Extrahepatic Portosystemic Shunt Research Articles

Comparison of Veterinary Student Understanding of Extrahepatic Portosystemic Shunts when Given a Pre-Lecture Activity of a Text-Only Narrative versus an Interactive Electronic Book.

Complex vascular anomalies are often difficult concepts for veterinary medical students to comprehend, as knowledge of normal anatomy, visualization of the abnormal anatomy, and understanding of the physiologic implications of that abnormality are all required to appreciate the clinical impacts of the anomaly. Access to interactive three-dimensional models of both the normal and abnormal vasculatures may improve student comprehension. In this study, third-year veterinary medical students in a core small animal digestive diseases course completed a pre-lecture assignment consisting of a text-only narrative (n = 100) or an interactive electronic book (e-book; n = 102) focused on extrahepatic portosystemic shunts, followed by two generative learning activities in which they described portal anatomy and extrahepatic portosystemic shunts. An optional, anonymous post-lecture learning assessment was given to both groups. Although no difference in post-lecture assessment scores was identified between the groups, students using the interactive e-book spent significantly longer on the pre-lecture assignment and activities than students in the text-only narrative group. Students in the text-only narrative group were more likely to use spatial visualization strategies during the generative learning activities than students in the e-book group. There was no correlation between time spent on the pre-lecture tasks and learning assessment score. Interactive e-books and generative learning activities may be useful adjunct pre-lecture learning tools for teaching of complex vascular anomalies to veterinary medical students.

Clinical presentation, conventional/4D spatio-temporal image correlation imaging findings, pregnancy and early postnatal outcomes in fetuses having anomalies of systemic venous return in the absence of significant intracardiac defects: A retrospective study from two centres in Southern India.

Recent advances in fetal ultrasound imaging, especially four-dimensional (4D) spatio-temporal image correlation techniques permit detailed evaluation of the fetal venous system and its abnormalities. In this report, we present the clinical presentation, conventional/4D spatio-temporal image correlation imaging findings, pregnancy, and early postnatal outcomes in fetuses having anomalies of systemic venous return in the absence of significant intracardiac defects from two centres in southern India. To report the clinical presentation, conventional/4D spatio-temporal image correlation imaging findings, pregnancy, and early postnatal outcomes in fetuses having anomalies of systemic venous return in the absence of significant intracardiac defects from two centres in Southern India. Retrospective study (October 2017 to March 2022). All fetuses referred with abnormal cardiac imaging findings who were diagnosed to have anomalies of systemic venous return in the absence of significant intracardiac defects were included. Imaging techniques like 2D with color and 4D spatio-temporal image correlation fetal imaging were used to evaluate systemic venous anomalies. Systemic venous anomalies were grouped into cardinal venous anomalies and umbilico-portosystemic venous anomalies. Thirty-nine fetuses were included; this represented 4.4% of all cardiac anomalies diagnosed during the study period. Cardinal venous anomalies were seen in 29 fetuses (74%); the mean gestation age at diagnosis was 25.5±3.4weeks. Absent dilated coronary sinus was associated with anomalous drainage of superior caval vein through completely unroofed coronary sinus into the left atrium (n=3) which resulted in cyanosis after birth in all infants. Among the three cases, one underwent surgery at 6 months of age due to a progressive increase in cyanosis (Spo2 78%) and others are awaiting surgery. A prenatal genetic evaluation was performed in 17 (58.6%). Cardinal venous anomalies were not associated with genetic abnormalities. Live births occurred in all fetuses with cardinal venous anomalies. Umbilico-portosystemic venous anomalies were seen in 10 (26%). The mean gestation age at diagnosis was 26.5±4.5weeks. Except in a fetus with the extrahepatic portosystemic shunt (umbilical vein to iliac vein), the genetic evaluation was normal in our cohort. Extracardiac anomalies (n=3/10; 30%) were seen in both intra (n=1) and extrahepatic portosystemic shunts (n=2). Anomalies of systemic venous return in the absence of significant intracardiac, extracardiac, and genetic abnormalities carried an overall favorable prognosis in our cohort. Precise characterization of anatomic details using advanced imaging techniques helps in the understanding of this complex three-dimensional anatomy and in the prognostication of these anomalies.

