Pancreaticoduodenectomy with choledochoduodenostomy and pancreaticojejunostomy in a cat with bile and pancreatic duct obstruction secondary to a recurrent carcinoid

Abstract

Objective

To describe the surgical procedure for pancreaticoduodenectomy with choledochoduodenostomy and pancreaticojejunostomy for carcinoids of the common bile duct (CBD) in a cat and to report its outcomes.

Study design

Case report.

Animal

A 6‐year‐old neutered male Munchkin cat.

Methods

A small tissue plug causing CBD obstruction was surgically removed from a cat. The obstructive plug was diagnosed histopathologically as carcinoid. Nine months after initial surgery, the cat developed anorexia and vomiting. Diagnostic imaging revealed dilation of both the CBD and pancreatic duct, and the cat underwent a second surgery 11 months after the initial procedure. En bloc resection of the pancreatic body and duodenum, including the site of the CBD obstruction, was performed. Following the duodenal reconstruction with end‐to‐end anastomosis, the biliary system was rebuilt with end‐to‐side anastomosis, connecting the CBD's resected end to the duodenum. Pancreatojejunostomy of the distal end of the left pancreatic lobe and jejunum was performed to reconstruct the pancreatic duct.

Results

No postoperative complications such as bile leakage, pancreatic fluid leakage, or pancreatitis were observed. Toceranib therapy was initiated postoperatively. The cat showed good general condition 524 days after the second surgery and exhibited favorable progress at the time of writing.

Conclusion

This is the first report of a successful reconstructive surgery with choledochoduodenostomy and pancreatojejunostomy after en bloc resection of the pancreatic body and proximal duodenum in a cat with recurrent carcinoid‐induced ductal obstruction. Pancreatic body duodenectomy may be a viable and effective option for managing pancreatic duct obstruction in cats.

Abbreviations

CBD

common bile duct

CRI

continuous rate infusion

CT

computed tomography

EHBDO

extrahepatic bile duct obstruction

POD

postoperative day

TBil

total bilirubin

1. INTRODUCTION

Carcinoids originating from the neuroendocrine system are rarely found in cats, with occurrences described in the hepatobiliary system, ¹ duodenum, ² and pancreas. ³ Carcinoids arising from the liver cause clinical symptoms including hepatomegaly, anorexia, weight loss, and vomiting. However, carcinoids from the extrahepatic biliary system may obstruct the biliary system, resulting in jaundice and elevated levels of serum liver enzymes. ⁴ To date, no effective treatment for extrahepatic biliary carcinoids has been established in small animal medicine. For example, due to the lack of effective treatments, 14 of 17 dogs undergoing surgical management of an extrahepatic biliary carcinoid were euthanized during the perioperative period. ¹ Reconstruction of the gastrointestinal tract and adjacent pancreatic duct and common bile duct (CBD) is needed when a tumor is located in the distal CBD. A previous feline case report described the resection of the pancreatic body and right lobe, followed by end‐to‐side duodenal anastomosis of the left pancreatic lobe for the treatment of abscesses. ⁵ In that report, the left pancreatic duct was isolated and an end‐to‐side pancreaticoduodenostomy was performed. However, there have been no reports of pancreatojejunostomy for reconstruction in cats with tumors. En bloc resection of the duodenum with the major papilla, including the pancreatic body and CBD, has not been described for complete tumor resection. This case report therefore describes the surgical procedures for choledochoduodenostomy and pancreatojejunostomy after en bloc resection of the pancreatic body and duodenum in a cat with recurrent CBD carcinoid, which resulted in a favorable outcome with the postoperative administration of toceranib.

