17December 13, 2010 CLINICAL SMALL ANIMAL

KELLY BOWLTBVM&S, MRCVS

ED FRIENDBVetMed, CertSAS, DipECVS, MRCVS

KATE MURPHYBVSc(Hons), DSAM, DipECVIM-CA, PGCert(HE), MRCVS

consider, in the second of their two-part article,the differing approaches to dealing with extrahepatic and intrahepatic variants

PORTOSYSTEMIC SHUNT SURGERY AND PO CARE IN CATS AND DOGSFOLLOWING diagnosis and appropriate stabilisation of dogs and cats with portosys-temic shunts (PSS), as detailed in part one of this article (VT40.45), the authors gener-ally recommend surgery.

The aim of surgical treatment

is to occlude the shunting vessel

(preferably completely at surgery

or gradually over time) so that

blood fl ow is diverted entirely

through the liver and the animal

can be slowly weaned off medi-

cal management.

Certain situations may be

infl uenced by both patient and

owner factors, where surgery

is not recommended and the

patient continues on long-term

medical management, as dis-

cussed in the previous article.

Finding the shunt (extrahepatic)Before surgery, the nature of

the shunt (intrahepatic or ext-

rahepatic) should be confi rmed

wherever possible using ultra-

sound, mesenteric portovenog-

raphy, computed tomography

or magnetic resonance imaging.

The shun t ing ves se l i s

approached via a ventral midline

laparotomy, taking particular

care when entering the abdo-

men because, rarely, shunts can

be located in the falciform liga-

ment (Brockman, 1998). In the

fi rst instance, exploration of the

caudal vena cava (CVC) is advis-

able and this can be achieved

by performing the duodenal

manoeuvre, followed by the

colonic manoeuvre. In a normal

dog, no vessels should enter the

CVC between the right renal/

phrenicoabdominal and hepatic

veins, so any large vessels identi-

fi ed in this region may be a shunt

(Figure 1).

Shunts can be very large

(15mm or larger) and the blood

fl ow within the shunt and the

CVC in this region will be tur-

bulent. Occasionally, CVC dila-

tion can also be seen at the

level of shunt.

If a vessel is not visualised

using this technique, explora-

tion of the epiploic foramen

may be rewarding. This can

be performed by opening the

two leaves of the omentum

and following them dorsally.

The boundaries of the epiploic

foramen include the CVC (dor-

sally), the hepatic artery and

portal vein (ventrally), and the

celiac artery (caudally).

A porto-azygous vessel is usu-

ally identifi ed at surgery as a ves-

sel that heads in a craniodorsal

direction arising from a contribu-

tory of the hepatic portal vein.

Exploration of the diaphragmatic

crura and oesophageal hiatus

should also be performed, by

retracting the liver and stomach

to the right to aid visualisation.

Very rarely, more than one

shunt may be present. Shunts

have been described associated

with the phrenic vein, left colic

vein or umbilical vein remnant.

A full abdominal exploration is,

therefore, strongly advised in

every case. If no shunt can be

found, intravenous mesenteric

continued overleaf

Figure 3. An example of intestinal cyanosis and pancreatic oedema/cyanosis (arrow) consistent with portal hypertension seen after complete occlusion of an extrahepatic PSS by Rummel tourniquet in a cat.

Figure 1 (above). Extrahepatic portocaval shunt (solid arrow). Acquired shunts can be seen in up to 20 per cent of dogs with congenital PSS and are secondary to chronic portal hypertension. Figure 2 (below). Rummel tourniquet placement around the extrahepatic PSS allows the opportunity to assess for changes consistent with portal hypertension.

VT40.49 InCopy.indd 17 03/12/2010 11:45

18 Veterinary Times

portovenography is recom-

mended, as is a liver biopsy to

rule out microvascular dysplasia

(hypoplasia of the portal vein).

Finding the shunt (intrahepatic)Intrahepatic shunts are very

challenging to locate because

they are usually completely sur-

rounded by hepatic parenchyma.

In a similar fashion to extrahe-

patic PSS, the hepatic and portal

vein branches associated with

the shunt may be identifi able as

dilated vessels containing turbu-

lent blood fl ow.

To minimise extensive paren-

chymal dissection (which may

cause profuse haemorrhage,

particularly in patients that may

have coagulation problems),

surgeons have attempted to

identify the shunts by palpat-

ing the aneurysms associated

with them through the liver

lobes (Breznock, 1983), per-

forming intraoperative ultra-

sonography (Wrigley, 1983) or

catheterising the shunt via the

portal vein (Tobias, 1996). Shunt

location can be confirmed by

digital occlusion of the vessel and

observation of changes in portal

pressure or visceral appearance.