Abernethy Syndrome Type 1B in a Young Male presenting with acute gastrointestinal bleeding: A Case report

Abernethy syndrome is a rare congenital extrahepatic portosystemic shunt (CEPS) in which splanchnic blood flows straightly into the inferior vena cava (IVC). Compared to type 1, in which the intra hepatic portal tree is not developed, in type 2 the portal vein is intact, but forms an anastomosis with the IVC. In the subtype 1a, superior mesenteric and splenic veins do not merge into the portal vein, while in type 1b they anatomically form the portal vein. CEPS can cause a wide spectrum of clinical manifestations including hepatic, pulmonary, metabolic and neurological symptoms and is usually diagnosed before adulthood. The diagnosis is established using the radiological imaging methods. Whileliver transplantation is the treatment of choice for type 1, surgical or minimally invasive endovascular shunt closure are treatment options for type 2 Abernethy syndome.

Attenuation of right gastrocaval extrahepatic shunt with cellophane band in a dog: Case report

Congenital extrahepatic portosystemic shunt is a vascular anomaly that consists in the communication between the portal and systemic circulation, causing substances normally metabolized and excreted by the liver to be diverted directly to the systemic circulation and triggering changes in neurological, gastrointestinal and urinary systems. Diagnosis is through imaging tests, such as ultrasound and computed tomography. For patient stabilization, initial clinical treatment is highly indicated, especially for those who manifest signs of hepatic encephalopathy, and the definitive treatment is gradual surgical attenuation. Currently, the most indicated techniques for shunt occlusion are the ameroid constrictor ring and the cellophane band, which have good long-term results. The prognosis of patients undergoing the surgical procedure varies according to the general condition of the patient at the time of diagnosis and the complications that may occur in the trans and postoperative periods, such as portal hypertension, seizures, hypoglycemia and failure to close the shunt. This report aims to describe a case of surgical attenuation of a right extrahepatic gastrocaval shunt using the cellophane band technique. The canine patient, pug, aged eight months, was treated at the Veterinary Hospital of the Federal University of Paraná, presenting neurological clinical signs and a previous diagnosis of portosystemic shunt. To determine the origin of the anomalous vessel and optimize surgical planning, computed angiotomography was indicated. Clinical treatment was instituted and, after 15 days, surgical attenuation of the shunt was performed using the cellophane band fixed with titanium clips. The patient showed signs of portal hypertension, ascites and postoperative hypoglycemia, which were treated during hospitalization. After 15 days of hospital discharge, the patient returned to the Veterinary Hospital with good general condition, absence of ascites and neurological signs and no significant changes were observed in laboratory tests, demonstrating the effectiveness of the chosen surgical technique.

Imaging findings in a minipig with congenital portosystemic shunt.

A 15-month-old, male minipig was presented with a clinical history of seizure activity for one year. The minipig was the smallest among the littermates and was referred due to an elevated blood ammonia level with suspected portosystemic shunt (PSS). Ultrasound and CT angiography were consistent with a congenital extrahepatic PSS. To the author's knowledge, this is the first description of a congenital extrahepatic PSS diagnosed by ultrasound and contrast-enhanced computed tomography in a minipig (pig). Partial shunt closure was performed by interventional stent application.

Shear wave elastography measurements in dogs treated surgically for congenital extrahepatic portosystemic shunts.

