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VSPN AOW : Comparison of survival af...
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Comparison of survival after surgical or medical treatment in dogs with a congenital portosystemic shunt.J Am Vet Med Assoc. June 2010;236(11):1215-20.1 Department of Veterinary Medicine, Veterinary School, University of Cambridge, Cambridge, CB3 0ES, England.
AbstractOBJECTIVE: To compare survival of dogs with a congenital portosystemic shunt (CPSS) that received medical or surgical treatment. DESIGN: Prospective cohort study. ANIMALS: 126 client-owned dogs with a single CPSS. PROCEDURES: Dogs were examined at 1 of 3 referral clinics, and a single CPSS was diagnosed in each. Dogs received medical or surgical treatment without regard to signalment, clinical signs, or results of hematologic or biochemical analysis. Survival data were analyzed via a Cox regression model. RESULTS: During a median follow-up period of 579 days, 18 of 126 dogs died as a result of CPSS. Dogs treated via surgical intervention survived significantly longer than did those treated medically. Hazard ratio for medical versus surgical treatment of CPSS (for the treatment-only model) was 2.9 (95% confidence interval, 1.1 to 7.2). Age at CPSS diagnosis did not affect survival. CONCLUSIONS AND CLINICAL RELEVANCE: Both medical and surgical treatment can be used to achieve long-term survival of dogs with CPSS, although results of statistical analysis supported the widely held belief that surgery is preferable to medical treatment. However, the study population consisted of dogs at referral clinics, which suggested that efficacy of medical treatment may have been underestimated. Although surgical intervention was associated with a better chance of long-term survival, medical management provided an acceptable first-line option. Age at examination did not affect survival, which implied that early surgical intervention was not essential. Dogs with CPSS that do not achieve acceptable resolution with medical treatment can subsequently be treated surgically.
Companion NotesProspective, nonrandomized, cohort study comparing the efficacy (survival) of medical and surgical therapy for congenital portosystemic shunt in 126 dogs - all dogs had a single congenital portosystemic shunt
Study design - introduction on the treatment of congenital portosystemic shunts in the dog - treatment may be medical or surgical - surgery redirects blood through the liver - theoretically stops ongoing hepatic hypoperfusion and atrophy - mortality rate: 2-27% - medical therapy reduces the amount of molecules entering the circulation (molecules absorbed during digestion) - requires ongoing treatment unlike surgical therapy - study population: dogs seen at 1 of 3 referral clinics in the UK from 06/02-10/07 - all 126 dogs had a single congenital portosystemic shunt (CPSS) - 110 dogs had a extrahepatic shunt and 16 dogs had a intrahepatic shunt - West Highland white terrier, 22.2% of the dogs - Yorkshire terrier, 14.3% - mean age at diagnosis: 1.2 years of age (range of 60 days to 6 years) - mean age at diagnosis in dogs with extrahepatic shunt: - 450 days with a range of 60 days to 6 years - mean age at diagnosis in dogs with intrahepatic shunt: - 174 days with a range of 60 days to 1.15 years - significantly younger than dogs with extrahepatic shunts - procedure: - medical or surgical treatment chosen by owner after consultation - owner told it was not known for sure which treatment was better - opinion of attending clinician and finances affected choices - many chose surgery because the referring veterinarian recommended it - medical therapy, 27 of the 126 dogs (21 of the 27 had an extrahepatic shunt) (given to all dogs for the 1st 3 weeks before final treatment choice) - dietary management with a liver or intestinal disease diet (Royal-Canin hepatic support, Crown Pet Food Ltd, Castle Cary, Somerset) (Hills l/d, Hill’s Pet Nutrition Ltd, Watford, Hertfordshire, England) (Royal-Canin sensitivity control, Crown Pet Food Ltd, Castle Cary) (Hills i/d, Hill’s Pet Nutrition Ltd, Watford, Hertfordshire, England) (Eukanuba intestinal, Proctor and Gamble, Geneva, Switzerland) - homemade diet based on chicken and cottage cheese + rice or pasta - given in small portions frequently - ampicillin PO, most dogs (metronidazole also used by some clinicians) - lactulose to create soft feces - surgical therapy: ameroid constrictor, cellophane bands and ligatures - survival data analyzed via a Cox regression model
Results (median follow-up period: 579 days) - death, 18 of the 126 dogs (due to CPSS) - survival time significantly longer in dogs undergoing surgery - hazard ratio (medical versus surgery for treatment-only model): - 2.9 (95% confidence interval: 1.1-7.2 - “medical management provided an acceptable first-line option” - percentage of dogs surviving at certain intervals after starting therapy - after 500 days - about 97% of surgically treated dogs were alive - about 78% of medically treated dogs were alive - after 1000 days - about 94% of surgically treated dogs were alive - about 63% of medically treated dogs were alive - after 1500 days - about 90% of surgically treated dogs were alive - about 63% of medically treated dogs were alive - dogs were seen at referral clinics - efficacy of medical therapy possibly underestimated - dogs effectively treated medically would not be referred - survival was not associated with age at diagnosis - early surgical therapy possibly not crucial - surgical intervention can follow medical treatment
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