2. MATERIALS AND METHODS

A 6‐year‐old neutered male Munchkin cat weighing 2.9 kg was presented to the referring hospital with the chief complaint of loss of appetite for 2 months and high levels of serum liver enzymes and total bilirubin (TBil). At the time of the first examination at our hospital, the cat's general condition had improved, and there was no increase in serum liver enzymes or TBil (0.1 mg/dL). However, computed tomography (CT) revealed dilation and tortuosity of the CBD (maximum diameter 4.6 mm). Although the cat was diagnosed with extrahepatic bile duct obstruction (EHBDO), the owner did not opt for surgery because of the cat's improved general condition; the cat was therefore returned to the referring hospital. Three months after the initial examination, the cat had a loss of appetite, and blood tests revealed increases in serum liver enzymes and TBil (1.6 mg/dL); the cat was therefore referred to our hospital again. Diagnostic imaging confirmed the presence of EHBDO and the owner opted for surgery. The surgery involved removing the CBD tissue plug that caused the EHBDO through choledochotomy. The EHBDO resolved. The resected plug was histopathologically diagnosed as a carcinoid tumor, positive for neuroendocrine markers. The cat had no postoperative complications, such as jaundice, was in good general condition, and was discharged on the 13th day after surgery. As the owner chose to return to the referring hospital after discharge, the cat was observed at the referring hospital, as it was in good overall condition without any complications such as jaundice. However, approximately 9 months after surgery, the cat was referred to our hospital because of loss of appetite, vomiting, and an increase in serum liver enzymes.

The cat presented with white‐yellow diarrhea, vomiting, and loss of appetite without apparent jaundice at revisit. Blood tests showed that TBil (0.3 mg/dL) was within the reference range (<0.4 mg/dL), and serum liver enzymes and lipase levels were elevated (Table 1). The cat did not show an increase in serum amyloid A levels, which were within the reference range. Abdominal ultrasound revealed dilation of the CBD (diameter, 5.4 mm) with a tortuous configuration caused by a masslike formation of the distal CBD. Pancreatic duct dilatation was also observed. The cat was scanned in ventral recumbency with breath holding using a 320 slice multi‐detector CT scanner (Aquilion ONE; Canon Medical Systems, Ohtawara, Japan). Computed tomography angiography images were acquired in the arterial, portal, and late phases after injection of contrast medium (Ioverin 300; Teva Takeda Yakuhin Ltd., Tokyo, Japan). Scan parameters were as follows: rotation time, 0.5 s; slice thickness, 0.5 mm; reconstruction interval, 0.5 mm; helical pitch, 65.0; X‐ray tube potential, 120 kV; and X‐ray tube current, maximum 350 mA. The CT images revealed dilation and tortuosity of the biliary system (maximum CBD diameter, 7.7 mm) and pancreatic duct dilation (maximum diameter, 3.0 mm) in the pancreatic parenchyma (Figure 1A). An irregularly enhanced masslike formation, approximately 10 mm in diameter, was found in the CBD near the major duodenal papilla (Figure 1B).

TABLE 1.

The patient's hematology, serum chemistry, and coagulation test results.

Variables	Units	Initial exam	Preop	POD 20	POD 402	Reference range
RBC	106/μL	8.52	7.85	7.45	8.78	5.00–10.00
Hgb	g/dL	13.1	12.3	11.8	14.3	8.0–15.0
PCV	%	39	37	34	43	24–45
WBC	/μL	9900	11 800	11 800	5300	5500–19 500
Plt	103/μL	264	383	458	360	300–700
TP	g/dL	8.3	8.3	6.7	8.4	5.7–7.8
Alb	g/dL	3.4	3	2.8	3.3	2.3–3.5
Glu	mg/dL	182	167	136	101	71–148
TBil	mg/dL	0.3	1.6	0.1	0	0–0.4
AST	U/L	138	125	16	33	18–51
ALT	U/L	644	806	49	48	22–84
ALP	U/L	79	200	35	25	0–58
GGT	U/L	3	10	2	0	0–10
Amy	U/L	1086	730	872	1146	200–1900
Lipa	U/L	36	25	21	25	0–30
BUN	mg/dL	15.9	15.9	15.7	22.9	17.6–32.8
Cr	mg/dL	0.94	0.77	0.81	0.89	0.90–2.10
TCho	mg/dL	201	285	130	200	95–259
Na	mmol/L	149	151	153	156	147–156
K	mmol/L	3.7	3.6	3.7	3.7	3.4–4.6
Cl	mmol/L	114	110	117	109	107–120
Ca	mg/dL	10	10.4	NA	NA	8.8–11.9
P	mg/dL	3.2	3.7	NA	NA	2.6–6.0
SAA	μg/mL	4.6	84.9	0.2	0	0–5.5
APTT	s	16.9	21.1	NA	NA	13.0–61.0
PT	s	6.6	6.5	NA	NA	7.0–8.0
Fib	mg/dL	182.9	226.5	NA	NA	82.0–204.0
ATIII	%	200	191	NA	NA	114–169
D‐dimer	μg/mL	0.17	0.55	NA	NA	0–1.50

Note: Abnormal values are shown in bold. Preoperative serum liver enzymes, TBil, and lipase levels were high and decreased to within the reference ranges postoperatively. The SAA level was dramatically reduced after surgery.