Assessing the postoperative surgical success of congenital extrahepatic portosystemic shunt (EHPSS) attenuation can be challenging and involve invasive imaging methods. Elastography is an ultrasound technique that allows qualitative and quantitative estimation of tissue stiffness and has extensively been used in people with liver disease. In recent years, increased interest in this technique has developed in veterinary medicine due to its non-invasive nature, availability, and low cost. The objective of this study was to compare liver stiffness values between dogs with closed EHPSS and those with multiple acquired portosystemic shunts (MAPSS) after gradual surgical attenuation and to assess whether shear wave elastography could be used to determine EHPSS closure. As a secondary objective, measurements obtained from both intercostal and subxiphoidal views were compared. Mean values for the average, median, and maximum two-dimensional shear wave velocities (2D SWV) for the closed EHPSS were 2.88 +/−0.11 m/s; 2.83 +/−0.11 m/s; and 3.75 +/−0.16 m/s, respectively. In the MAPSS dogs, mean values for the average, median, and maximum 2D SWV were 2.77 +/– 0.17 m/s; 2.71 +/– 0.17 m/s; and 3.66 +/−0.24 m/s, respectively. No significant differences in 2D SWV were present between dogs with closed EHPSS and those with MAPSS (P = 0.33; P = 0.33; P = 0.42, respectively). When assessing potential differences between intercostal and subxiphoidal 2D SWV measurements, no effect was observed for the average and median 2D SWV (P = 0.06; P = 0.07, respectively). Yet, a significant difference was identified for the maximum 2D SWV between intercostal 4.00 +/−0.20 m/s and subxiphoidal 3.41 +/−0.17 m/s measurements (P = 0.02). The relevance of this finding is uncertain as many other studies about liver elastography only report mean and not maximum values.

Short- and long-term outcomes of polyethylene band attenuation of congenital extrahepatic portosystemic shunts in dogs: 60 cases (2010-2020).

To report the short- and long-term outcomes following attenuation of congenital extrahepatic portosystemic shunts in dogs using a novel polyethylene band. Records were retrospectively reviewed for dogs that underwent congenital extrahepatic portosystemic shunt attenuation by a polyethylene banding technique, at a single institution between 2010 and 2020. Short-term outcome data were collected from peri-operative clinical records with follow-up examinations, scheduled at 6 and 18 weeks post-operatively, and post-operative imaging when performed. Long-term follow-up was collected by validated owner questionnaire, telephone interview or medical records. Long-term outcomes were categorised by "excellent", "good" or "poor". Sixty dogs were included. Post-operative complications occurred in 10 of 60 dogs (16.7%), four major and six minor, with a peri-operative mortality of 6.7%. Persistent shunting was identified in nine of 53 dogs (17%) available for follow-up examination and four dogs underwent a revision surgery. Long-term follow-up was available for 44 dogs at a median of 75 months post-operatively (range 7 to 128). Long-term outcomes were "excellent" (26) or "good" (8) in 81.8% of dogs and "poor" (8) in 18.2%. At the time of follow-up, 30 of 44 (68.2%) dogs were not receiving any medical treatment and 27 of 28 (96.4%) questionnaire respondents were satisfied with the response to surgery. Polyethylene band attenuation of congenital extrahepatic portosystemic shunts provides comparable outcomes to cellophane. The material used in this study is widely available and consistent while being pre-sterilised and pre-folded makes it easy to use.

Wolf-Hirschhorn syndrome with intrauterine growth restriction in a fetus: A case report

Introduction: Wolf-Hirschhorn syndrome (WHS), a genetic syndrome caused by deletion of the short arm of chromosome 4 (4p), is clinically characterized by “Greek warrior helmet” facial appearance, growth retardation, intellectual disability, seizures, skeletal anomalies, congenital cardiovascular defects, and other systemic defects. The severity of the WHS phenotype is related to the size of the missing 4p terminal fragment. In this article, we report and analyze a case of atypical WHS manifestations that revealed a 21-Mb deletion of the 4p terminal fragment in prenatal amniotic fluid examination by copy number variation sequencing (CNV-seq). Patient concerns: In our case, the fetal ultrasound results presented with intrauterine growth restriction and ocular hypertelorism and were characterized by atypical manifestations such as persistent left superior vena cava, nuchal fold thickness, and extrahepatic portosystemic shunt at 21 + 6 weeks of gestational age. Diagnosis: A fetus with WHS was detected by noninvasive prenatal screening and further diagnosed by chromosome karyotype analysis and CNV-seq. Interventions: After genetic counseling, the couple opted to terminate her pregnancy. Outcomes: Cytogenetic examination of the fetus revealed karyotype 46,XX,del(4)(p15.3). The CNV results showed a 21-MB deletion at the 4p16.3-p15.31 locus. Lessons: The WHS phenotype is atypical in fetuses. Prenatal molecular genetic testing combined with ultrasound screening is an effective method for diagnosing fetal WHS and can help clinicians offer subsequent clinical genetic counseling, manage fetal WHS, and guide the next pregnancy.