Shunt occlusion (extraheptic)Once the shunt has been

located, the authors place a

Rummel tourniquet (Figure 2) to achieve complete occlu-

sion for five minutes, while

carefully observing for signs of

portal hypertension. Grossly,

changes suggestive of this include

intestinal cyanosis, increased

intestinal peristalsis, pancreatic

cyanosis/oedema (Figure 3)

and increased mesenteric vascu-

lar pulsations.

Pressure measurements

should be carefully assessed

while completely occluding the

shunt: central venous pressure

should not decrease by greater

than 7mmHg, arterial blood

pressure should be limited to

changes of 5mmHg or less and

the heart rate should not dra-

matically change. Changes in

excess of this mean that com-

plete ligation is not possible at

this stage because the risk of

portal hyperten-

sion is too great.

S o m e s u r -

g e o n s a l s o

measure portal

pressure v ia a

je juna l venous

catheter to assess

f o r hype r ten -

s i o n . N o r m a l

portal pressure

i s 6mmHg to

10mmHg and animals with PSS

have pressure of 0mmHg to

8mmHg. Post-ligation pressure

should be limited to between

12mmHg and 17mmHg, with a

maximum change of 6mmHg to

7mmHg (Martin, 1987; Swalec,

1991; Tobias, 2003).

If gross clinical changes and

pressure measurements are

acceptable, the Rummel tour-

niquet can be removed and a

ligature placed (the authors use

polypropylene) to achieve com-

plete ligation of the shunt, but

only 40 per cent to 68 per cent

of dogs and cats can tolerate this

(Swalec, 1990; Tobias, 2003).

Partial ligation is possible and

this may be performed with

suture, followed by complete

occlusion at a subsequent laparot-

omy. In the authors’ experience,

owners are often reluctant to

proceed with a second proce-

dure and, for this reason, we

recommend the use of ameroid

constrictors or cellophane band-

ing where complete ligation is not

possible. These techniques cause

gradual occlusion

and fewer post-

operative com-

plications (Tobias,

2003), and reduce

the need for sec-

ond surgery.

A m e r o i d

c o n s t r i c t o r s

are casein rings

encased in stain-

less steel (Figure 4). The casein absorbs fl uid from

the body and swells inwards,

compressing the shunt placed

within the lumen over four to

five weeks, although this can

be highly variable (Vogt, 1996;

Monnet, 2005). Rings are avail-

able in a variety of sizes and

should be selected so that the

ring fi ts snugly around the shunt,

causing minimal occlusion when

first placed. Ideally, dissection

around the shunt should be kept

to a minimum to reduce move-

ment of the heavy ring, which

otherwise may cause kinking

and, therefore, premature occlu-

sion of the shunt. For this reason,

placement as close as possible to

the vena cava is also advised.

Folded strips of cellophane

bands are easy to place and

cause gradual occlusion of the

shunt over eight weeks by incit-

ing a fi brous reaction (Youmans,

1998). In the same manner as

the ameroid constrictors, they

should not cause any occlusion

when fi rst placed, and security

of the band is achieved using

vascular clips (Figures 5 and 6).

Particularly large shunts may not

occlude completely after cel-

lophane banding.

Following shunt attenuation, a

liver biopsy should be obtained

to assess for other hepatic dis-

ease, such as copper storage

disease. The clinician should be

aware that the histopathological

changes seen in a liver biopsy

from an animal with PSS will be

similar to that from an animal

with microvascular dysplasia/

hypoplasia of the portal vein.

Biopsy alone cannot differentiate

between the two conditions and

a gross shunt must be excluded

by visualisation, contrast studies

or advanced imaging.

Shunt occlusion (intrahepatic)Complete ligation of intrahepatic

shunts is only possible in 27 per

cent of cases, but the shunts

may also be occluded with cel-

lophane or ameroid constrictors.

Because the shunts are often dif-

fi cult to locate and dissect, treat-

ment often consists of ligation of

the portal vein or hepatic vein

associated with the shunt. For

intrahepatic shunts, the authors

prefer to use transvenous coil

embolisation, which has also

been described for extrahepatic

PSS (Leveille, 2003; Schneider,

2005; Bussadori, 2008).