Abbreviations: Alb, albumin; ALP, alkaline phosphatase; ALT, alanine aminotransferase; Amy, amylase; APTT, activated partial thromboplastin time; AST, aspartate aminotransferase; AT, antithrombin activity; BUN, blood urea nitrogen; Cr, creatinine; Eos, eosinophil; Fib, fibrinogen; GGT, gamma‐glutamyl transferase; Glu, glucose; Hgb, hemoglobin; Lipa, lipase; Lym, lymphocytes; Mon, monocytes; NA, not analyzed; PCV, packed cell volume; Plt, platelet count; POD, postoperative day; Preop, preoperative; PT, prothrombin time; RBC, red blood cell count; SAA, serum amyloid alpha; Seg, segmented neutrophil; TBil, total bilirubin; TCho, total cholesterol; TP, total protein; WBC, white blood cell count.

FIGURE 1.

Computed tomography images at initial evaluation. (A) Coronal image. The common and intrahepatic bile ducts had a maximum diameter of 7.7 mm and were dilated and tortuous. The pancreatic duct (white arrow) was also dilated to a maximum diameter of 3.0 mm and was clearly visible within the pancreas. (B) Axial image. An irregularly enhancing masslike formation approximately 10 mm in diameter was identified in the common bile duct near the major duodenal papilla.

The re‐evaluation and surgery were scheduled based on the client's schedule. On preoperative day 1 (the 22nd day after the revisit) blood tests revealed increased TBil (1.6 mg/dL) and serum liver enzyme levels, showing a worsening trend (Table 1). Given the cat's deteriorating general condition, a second surgical intervention was performed, with the owner's consent.

Preoperative medication included following subcutaneous administrations; 1.0 mg/kg of maropitant citrate hydrate (Cerenia, Zoetis Inc., Parsippany, New Jersey), 0.04 mg/kg of atropine sulfate hydrate (Nipro Co., Ltd., Osaka, Japan), 1.0 mg/kg of famotidine (Gaster, Astellas Pharma Inc., Tokyo, Japan), and 1.0 mg/kg of prednisolone (Kyoritsu Seiyaku Co. Ltd., Tokyo, Japan). Subsequently, 20 mg/kg of ampicillin (Bixilin, Meiji Seika Pharma, Tokyo, Japan) and 5.0 μg/kg of fentanyl hydrochloride (Terumo Co., Tokyo, Japan) were administered intravenously. Propofol (Nichi‐Iko Co., Ltd., Toyama, Japan) was administered intravenously for general anesthesia, followed by endotracheal intubation. During the surgery, anesthesia was maintained with sevoflurane (Sevoflu, Zoetis Inc.). For intraoperative circulatory support, initial intravenous fluid boluses were administered, followed by continuous rate infusion (CRI) of the following medications as needed: 1.25–3.75 μg/kg/min dopamine hydrochloride (Nichi‐Iko Co. Ltd.), 1.25–2.5 μg/kg/min dobutamine hydrochloride (Dobutrex, Kyowa Pharmaceutical Co. Ltd., Osaka, Japan), and 0.05–0.1 μg/kg/min carperitide (HANP, Daiichi Sankyo Co. Ltd., Tokyo, Japan). In the event of hypotension despite these circulatory supports, the intravenous administration of 2.5–7.5 μg/kg phenylephrine (Neosine, Kowa Co. Ltd., Tokyo, Japan) was added as needed. For intraoperative analgesia, 10–20 μg/kg/h remifentanil hydrochloride (Maruishi Pharmaceutical Co. Ltd., Osaka, Japan) and 2.5 μg/kg/h fentanyl hydrochloride (Terumo Co.) were administered continuously and intravenously. Nafamostat mesylate (Fusan, Nichi‐Iko Co. Ltd.) at a dose of 0.2 mg/kg/h was administered continuously and intravenously throughout the surgery. Bupivacaine (Marcaine, Sando Pharma Co., Ltd., Tokyo, Japan) was administered postoperatively as a local paravertebral nerve block.