In dogs undergoing extrahepatic portosystemic shunt attenuation, does pretreatment with levetiracetam reduce postoperative seizure incidence?

PICO question
 PICO
 
 Clinical bottom line
 Category of research question
 Treatment
 The number and type of study designs reviewed
 Four papers were critically reviewed. All were retrospective cohort studies
 Strength of evidence
 Moderate
 Outcomes reported
 In one paper levetiracetam was found to reduce the risk of post-attenuation seizures. In the remaining three papers no difference was found between the frequency of post-attenuation seizures and the use of levetiracetam
 Conclusion
 That prophylactic levetiracetam is not indicated for the use of preventing post-attenuation seizures in dogs surgically treated for extrahepatic portosystemic shunts
 
 How to apply this evidence in practice
 The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources.
 Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.
 

Evaluation of different blood tests in dogs with extrahepatic portosystemic shunts to assess shunt closure after surgical treatment.

To determine the sensitivity and specificity of different individual and combined blood tests to assess extrahepatic portosystemic shunt (EHPSS) closure after gradual attenuation of EHPSS in dogs. Clinical prospective study. Twenty client-owned dogs with EHPSS. Fasting ammonia (FA), preprandial, postprandial, and paired serum bile acids (SBA), the lidocaine/monoethylglycylxylidide (L/MEGX) test, and serum hyaluronic acid (SHA) were performed at diagnosis, and 1, 3, and 6 months postoperatively. Transsplenic portal scintigraphy was performed to determine EHPSS closure 3 months postoperatively. Their sensitivity and specificity in determining shunt closure postoperatively were calculated. When assessing a single blood parameter, FA had the highest specificity (100%), whereas SHA and MEGX measured 15 min after lidocaine administration (T15) had the highest sensitivity (96.9% and 96.2%, respectively) for determining shunt closure postoperatively. The most promising blood test combinations were SHA (sensitivity 96.9%, specificity 81.8%), combined with the L/MEGX test (MEGX at T15: sensitivity 100%, specificity 72.4%) or the L/MEGX test (MEGX at T15) combined with either FA (sensitivity 100%, specificity 82.8%) or postprandial SBA (sensitivity 100%, specificity 81.5%). Both SHA and the L/MEGX test were sensitive tests for determining shunt closure after gradual attenuation of EHPSS. Test performances could even be improved by combining these tests with each other or with traditional tests such as FA or postprandial SBA. Although SHA and the L/MEGX test are sensitive blood tests for determining EHPSS closure, especially when combined with traditional blood tests, imaging is still needed to confirm EHPSS closure.

Total lipid concentration of hairs increases after successful attenuation of extrahepatic portosystemic shunts in dogs.

