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					Animals Asia Foundation Report

Problems associated with the ‘Free-dripping
Fistula Technique’ as a method of bile extraction
from Asiatic Black Bears.

E-MAIL: gcochrane@animalsasia.org
WEBSITE: www.animalsasia.org

July 2003

                             Animals Asia Foundation - www.animalsasia.org
The Asiatic Black Bear (Ursus thibetanus) is the only species of bear currently legally allowed
to be utilized for extraction of bile within China. The ‘Free-dripping Fistula Technique’ is the
only method allowed under current regulations. Officials within China believe that this
technique “can ensure the health of the bears and avoid their maltreatment”.

Cholecystectomies performed on Asiatic Black bears rescued from bear farms that have had
the ‘Free-dripping Fistula Technique’ performed indicate cholecystitis, cholelithiasis, polyp
formation and the presence of foreign bodies within the gall-bladder. These are common
problems found in these bears and lead to significant health problems and a reduced lifespan.

Bear bile has been used in Traditional Medicine for over 3000 years, but the practice of bear-
farming was only introduced in the 1980’s in an attempt to curb poaching of huge numbers of
wild bears killed for their whole gall-bladders. Synthetic and herbal alternatives are readily
available to replace bile in both allopathic and Traditional Medicines. ‘The Notice on
Strengthening the Management and Administration of Bear Farms’ issued in 1996 by the then
Ministry of Forestry stipulates that only the ‘free-dripping’ method of bile extraction is now

Between October 2000 and July 2003, 99 bears arrived at the Animals Asia Foundation Moon
Bear Rescue Center in Sichuan Province. Of those 99 bears, 46 previously had the ‘Free-
dripping Fistula Technique’ performed on them in order for the farmers to extract the bile. The
remaining bears either had a stainless steel catheter, latex catheter or no previous surgery.

To extract the bile from the free-dripping fistula, an un-sterile stainless steel catheter or red
rubber feeding tube is inserted through the external fistula directly into the gall-bladder. The
bear’s abdomen is not clipped or cleansed before this procedure. Bile is then collected either
by gravity into a tray or by attaching an un-sterile syringe and applying negative pressure.
Inserting this catheter once or twice per day is needed to help prevent the fistulas granulating
and closing over.

All bears were anaesthetised in order to remove them from the crush cages and place them in
a transport cage. At this time a full health check was performed and included a full physical
examination, weighing, ultrasonography of the gall-bladder, complete blood count and
biochemistry, microchip insertion, assessment of range of motion in their joints, ear-tagging,
nail clipping, ear-cleaning, deworming and ectoparasite treatment.

                                                                                           Animals Asia Foundation Report
        Problems associated with the ‘Free-dripping Fistula Technique’ as a method of bile extraction from Asiatic Black Bears   page 2
The Animals Asia Foundation Moon Bear Rescue Center currently holds 9 bears that have had no
bile extraction surgery performed, these are classed as the ‘control’ bears.

The initial ultrasonography examination allowed us to prioritise the bears for surgery; unless judged
to be critical the bears were left in the transport cage for one month in order for them to rehydrate
and improve body condition.

On reviewing the records it was possible to accurately select which bears had major abnormalities
in the gall-bladders e.g. cholelithiasis, large polyps, severely thickened walls, and further
complications in the surrounding tissues e.g. abscesses and partial gall-bladder herniation. These
bears were classed as ‘high risk’ and corrective surgery was planned as soon as possible.

Bears that did not have such severe problems evident were classed ‘lower risk’ and had corrective
surgery at a later date.

At the time of surgery the bears were anaesthetised, reweighed, intubated and maintained on gas
anesthetics and intravenous fluids. During surgery the following physiological parameters were
constantly monitored: heart rate, respiratory rate, core body temperature, blood oxygen
concentration and blood pressure.

During corrective surgery the veterinary nurse removed blood for a complete blood count,
biochemistry and extra serum was frozen for future viral studies. A premolar was extracted for aging
and a hair pluck taken for future DNA studies. Teeth were assessed for future dental work, then
scaled and polished. Antibiotics and analgesics were administered pre- and post-operatively.