The cat was prepared for an aseptic abdominal surgery and positioned in dorsal recumbency. During midline celiotomy, an indurated mass lesion invading the CBD and pancreatic body, a dilated CBD, and pancreatic atrophy were identified (Figure 2A). Although a duodenotomy was performed to confirm the major duodenal papilla, catheter insertion from the papilla was not possible. Hence, en bloc resection of the distal CBD, pancreatic body, and duodenum, including the major duodenal papilla, was performed to remove the mass completely.

FIGURE 2.

Intraoperative findings. (A) The duodenum and pancreas around the common bile duct. Dilation of the common bile duct (white arrow) was observed near the duodenum (black arrow). The mass lesion around the common bile duct near the duodenal orifice exhibited signs of hardening. Atrophy of right pancreatic lobe (yellow arrow) was also observed. (B) Resection of the left pancreatic lobe. After dissection of the right pancreatic lobe and duodenum distal to the tumor (white circle), the left pancreatic lobe (white arrow) was double ligated. The 2–0 polypropylene sutures were used to ligate between the pancreatic body and the left pancreatic lobe, and subsequent resection between the pancreatic body and the left pancreatic lobe was performed. (C) Duodenal reconstruction (end‐to‐end anastomosis). As both sides of the pancreatic body and duodenum were transected, the segment of duodenum (*) including major papilla and the pancreatic body including the tumor was freed and only connected by the common bile duct. Duodenal reconstruction was performed through end‐to‐end anastomosis using a simple interrupted pattern with 4–0 polydioxanone sutures. (D) Resection of the common bile duct (white arrow) connected with the mass lesion. Thus, en bloc resection of the mass lesion (*) including the segment of the duodenum with major papilla, the pancreatic body, and distal segment of common bile duct was achieved. (E) End‐to‐side anastomosis of common bile duct (black arrow) and duodenum (*). A 12 mm incision was made approximately 5 cm distal to the duodenal anastomosis, and an end‐to‐side anastomosis between the resected common bile duct stump and the incised site of duodenum was performed using two suture lines of 4–0 polydioxanone in a continuous pattern. (F) Insertion of a 3 Fr catheter into the pancreatic duct. The left end of the left pancreatic lobe (*) was resected, and the orifice of the pancreatic duct was identified from which the pancreatic fluid overflow was confirmed. A 3 Fr catheter was then inserted into the pancreatic duct orifice. (G) Parachute suturing of an end‐to‐side anastomosis between the pancreatic duct and jejunum (black arrow). Six 5–0 polypropylene sutures with a simple interrupted pattern were used for the pancreaticojejunostomy. The distal end of left pancreatic lobe (white arrow) is shown. (H) Positional relationship of end‐to‐side pancreaticojejunostomy (white circle) and the location of the jejunal incision. The catheter was fixed through the jejunum incision using 4–0 poliglecaprone 25 as a temporary stent, and the incised jejunum was closed with a single interrupted pattern using 4–0 polydioxanone sutures (white arrow).

For the mass lesion resection involving the CBD and pancreatic body, 2–0 polypropylene (Prolene, Johnson & Johnson, New Brunswick, New Jersey) sutures were used for double ligation between the pancreatic body and the right pancreatic lobe, followed by resection between the ligations. The distal portion of the duodenum was resected at the same level as the right pancreatic lobe. The left pancreatic lobe was ligated after the resections of the right pancreatic lobe and the duodenum distal to the mass with 2–0 polypropylene sutures (Figure 2B). Then, the pancreatic body and the left pancreatic lobe were resected. The gastroduodenal artery and vein were ligated and cut, and the proximal duodenum was resected. Duodenal reconstruction was performed through an end‐to‐end anastomosis using a simple interrupted pattern with 4–0 polydioxanone sutures (PDS‐II, Johnson & Johnson) (Figure 2C). The connected CBD was resected (Figure 2D), and en bloc resection of the mass lesion was performed, including the segment of the duodenum with the major papilla, pancreatic body, and distal segment of the CBD. For the reconstruction of the biliary excretion route, a 12 mm incision was made approximately 5 cm distal to the duodenal anastomosis, and an end‐to‐side anastomosis between the resected CBD stump and the incised site of duodenum was performed using two suture lines of 4–0 polydioxanone with a continuous pattern (Figure 2E).