Skin and coat quality can reflect nutritional deficiencies in humans and dogs with liver diseases. Determine skin and coat quality based on a scoring protocol and skin biopsies in dogs with an extrahepatic portosystemic shunt (EHPSS), and determine total lipid concentrations in hairs of dogs at time of surgery and 3 months after successful shunt closure. Ten client-owned dogs that underwent successful gradual attenuation of EHPSS, as defined by transsplenic portal scintigraphy, were included. A prospective cohort study was performed. All dogs underwent gradual attenuation of the EHPSS. Skin and coat scoring was performed at diagnosis, surgery, and 1 and 3 months postoperatively. Hair was plucked from the lumbar region for total lipid analysis and an 8 mm punch skin biopsy was taken at time of surgery and 3 months postoperatively, when the dogs underwent transsplenic portal scintigraphy to determine EHPSS closure. No significant differences were observed in skin and coat scoring over time. Total lipid concentrations of hairs increased significantly from surgery to 3 months postoperatively [30 μg/mg hair (13-56 μg/mg hair) to 47 μg/mg hair (25-63 μg/mg hair); p= 0.005]. Skin biopsies showed the presence of significantly more scales 3 months postoperatively (p= 0.018). A significant increase in total lipid concentrations in hairs suggests that successful surgical attenuation of EHPSS improves either intestinal absorption of lipids, fat metabolism in the liver, or a combination of both.

Comparison of diet, lactulose, and metronidazole combinations in the control of pre-surgical clinical signs in dogs with congenital extrahepatic portosystemic shunts.

BackgroundHepatic supportive diet (HSD), lactulose, and antimicrobials are medical treatments for dogs with congenital extrahepatic portosystemic shunts (cEHPSS). The relative contribution of these treatment components is currently unknown.ObjectivesTo determine which treatment combinations are most efficacious in pre‐surgical control of clinical signs of cEHPSS in dogs.AnimalsThirty‐six dogs with untreated cEHPSS.MethodsThree‐arm randomized clinical trial. At inclusion (T0), dogs were divided into 3 groups: HSD (n = 12), HSD + lactulose (n = 12), or HSD + metronidazole (n = 12) and received the randomized treatment for 4 weeks (T1) followed by combined treatment of HSD + lactulose + metronidazole for 2 weeks or until cEHPSS attenuation (T2). Clinical score as well as fasting ammonia (FA) and C‐reactive protein (CRP) concentrations were compared among groups and time points.ResultsThirty‐four dogs were evaluated. Thirty‐four dogs reached T1 and 29 dogs T2. At T1, clinical scores decreased in the HSD + lactulose (n = 11; P = .001), but not in the HSD (n = 8; P = .96) and HSD + metronidazole (n = 10; P = .06) groups. Adding metronidazole to HSD + lactulose (n = 11) did not result in further clinical score improvement (T2; P = 1.000). Moderate and weak correlation between clinical score and FA and clinical score and CRP was present (ρ = .35, P < .001; ρ = .27, P = .01, respectively) with FA decreasing over time on medical treatment (P = .001).Conclusions and Clinical ImportanceCombined HSD + lactulose seems sufficient for pre‐surgical cEHPSS stabilization unlike sole HSD or HSD + metronidazole. Medical treatment of cEHPSS clinical signs decreases FA.

Treatment of an extrahepatic portosystemic shunt by placement of a hydraulic occluder followed by a thin film band in a dog: An eventful story

AbstractA 1‐year‐old, female, Yorkshire terrier was evaluated for two episodes of disorientation and severe depression. A portosystemic shunt was suspected based on clinical signs and biochemical analysis, and further confirmed by computed tomography angiography. After initial stabilisation with medical treatment, the dog underwent surgery. Invasive measurement of portal pressure after temporary complete shunt occlusion revealed a very high pressure of 40 mmHg, motivating placement of a hydraulic occluder. Several complications occurred in the postoperative period, including kinking of the device, necessitating removal of the hydraulic occluder in emergency; development of signs of portal hypertension during inflation of the hydraulic occluder, requiring partial balloon deflation; and persistent shunting, which was managed by replacing the hydraulic occluder by a thin film band.

Quantitative analysis of contrast-enhanced ultrasound estimates intrahepatic portal vascularity in dogs with single extrahepatic portosystemic shunt.