For this technique, a guide

wire, under fl uoroscopic guid-

ance, is passed from the jugular

vein, via the cranial vena cava

and right atrium, into the caudal

vena cava. A catheter is advanced

over the guide wire (Figure 7)

and contrast angiography is per-

formed to confi rm the location

of the shunt, using fl uoroscopy

CLINICAL SMALL ANIMAL

Figure 4. An ameroid constrictor.

Figure 5 (above). The shunt shown in Figure 1 with a folded cellophane band (open arrow) placed around the extrahepatic PSS (solid arrow). Figure 6 (below). The cellophane is secured by two vascular clips (arrow).

Figure 7 (above). Intraoperative ventrodorsal fl uoroscopy of the liver (left). On the right, the same image undergoes digital subtraction, and a guide wire has been passed into the caudal vena cava (arrow). Heart (H), diaphragm (D) and colon (C).

Figure 8. Intraoperative digital subtraction angiography showing the caudal vena cava (CVC), left hepatic vein (LHV) and left divisional shunting vessel. The guide wire is identifi ed by the arrow.

� PORTOSYSTEMIC SHUNT SURGERY AND PO CARE IN CATS AND DOGS – from page 17

Figure 9. The ensheathed stent is fed along the guide wire and removal of the blue cover deploys the self-expanding stent. Radiopaque markers in the stent catheter aid its accurate placement across the shunt entrance and the shunt can be recaptured and moved within the CVC so long as it has not been completely deployed.

“Following shunt attenuation, a liver

biopsy should be obtained to

assess for other hepatic disease, such as copper

storage disease.”

Outer metal ring

Inner casein ring

Metal plug

VT40.49 InCopy.indd 18 03/12/2010 11:49

19December 13, 2010 CLINICAL SMALL ANIMALand digital subtraction (Figure 8).

The diameter of the caudal

vena cava is measured and an

appropriately sized, ensheathed,

self-expanding nitinol stent (Fig-ure 9) is advanced over the

guide wire and deployed under

fl uoroscopic guidance so that it

covers the vessel entry point into

the CVC – the left hepatic vein in

this case (Figure 10).

Accurate placement is con-

firmed by repeat angiography,

which is especially important

because dilation of the CVC

in the region of the shunt is

not uncommon

and may lead to

incorrect s tent

positioning.

A cobra-tipped

catheter is passed

down the guide

wire, through the

interstices of the

stent in to the

shunt, and is used

to pass thrombo-

genic coils in to it (Figure 11).

The stent prevents migration

of the coils into the CVC and the

catheter tip also allows meas-

urement of portal pressures.

Coils are added until the portal

pressures increase by 7mmHg

to 14mmHg and, in the authors’

experience, three to fi ve coils are

required to achieve this.

Postoperative careFollowing surgery, animals should

be constantly monitored in the

intensive care unit for at least 24

hours, recording demeanour,

heart rate, pulse quality, respira-

tory rate, blood pressure and

urinary output.

Postoperative complications

include hypoglycaemia, pro-

longed anaesthetic recovery,

haemorrhage (surgical or gas-

trointestinal haemorrhage), sei-

zures or portal hypertension,

all of which are reported to be

common in up to 75 per cent of

cats (Kyles, 2002).

Signs of portal hypertension

include gastrointestinal haem-

orrhage, abdominal pain and

ascites, but this is uncommonly

seen with techniques that cause

gradual occlusion.

Other parameters measured

at the authors’ institution include

blood gas analysis, electrolytes

and glucose, and appropriate

treatment, such as potassium

or glucose-spiked fl uids, is pro-

vided as required and assessed

frequently in the immediate

postoperative period.

It is particularly important to

assess pain levels closely because

increased pain may be an indi-

cation of portal hypertension

or pancreatitis. Patients recovering

from PSS surgery are particularly

challenging in this respect because

they respond unpredictably to

analgesia as a result of their slowed

liver metabolism.

For this reason, full opioid

analgesia – administered as

required – may be more advis-

able that a static standard protocol

of one dose every four hours.

The development of hepatic

encephalopathy may also be mis-

interpreted as dysphoria or pain,

so careful monitoring by experi-

enced personnel is essential.

Ideally, PSS patients should

require no long-term medical

management following successful

surgical attenuation of the shunt.

If animals are otherwise clinically

well, they should be reviewed

after one month to allow meas-

urement of serum biochemical

(particularly bile acids) parame-

ters. At this stage, antibiotics may

be stopped if results are normal.