The distal end of the left pancreatic lobe was resected, and the orifice of the pancreatic duct was identified, confirming the overflow of pancreatic fluid. A 3 Fr catheter was then inserted into the pancreatic duct through the orifice (Figure 2F). To create the pancreaticojejunostomy site, a hole was incised on the antimesenteric side of the jejunum near the resected stump of the left pancreatic lobe using a 4 mm skin biopsy punch (Kai Industries Co., Ltd., Gifu, Japan). The jejunum distal to the hole was incised and dilated to facilitate anastomosis with the resected pancreatic stump. The external portion of the catheter was trimmed to approximately 5 cm to serve as a temporary stent. The remaining external portion was inserted at the pancreaticojejunostomy site and advanced caudally into the distal jejunum. Anastomosis between the pancreatic duct and the jejunum was performed using a parachute suturing technique with six simple interrupted sutures of 5–0 polypropylene (Prolene Hemo‐Seal, Johnson & Johnson) (Figure 2G). Following pancreaticojejunostomy, a small incision was made on the antimesenteric side of the jejunum, distal to the anastomosis. Through this incision, the temporary stent catheter was fixed to the jejunal mucosa using 4–0 poliglecaprone 25 (Monocryl, Johnson & Johnson). After fixation, the jejunal incision was closed with 4–0 polydioxanone simple interrupted‐patterned sutures (Figure 2H).

Abdominal lavage was performed using sterile saline solution. Following the insertion of an active drain (J‐VAC Drainage System, Johnson & Johnson) into the abdominal cavity, the abdominal incision was routinely closed.

3. RESULTS

The surgery was completed without any complications, and the operative time from the beginning of the skin incision to the end of skin closure was 168 min.

3.1. Postoperative care in the hospital

During hospitalization, the cat exhibited normal consciousness on the first postoperative day (POD) and remained in good condition. Imipenem hydrate/cilastatin sodium (Thienam, Merck & Co., Rahway, New Jersey) at 5.0 mg/kg was administered intramuscularly twice a day; 1.0 mg/kg maropitant and 1.0 mg/kg famotidine were administered continuously postoperatively, and 0.4 mg/kg fuzapradib sodium hydrate (Brenda Z, Nippon Zenyaku Kogyo Co. Ltd., Fukushima, Japan) was administered intravenously once a day. For postoperative circulatory support, the following CRIs were continued: 2.5 μg/kg/min dopamine hydrochloride and 2.5 μg/kg/min dobutamine hydrochloride. For postoperative analgesia management, CRI with 1.25–2.5 μg/kg/h fentanyl hydrochloride was continued postoperatively, and CRI with 0.2 mg/kg/h nafamostat mesylate was continued for the prevention of pancreatitis. Blood tests revealed no abnormalities other than elevated serum liver enzymes. Hemoexudate was drained from the active drainage tube at a rate of 16 mL/kg/day; however, bile and pancreatic fluid were not present. Oral feeding commenced on POD 3 without any clinical signs indicating pancreatitis, such as vomiting or abdominal pain. On POD 5, the drained fluid volume decreased to 4.6 mL/kg/day, with no evidence of bile or pancreatic fluid leakage. On POD 6, blood tests revealed an increase in alanine aminotransferase levels. The drain tube was removed and the cat was discharged in good condition.

3.2. Histopathological evaluation

Histopathological diagnosis revealed a carcinoid originating from the CBD, with partial infiltration into the pancreas. Histopathological examination revealed a complete resection of the tumor.