To evaluate the clinical impact on quantitative analysis of contrast-enhanced ultrasound (CEUS) on single extrahepatic portosystemic shunt (PSS) in dogs. 21 client-owned dogs with single extrahepatic PSS and 5 healthy Beagles. In all dogs, CEUS was performed to calculate the rising time (RT), rising rate (RR), and portal vein-to-hepatic parenchyma transit time (ΔHP-PV) from the time-intensity curve obtained in the hepatic parenchyma and portal vein. All dogs in the PSS group underwent preoperative CT angiography (CTA) and surgery. The CEUS variables in the PSS group were compared with those in the healthy dogs (control group) and were analyzed for shunt types and grades of intrahepatic portal venous branches based on CTA findings, intraoperative portal pressure, and surgical procedures. All 3 CEUS variables showed no significant differences between the PSS and control groups. The RT and ΔHP-PV in the left gastrophrenic shunt group were significantly longer than in the other shunt types. In the intrahepatic portal vascularity, the RT in grade 1 was significantly shorter than in grades 3 and 4, and the RR in grade 1 was significantly higher than in grade 4. The RT and ΔHP-PV were significantly correlated with portal pressure variables. The RT in dogs with partial ligation was significantly shorter than in dogs with complete ligation and percutaneous transvenous coil embolization. Quantitative assessments of CEUS may be useful for estimating intrahepatic portal vascularity in dogs with single extrahepatic PSS.

Dogs ≥ five years of age at the time of congenital extrahepatic portosystemic shunt diagnosis have better long-term outcomes with surgical attenuation than with medical management alone.

To determine the outcome in dogs diagnosed with congenital extrahepatic portosystemic shunts (EHPSS) at ≥ 5 years of age treated with medical management only (M) or with surgical attenuation (S). The hypothesis was that dogs undergoing surgical attenuation would have a longer survival time than dogs undergoing medical management only. 351 dogs definitively diagnosed with EHPSS at ≥ 5 years of age. Medical records from 2009 to 2019 at 16 veterinary teaching hospitals were evaluated. Data collected included signalment, clinical signs at diagnosis, clinicopathologic data, surgical and medical treatments, shunt morphology, clinical signs and medical treatments at 6 to 12 months after diagnosis, and survival time. 351 dogs (M, 119 [33.9%]; S, 232 [66.1%]) were included in the study. Survival time was longer with surgery than medical management (hazard ratio, 4.2; M, 3.4 years; S, 10.9 years). Continued clinical signs at 6 to 12 months after diagnosis were more common with medical management (M, 40% [33/88]; S, 14% [21/155]). Continued medical treatments at 6 to 12 months after diagnosis were more common in the medical management group (M, 78% [69/88]; S, 34% [53/155]). Perioperative mortality rate was 7.3%. Dogs diagnosed at ≥ 5 years of age with EHPSS have significantly better survival times and fewer clinical signs with surgical attenuation, compared with medical management. Older dogs have similar surgical mortality rates to dogs of all ages after surgical EHPSS attenuation.

Surgical shunt ligation for a congenital extrahepatic portosystemic shunt with pulmonary hypertension: A case report.

Introduction and importanceCongenital extrahepatic portosystemic shunt (CEPS) presents with various symptoms due to abnormal communication between the portal venous system and inferior vena cava. And Klippel-Trenaunay-Weber syndrome is another rare congenital disorder characterized by vascular malformations.Case presentationA 16-year-old male with Klippel-Trenaunay-Weber syndrome was referred to our hospital for surgical treatment of pulmonary hypertension due to CEPS since childhood. Dyspnea had developed about two years before presentation at our hospital and gradually worsened. Right heart catheterization had revealed pulmonary hypertension and a high cardiac output state associated with a portosystemic shunt. Although pulmonary vasodilators improved the dyspnea, pulmonary hypertension remained. The patient was then referred to our hospital for surgical shunt occlusion. The results of the preoperative and intraoperative shunt occlusion tests were within acceptable limits. Therefore, primary shunt ligation was performed. There were no postoperative complications. Continuous intravenous vasodilator was tapered off four months after discharge. No additional or increased doses of medications were required for four years after surgery.Clinical discussionSurgical shunt ligation for CEPS is effective but can cause acute portal hypertension. Primary shunt ligation could be performed without complications according to the criteria for safe shunt occlusion.ConclusionSurgical portosystemic shunt ligation could be performed safely and ameliorated pulmonary hypertension. Patients with CEPS, especially young patients, should be referred to a tertiary center while asymptomatic, and early therapeutic intervention is necessary.