After two months of satisfac-

tory progression,

lactulose may be

t i t r a ted down

a n d s t o p p e d .

After three to

four months, the

gradual introduc-

t ion of a nor-

mal diet may be

considered. It is

important to per-

form dynamic bile

acid assessment at this stage.

Mortality rates for patients

treated surgically are illustrated

in Table 1. Good-to-excellent

outcomes can be expected in up

to 94 per cent of dogs undergo-

ing surgery for extrahepatic PSS,

regardless of the method used.

Where the shunt is intrahe-

patic, the same results may be

expected for 70 to 89 per cent of

dogs receiving ameroid constric-

tors, 76 to 100 per cent under-

going complete occlusion and 50

per cent undergoing cellophane

band placement (Berent, 2009).

In cats, an excellent long-term

outcome is less guaranteed,

being seen in up to 75 per cent

of cats undergoing ligation or

ameroid constrictor placement,

and 80 per cent receiving cel-

lophane bands.

AcknowledgementsEd Friend acknowledges the col-

laboration with Jackie Demetriou

for the interventional radiol-

ogy technique described here,

and the mentorship of Ally-

son Berent, Chick Weisse and

Jeff Solomon.

References and further readingBerent A C and Tobias K M (2009).

Portosystemic vascular anomalies,

Veterinary Clinics of North America

Small Animal Practice 39: 513-541.

Breznock E M, Berger B, Pendray

D, Wagner S, Manley P, Whiting

TABLE 1. Mortality rates for patients undergoing surgery for PSS (Berent, 2009)

Dogs (%)

Cats (%)

Extrahepatic PSS

Complete ligation

2 to 32 0 to 4

Ameroid 7 0 to 4

Cellophane 6-9 0 to 23

Intrahepatic PSS

Complete ligation

6 to 23

Ameroid 0 to 9

Cellophane 27

Coil embolisation

Less than 3

Figure 10. Suitable placement of the coil over the entry point of the shunt into the CVC. Figure 11. An example of intraoperative deployment of a thrombogenic coil into the left hepatic vein. The stent in the CVC is indicated by an arrow.

P, Hornof W and West D (1983).

Surgical manipulation of intrahepatic

portocaval shunts in dogs, Journal

of the American Veterinary Medicine

Association 182: 798-805.

Brockman D J, Brown D C and Holt

D E (1998). Unusual congenital por-

tosystemic communication resulting

from persistence of the extrahepatic

umbilical vein, Journal of Small Animal

Practice 39: 244–248.

Bussadori R, Bussadori C, Millan L,

Costilla S, Rodriguez-Altonaga J A,

Orden MA and Gonzalo-Orden J M

(2007). Transvenous coil embolisation

for the treatment of single congenital

portosystemic shunts in six dogs, The

Veterinary Journal 176: 221-226.

Kyles A E, Hardie E M, Mehl M and

Gregory C (2002). Evaluation of

ameroid ring constrictors for the

management of single extrahepatic

portosystemic shunts in cats: 23 cases

1996-2001), Journal of the American

Veterinary Medical Association 220:

1,341-1,347.

Leveille R, Johnson S and Birchard S

(2003). Transvenous coil embolisa-

tion of portosystemic shunts in dogs, continued overleaf

Veterinary Radiology and Ultrasonogra-

phy 33: 32-36.

Martin R A and Freeman L E (1987).

Identifi cation and surgical manage-

ment of portosystemic shunts in the

dog and cat, Seminars in Veterinary

Medicine and Surgery, Small Animal

2: 302-306.

Monnet E and Rosenberg A (2005).

Effect of protein concentration on

rate of closure of ameroid constric-

tors in vitro, American Journal of

Veterinary Research 66: 1,337-1,340.

Schneider M, Plassmann M and

Rabuer K (2005). Coil embolisation

of portosystemic shunts in com-

parison with conventional therapies,

“Good-to-excellent outcomes can be expected in up to

94 per cent of dogs undergoing surgery

for extrahepatic PSS, regardless of the method used.”

Diaphragm

Cranial

CaudalCVC

Left hepatic vein and shunt

VT40.49 InCopy.indd 19 03/12/2010 11:50

20 Veterinary Times

BEATING DEMONS, SAVING LIVES: PLEDGE DONATIONS TO THE VBF

JOEL DUDLEYVeterinary Times reporter

talks to the national coordinator of the Veterinary Surgeons’ Health Support Programme about the life-changing effects its assistance can have

THIS Christmas, the Veterinary Benevolent Fund (VBF), the profession’s own charity, is seeking donations to support the work of the Veterinary Surgeons’ Health Support Pro-gramme (VSHSP).