When corrective surgery was initially performed to repair the gall-bladder fistulas, it was noted that
the main area of reaction and damage was in the ventral pendulous end of the gall-bladder. The area
of the gall-bladder near the cystic duct generally appeared normal. During these initial surgeries
partial cholecystectomies were performed in order to remove only the damaged area and any foreign
bodies from within the lumen.

Six months after corrective surgery, one bear (S010) presented with decreased appetite, lethargy, and
a change in behavior. The decision was made to anaesthetise her and perform further blood work
and ultrasound examination. The remaining portion of the gall-bladder was difficult to assess so an
exploratory laparotomy was immediately performed. S010 was found to have a 6cm diameter gall-
stone obliterating the lumen of the remaining part of the gall-bladder. After removal of the stone and
a total cholecystectomy she had an uneventful recovery.

All subsequent bears had a total cholecystectomy performed on them and as much of the cystic duct
as possible was removed.

                                                                                            Animals Asia Foundation Report
         Problems associated with the ‘Free-dripping Fistula Technique’ as a method of bile extraction from Asiatic Black Bears   page 3
Notable findings were:
• Most bears had polyp formations; these ranged from polyps 1mm in diameter (S087) to
  large pendulous grape like projections 3cm long (S094, S092, S088 and S086).
• Many of the bears were found to have abscesses at the connection of the gall-bladder to the
  abdominal wall.
• Eleven bears (23%) had gall-stone formation.
• Eleven bears (23%) had foreign bodies: either suture material or plastic tubing.
• Bears S084 and S086 had ‘hole’-like lesions on the inner surface of the gall-bladder wall.
• Bear S096, S094, S054 and S049 had either gall-stones or foreign material partially
  blocking the cystic duct.
• Bears S087 and S086 had strictures of the gall-bladder wall.
• Bear S087 had a partial herniation of the gall-bladder into the subcutaneous area.
• Bear S086, S085, S081 had a ‘pouch’ of bile in the subcutaneous area.
• Bear S074 had bile leakage through the layers of abdominal musculature which caused
  severe inflammation and infection of the abdominal wall resulting in multiple discharging
  fistulas over the abdomen and thorax.
• Bear S071 had a 10cm diameter abscess walled of by the mesentery, due to bile leakage.
• Bear S095, who had been placed in the ‘lower’ risk group, was found to have suture
  material covered in bile crystals within the lumen of the gall-bladder at surgery. On
  reviewing the record it had been noted that due to severe scarring in the abdominal area a
  full and clear picture of the gall-bladder could not be elicited.
• One bear (S021) died 12 hours after arrival due to bile peritonitis and septicemia.
• All of the gall-bladders, except two, showed some type of gross pathology macroscopically.
  This ranged from mild erythema of the gall-bladder lining to massive thickening of up to
  1 cm (bears S084 and S095).

Samples were taken for histopathology from most of the gall-bladders, but have not been
processed as yet.

The control bears have not yet shown any of the above problems on ultrasound, hematology
or biochemistry examinations.

                                                                                           Animals Asia Foundation Report
        Problems associated with the ‘Free-dripping Fistula Technique’ as a method of bile extraction from Asiatic Black Bears   page 4
The regular daily insertion of an un-sterile catheter directly into the gall-bladder will increase the
chance of ascending bacterial infection from the environment.

‘In a research environment, when gall-bladder fistulas are created, the laboratory animals must be
maintained in sterile conditions while the fistula is patent, to prevent infections ascending.’ ( Dr T
James pers.com).

No attempt is made on the bear farms to maintain ‘sterile conditions’ while the fistulas are patent.
The fistulas remain patent for a variable length of time. If the fistula closes the bear farms will re-
operate to enable them to continue to extract bile. Bile extraction continues until the bears dies.