Use of an ameroid constrictor ring for gradual occlusion in canine congenital extrahepatic portosystemic shunts: Review

Congenital extrahepatic portosystemic shunts may be caused by embryological failure and are related to normal abdominal vascular development. They are noteworthy due to the higher prevalence of portosystemic vascular shunts and small to miniature breeds are the most affected. In this literature review, we carefully compiled in international articles in the field on the use of the ameroid constrictor ring in surgery for the gradual occlusion of unique congenital extrahepatic portosystemic shunts in dogs. In this sense, aspects of pathophysiology, etiopathogenesis, clinical symptoms and technical aspects regarding the surgical area were addressed. It is concluded that the use of the constrictor ring becomes a safe and highly recommended method, resulting in low rates of morbidity and mortality and prolonged postoperative survival in dogs.

Status of congenital extrahepatic portosystemic shunt.

Status of congenital extrahepatic portosystemic shunt.

Laparoscopic portosystemic shunt attenuation in 20 dogs (2018-2021).

To describe the technique, complications, and outcome of laparoscopic portosystemic shunt attenuation (LPSSA) in dogs. Retrospective study. Twenty client-owned dogs. Medical records were searched for dogs with a single congenital extrahepatic portosystemic shunt (CEPSS) that was treated with LPSSA. Signalment, clinical signs, CEPSS location, diagnostic imaging, laparoscopic approach, operative technique, complications, and clinical outcome were reviewed. Fourteen dogs with CEPSS located in the epiploic foramen had a right (13/14) or left (1/14) paramedian approach. In 6 dogs a CEPSS was not located in the epiploic foramen, and a left paramedian approach was used. A 3 or 4-port technique was used in 7 and 13 dogs, respectively. A thin film band was used for CEPSS attenuation in all dogs. The median operating time for LPSSA was 62 min (range 27-98 min). Intraoperative complications requiring conversion to an open technique occurred in 5 dogs. Mild perioperative self-limiting portal hypertension occurred in 3 dogs, while severe portal hypertension with surgical revision occurred in 1 case. The complications were resolved, and all dogs had a good outcome. Laparoscopic portosystemic shunt attenuation can be performed in dogs, in particular for a CEPSS located in the epiploic foramen using a right paramedian approach. For CEPSS not located in the epiploic foramen, a left paramedian approach is recommended. Conversion to open celiotomy was required in around a third of cases. Laparoscopic attenuation of CEPSSs can be performed in dogs and has a good clinical outcome, particularly for CEPSS located in the epiploic foramen.

Does surgical or medical management of extrahepatic portosystemic shunts in dogs carry a better prognosis for the resolution and reduction of neurological dysfunction?

PICO question&#x0D; In dogs with congenital extrahepatic portosystemic shunts that are treated with surgical attenuation what is the persistency, frequency, severity and outcome of neurological signs when compared to dogs that are treated medically?&#x0D; &#x0D; Clinical bottom line&#x0D; Category of research question&#x0D; Prognosis&#x0D; The number and type of study designs reviewed&#x0D; Ten papers were critically reviewed&#x0D; Strength of evidence&#x0D; Weak&#x0D; Outcomes reported&#x0D; For short-term success, owners reported an overall decrease in neurological signs associated with neurological dysfunction and an increase in quality of life after the initiation of either medical management or surgical management. Surgical management has a weak association with higher mortality or severe neurological signs in the immediate postoperative period&#x0D; Conclusion&#x0D; It is challenging to make a direct comparison between medical and surgical management but, overall, both strategies seemed to decrease neurological signs in the short term. There was a lack of evidence and available data about the efficacy of each for long-term control of neurological signs&#x0D; &#x0D; How to apply this evidence in practice&#x0D; The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources.&#x0D; Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.&#x0D; &#x0D;