The programme provides

support and treatment for vet-

erinary surgeons, nurses and

students who suffer as a result

of mental health and addiction

problems. The service works

alongside the other VBF support

services – Vet Helpline and the

Vetlife website.

Rory O’Connor has been the

national coordinator of VSHSP

for the past two years. Rory

has many years of experience

as a mental health nurse, which

offered him specialist training in

treating addictions. He also has an

undergraduate degree in psychol-

ogy and an MSc in addictions.

Over his career, Rory has

engaged with hundreds of doc-

tors, dentists, veterinary sur-

geons, nurses and students to

help them overcome addictions

or cope with mental health dif-

fi culties – and keep their careers.

In his spare time, Rory is a long-

distance runner and he plans to

run next year’s London Mara-

thon to raise money to support

VSHSP service users.

Idealism � What kind of person does

the VSHSP typically treat?Early in my career, I learned that

many vets resort to chemicals

for relief from emotional turmoil.

Vets, along with dentists and

doctors, are often idealists, per-

fectionists and work-addicted

in the name of healing every-

one else, but they don’t always

know how to handle their own

personal and emotional lives.

Sometimes this is a by-product of

the obsessive-compulsive traits

engendered by the education

and training process of medicine

and veterinary science. � How do you identify who

needs help from the pro-gramme and how do you go about engaging them?Identification is typically a tel-

ephone call to my offi ce from

someone associated with the

p e r s o n w h o

needs help – usu-

ally from a con-

cerned fellow vet,

nurse or other

personal contact,

such as the prac-

tice manager or

a family member.

Firstly, I verify

the ident i f i ca -

tion. I make the

necessary checks

to ensure that

there’s no malice

connected to the

report. I check

with members of

the community,

talk with peers and do a lot

of research before I approach

someone to offer help. � How do people react when

you get in touch with them? Those who a re severe l y

impaired by their addiction or

mental health problems are so

protected by their denial systems

that frequently they don’t recog-

nise that they need support.

We have to deliver that help

to them – sometimes we have

to keep pushing before they

accept help. � How do you treat people?

First and foremost, the pro-

gramme is anonymous and con-

fi dential. That is crucial. When

vets, nurses and students are

made aware of how veterinary

support works, many start calling

for help voluntarily.

Each treatment is tailored

according to the patient’s needs

and responses. The more seri-

ously addicted often need at

least four months away from the

workplace and in treatment. For

those vets who cannot afford it,

VSHSP will consider funding a

combined inpa-

tient and residen-

tial programme at

a well-respected

clinic. While they

are in treatment,

we can work with

one of our local

volunteers to try

to ensure that

their practice and

affairs are looked

a f t e r b y c o l -

leagues, friends

and peers. Eve-

ryone around the

affl icted person is

usually very sup-

portive, but I also

work with the practice if any

feelings of hostility, anger, fear

or other strong emotions are

present. In a small business, the

practical fall-out needs careful

management.

Some don’t need to go into

inpatient treatment, but can

benefi t from counselling. Often, I

am able to provide this myself by

telephone. Vets and nurses often

need counsellors with personali-

ties at least as strong as theirs.

� What happens after treat-ment is complete?I maintain regular contact and,

where necessary, we have some

practices that will provide work

experience to those who need

to rebuild their confi dence.

In the case of those with

mental health diffi culties, I work

to ensure they are adequately

supported and in touch with their

local NHS mental health team. � Do you report vets or

nurses to the RCVS? Certainly not. Contact with the

RCVS is only at the request,

and with the written agree-

ment, of the individual involved

with VSHSP.

Although you will be encour-

aged to give all your details,

you don’t have to give them to

receive support – although they

will be needed for referrals on

to specialist services. It may take

time to build a trusting, thera-

peutic and effective relationship. � What is the success rate of

cases at the VSHSP?I defi ne success as returning to

work with no further complaints

or, in the case of addiction, no

relapses, and I would estimate

our success rate at about 80 per

cent. Part of our success can be

attributed to tailoring treatment

to each person according to

his or her needs. I don’t think

I will ever stop getting excited

over seeing the remarkable

transformation when someone

conquers an addiction or eating

disorder and receives relief from

suffering depression.

I get to see them not only

functioning again in the profes-

sion they have chosen, but often

functioning better than they had

done previously. At this time of

year, it is especially moving to see

their families heal too.