3.3. Postoperative care after discharge and outcome of the procedure

Following discharge, the patient defecated with naturally colored stools, indicating normal excretion of bile and pancreatic fluid, in contrast with the white‐yellow diarrhea observed before surgery. Given the history of recurrence, the owner requested additional treatment and toceranib was administered. On POD 20, the cat showed no abnormalities so a low dose (1.9 mg/kg) of toceranib was orally administered every Monday, Wednesday, and Friday without any side effects. Approximately 1 year after surgery, the cat had no clinical signs of carcinoid recurrence or metastases and normal serum liver enzymes, TBil, and lipase levels (Table 1).

At the time of writing (POD 524), the cat weighed 3.16 kg and was in good condition while receiving toceranib. Chest radiography did not reveal any pulmonary metastases, and abdominal ultrasonography did not show any clear signs of recurrence in the liver or pancreas.

4. DISCUSSION

A previous study described the application of choledochoduodenostomy in cats; ⁶ however, clinical information regarding its use in small animal practice remains limited. Computed tomography revealed that the CBD and pancreatic duct were dilated by the recurrent carcinoid, necessitating choledochoduodenostomy and pancreatojejunostomy after pancreatic body duodenectomy. After surgery, the patient had no complications such as bile leakage, anastomotic stenosis, pancreatitis, or pancreatic fluid leakage. This case report therefore suggests that en bloc resection of the distal CBD, pancreatic body, and duodenum, followed by choledochoduodenostomy and pancreatojejunostomy, is feasible in cats with malignant tumors originating from the pancreatic body.

The surgical procedure used in this study is similar to that used for pancreaticoduodenectomy in humans. Pancreatic fistulas are caused by pancreatic fluid leakage during resection and are an important complication of pancreaticoduodenectomy. Pseudoaneurysms occur after pancreatic resection when the arterial stump is severed during surgery or the arterial wall is weakened by the dissection procedure and ruptures after exposure to gastrointestinal fluids, including pancreatic juices. Postoperative bleeding due to pseudoaneurysm occurs in approximately 3% to 16% of patients after pancreatic resection. ⁷ , ⁸ , ⁹ , ¹⁰ Pseudoaneurysm resulting from pancreatic fluid leakage is a potentially life‐threatening complication, underscoring the importance of preventing pancreatic fistula after pancreaticoduodenectomy. Several pancreatojejunostomy techniques have been described in human medicine, including gastropancreatic anastomosis, ¹¹ pancreatojejunostomy—in which the pancreatic stump is invaginated into the jejunum ¹² —and anastomosis between the pancreatic parenchyma and gastrointestinal seromuscular layer. ¹³ The method described in this report involved the anastomosis of pancreatic stump and jejunal wall using six to eight interrupted sutures. However, only one case report has described end‐to‐side pancreaticoduodenostomy between the dilated pancreatic duct and duodenum in a cat with pancreatic cyst. ⁵ To prevent pancreatic leakage, the pancreatic duct was anastomosed with polypropylene suture materials to the jejunum using a simple interrupted pattern six‐suture parachute technique in our case. Polypropylene suture material is associated with relatively low tissue reactivity, which may help prevent postoperative stenosis caused by inflammation. The specific type used (Prolene Hemo‐Seal) features a minimal gap between the needle and suture diameters, which may contribute to a reduced risk of postoperative leakage. The full thickness of the pancreas and jejunum were also anastomosed using a temporary stent. No postoperative pancreatic fistulae developed, suggesting the effectiveness of the approach used in our study. Postoperative pancreatic fluid leakage was therefore prevented by inserting the catheter into the pancreatic duct from the resection stump of the left pancreatic lobe as a temporary stent, and by selecting the jejunum where little tension would be added to the pancreaticojejunostomy site. A previous study ¹⁴ using experimental dogs, involving invagination of the pancreatic stump into the jejunum, revealed no major postoperative complications; however, the opening of the pancreatic duct at the anastomosis site was not identified in four of the 10 dogs, and considerable fibrosis of the remaining pancreas was observed, indicating a potential risk of pancreatic exocrine insufficiency. In the present case, the postoperative disappearance of the preoperative white‐yellow diarrhea suggests a return to normal levels of pancreatic fluid drainage, indicating the potential preservation of exocrine function in the left pancreatic lobe.