The extraction catheter is frequently ‘stabbed’ through the fistula to break down any granulating
tissue blocking the fistula. The lining of the gall-bladder is subject to the direct trauma associated
with the catheter being inserted. In some cases there have been ‘hole’ like lesions found on the inner
surface of the gall-bladder wall that are presumed to have resulted from partial penetration when
forcing the extraction catheter through the fistula.(Bear S086 and S084). The insertion of this un-
sterile catheter during extraction also helps introduce environmental contaminants directly into the

On visual examination most of the gall-bladders showed gross signs of cholecystitis. It has not been
possible to culture the bile from the gall-bladders as the local hospital does not have adequate
facilities to perform culture and sensitivity tests. Samples for histopathology have been taken but
results have not been received as yet. (CITES permits were not being issued due to SARS.)

Most gall-bladders had grossly visible polyp formation. These polyps were generally concentrated
at the ventral end of the gall-bladder where the free-dripping fistula had been created. The polyps
were presumed to have formed in reaction to the chronic cholecystitis.

In gall-bladders with severe polyp formation it was noted that on dissection many had bile ‘sludge’
collecting. This was presumed to be secondary to the physical obstruction the polyps caused during
gall-bladder contraction, leading to improper emptying of bile.

Extraction of bile in these bears would have been impossible due to the physical obstruction caused
by the polyps.

Non-absorbable suture material is frequently used during the surgery to create the free-dripping
fistulas. This suture material is often found embedded in abscesses in the wall of the gall-bladder or
free in the lumen. Most of the suture material found in the lumen is coated in bile sludge and appears
to act as a nidus for the formation of gall-stones. The suture material used is generally un-sterile
cotton thread.

                                                                                            Animals Asia Foundation Report
         Problems associated with the ‘Free-dripping Fistula Technique’ as a method of bile extraction from Asiatic Black Bears   page 5
Two bears were found to have strictures of the gall-bladder wall but the exact etiology of why they
had developed was not determined.

Bear S021 died as a direct consequence of bile leaking into the abdominal cavity resulting in bile
peritonitis and septicemia. Bile leakage in S071 resulted in the formation of localized peritonitis and
abscess formation which was then effectively sealed of by the mesentery. Bear S074 had bile
leakage through the abdominal musculature which resulted in massive inflammation, thickening and
fistula formation over the thorax and abdomen.

From the data so far it appears that chronic ascending infections, direct trauma and foreign bodies
cause disruption to the lining of the gall-bladder. This appears to result in a variety of problems
including cholecystitis, polyp formation, cholelithiasis and occasionally stricture formation. More
information should be gained when histopathology reports are received.

Whilst the gross appearance of the gall-bladders of the ‘control’ bears has not been visualised,
ultrasonography indicates that their gall-bladders are normal. In most of the ‘Free-dripping fistula’
bears, lesions seen during ultrasonography were confirmed on dissection of the gall-bladder after

The Animals Asia Foundation Moon Bear Rescue Center will try, in the future, to determine the
exact relationships between these problems in order to determine if they are directly related to the
creation of the ‘Free-dripping fistula.’

Some Government officials and most bear farmers believe that creation of the ‘Free-dripping fistula’
and the subsequent extraction of bile is a ‘humane’ procedure and does not cause any harm to the
bear. Their belief that creating a fistula in the abdomen is: ‘just like creating an anus’ indicates their
lack of knowledge of anatomy, physiology and disease processes.

Our current work strongly suggests that the creation of the ‘Free-dripping fistula’ results in
cholecystitis, cholelithiasis, polyp formation and the presence of foreign bodies within the gall-
bladder. These problems lead to significant health problems and a reduced lifespan therefore the
Animals Asia Foundation classes the procedure as inhumane.

The Animals Asia Foundation is most grateful to the China Wildlife Conservation Association
(CWCA) in Beijing, the Sichuan Forestry Department and the Sichuan CWCA for their guidance
and help in the ongoing rescue of 500 bears in China.

                                                                                            Animals Asia Foundation Report
         Problems associated with the ‘Free-dripping Fistula Technique’ as a method of bile extraction from Asiatic Black Bears   page 6

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