Real-life case study“A few years ago, I was in a

hopeless state with severe para-

lysing depression and anxiety,

and was unable to carry out

even basic daily tasks, let alone

work as a vet.

“It seemed any return to

‘normality’ was impossible. I was

also oblivious to the role drug

use had played in my demise,

and continued to use my drug of

choice throughout my descent,

believing it was helping me to

cope. After all, my family and

‘friends’ were also regular drug

users and seemed okay. I was

convinced there was something

else fundamentally wrong with

me to end up in this state.

“As my condition worsened,

I was really struggling to keep it

together on the work front and

eventually realised I couldn’t. My

head was always jumbled and I

couldn’t make decisions or be

objective about anything. Pretty

soon I was jobless, on income

support and on a cocktail of

antidepressants, antipsychotics

and sleeping pills prescribed by

my GP. My call to the VSHSP was

to ultimately turn my life around.

“It helped me to get and stay

clean, arranged for me to ‘see

practice’ in a friendly environment

as a stepping stone to returning to

the workplace and, as I began to

work again, it found me a mentor

to support me in the early days.

Today I have my life back – a new

and better life.”

How readers can support the VSHSPOnline donations can be made

at www.justgiving.com/vbf or

cheques made out to VBF can

be addressed to the administra-

tor at 7 Mansfi eld Street, London

W1G 9NQ. � You can also become a mem-

ber of the VBF by telephoning

020 7908 6385 or emailing

info@vetlife.org.uk � Contact the VSHSP by

telephoning Rory on 07946

634220 or emailling VSHSP@

vetlife.org.uk �Rory O’Connor.

“Everyone around the affl icted person

is usually very supportive, but I also work with

the practice if any feelings of hostility, anger, fear or other

strong emotions are present. In a small business,

the practical fall-out needs careful

management.”

PEOPLE CLINICAL SMALL ANIMAL

Proceedings of 15th European Colleges of Internal

Medicine.

Swalec K M and Smeak D D (1990). Partial versus

complete attenuation of single portosystemic

shunts, Veterinary Surgery 19: 406-411.

Tobias K M S and Rawlings C A (1996). Surgical

techniques for extravascular occlusion of intra-

hepatic shunts, Compendium for the Continuing

Education of the Practising Veterinarian 18: 745.

Tobias K M (2003). Portosystemic shunts and

other hepatic vascular anomalies. In Slatter D

(ed), Textbook of Small Animal Surgery (3rd edn),

Elsevier Science (USA): 727-752.

Vogt J C, Krahwinkel Jr D J, Bright R M, Daniel

G B, Toal R L and Rohrbach B (1996). Gradual

occlusion of extrahepatic portosystemic shunts

in dogs and cats using the ameroid constrictor,

Veterinary Surgery 25: 495-502.

Youmans K R and Hunt G B (1998). Cellophane

banding for the gradual attenuation of single

extrahepatic portosystemic shunts in 11 dogs,

Australian Veterinary Journal 76(8): 531-537.

Wrigley R H, Macy D W and Wykes P M

(1983). Ligation of ductus venosus in a dog

using ultrasonographic guidance, Journal of the

American Veterinary Medicine Association 183:

1,461-1,464. �

KELLY BOWLT qualifi ed from the University of Edinburgh in 2005. She spent two years in small animal practice in Nottinghamshire and one year as a junior clinical training scholar at the RVC. In 2008, she began an ECVS-approved residency in small animal surgery at the University of Bristol, where her interests include soft tissue surgery, particularly reconstructive surgery and management of trauma patients.

ED FRIEND graduated from the RVC in 1996 and worked in a mixed practice in Buckinghamshire for a year, before undertaking training positions at the RVC, University of Liverpool and University of Cambridge. He became a diplomate of the ECVS and a European specialist in small animal surgery in 2003. He joined the University of Bristol surgery department as a soft tissue surgeon in 2009 and enjoys ear, nose and throat surgery, thoracic surgery, trauma cases and wound management.

KATE MURPHY is senior clinical fellow in small animal emergency medicine and intensive care at the University of Bristol. She is interested in all aspects of internal medicine, but particularly enjoys the challenges posed by more critically ill patients.

Looking for a new job? Turn to our recruitment section, starting on page 25, for the latest veterinary vacancies

� PORTOSYSTEMIC SHUNT SURGERY AND PO CARE IN CATS AND DOGS – from page 19

VT40.49 InCopy.indd 20 03/12/2010 11:53