is possible that the mean surgery time would have been shorter if the
procedures were performed by a more experienced surgeon.
Conclusion
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The PLL is a successful and safe method to obtain laparoscopic liver biopsies. The resulting samples
were on average >3 times as heavy and larger in volume compared to samples obtained with cup
biopsy forceps. Although both methods resulted in biopsies of diagnostic value, the samples obtained
with the PLL showed superior quality in terms of number of portal tracts, crushing and fragmentation
artefacts.
We propose that obtaining laparoscopic hepatic biopsies with a PLL method can be considered a good
alternative method to the cup biopsy forceps method in dogs.
Conflict of interest
No conflicts of interest have been declared.
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Figure 1. Laparoscopic Babcock forceps holding the liver lobe through the pre-tied ligating loop ready
to position the loop around the hepatic tissue (left). Cuff of liver tissue and visible ends of the PLL
(white asterisk) and biopsy sites from the CBF (white arrows) (right).