The right pancreatic lobe, including the duct, was ligated with polypropylene sutures to prevent postoperative pancreatic fluid leakage. Considering the risk of postoperative pancreatic leakage, nonabsorbable 2–0 polypropylene sutures were selected instead of absorbable materials or a vessel sealing device. In our hospital, 2–0 polypropylene is routinely used for partial pancreatectomy in both dogs and cats. In the present case, it was deemed appropriate to ensure long‐term closure, particularly given the blind‐ended anatomical structure of the right pancreatic lobe. In the present case, exocrine function may have ultimately been lost in the right pancreatic lobe; however, endocrine function in the remaining right lobe was potentially preserved.

In the previous study, almost all cats were euthanized during the perioperative period after the surgical removal of carcinoids that occurred in the biliary system. ¹ In contrast, the cat in this case report was making positive progress at the time of writing. Cats are therefore expected to have a favorable long‐term prognosis after aggressive biliary carcinoid resection. Toceranib was administered as postoperative adjuvant chemotherapy following the second surgery. Although no standardized chemotherapeutic regimen has been established for feline bile duct carcinoids and the efficacy of toceranib in such cases remains unproven, the owner opted to pursue this therapy to reduce the risk of recurrence. In this case, no evidence of recurrence was observed after the second surgery, suggesting that postoperative adjuvant therapy with toceranib may have contributed to tumor control.

Both the CBD and pancreatic duct were dilated because of tumor obstruction. Choledochoduodenostomy and pancreatojejunostomy may therefore be feasible for reconstruction. The feasibility of these procedures without complications in patients without CBD or pancreatic duct dilation remains unclear. During the postoperative follow‐up period, no evidence of recurrence or metastasis was found using radiology and abdominal ultrasonography. However, CT was not used. This could have revealed micrometastases. The cat may therefore have developed micrometastases at the time of writing. However, the cat's progress has been stable, with no signs of recurrence or metastasis. Further follow up is required to confirm this prognosis.

In the present case, a single dose of corticosteroids was administered prior to surgery. In our hospital, preoperative administration of corticosteroids is commonly performed in major surgical procedures based on accumulated clinical experience. This is intended to mitigate intraoperative stress and hemodynamic shock, such as that caused by bleeding, and to help prevent postoperative hypoglycemia, which is frequently observed in gastrointestinal surgeries. As the corticosteroid administration in the present case was limited to a single preoperative dose, it was considered unlikely to have a substantial impact on the surgical outcome. Further studies are warranted to evaluate the efficacy and safety of preoperative corticosteroid use in such surgical procedures.

Imipenem was administered as a postoperative antibiotic in this case. As a tier 3 antimicrobial, imipenem is typically reserved for situations in which no effective tier 1 or 2 agents are available, in accordance with antimicrobial stewardship guidelines. In this case, the disease had progressed over a prolonged period prior to the second surgery, and it was likely that multiple antimicrobials had already been used. Given the presence of multiple anastomotic sites, imipenem was selected for its broad‐spectrum activity and anticipated efficacy against potential postoperative infections. Further consideration may be warranted regarding the appropriate use of prophylactic antibiotics in gastrointestinal surgery involving multiple anastomoses.

In conclusion, this is the first report of a successful reconstructive surgery with choledochoduodenostomy and pancreatojejunostomy after en bloc resection of the pancreatic body and proximal duodenum in a cat with recurrent carcinoid‐induced ductal obstruction. Pancreatic body duodenectomy may be a viable and effective option for managing pancreatic duct obstruction in cats.

FUNDING INFORMATION

The authors received no grants or financial support related to this report.

CONFLICT OF INTEREST

The authors declare that they have no conflicts of interest.

Suzuki K, Ishigaki K, Hayakawa T, Tomo Y, Asano K. Pancreaticoduodenectomy with choledochoduodenostomy and pancreaticojejunostomy in a cat with bile and pancreatic duct obstruction secondary to a recurrent carcinoid. Veterinary Surgery. 2025;54(8):1661‐1669. doi: 10.1111/vsu.14282

DATA AVAILABILITY STATEMENT

All data supporting the conclusions of this article are included within the article.