Appendix as Biliary Conduit tn Children with Biliary as a Biliary Conduit tn Children with Biliary...
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Appendix as a Biliary Conduit tn Children with Biliary Atresia
Amar A. Shah, Anirudh V. ShahDepartment of Pediatric Surgery, K. M. School of Postgraduate Medicine & Research, N. H. L. Municipal Medical College,V.S. Hospital, Ahmedabad, India
AbstractBiliary conduits are constructed during operations for biliary atresia. A wide variety of options are availablefor biliary tract reconstruction. We present our experience of treating three children with extrahepatic biliaryatresia by using appendix as biliary conduit. After mobilizing the appendix on its vascular pedicle, nonrefluxing,tunneled anastomosis was made with the 2-d part of duodenum and the appendix. The operative procedure issimple and less time consuming. From our preliminary experience with this technique, the operation seemssimpie and satisfying. The postoperative cholangitis was conspicuously absent. Though the long-term efficacystill remains to be proven, the appendix should prove durable as a functional conduit.
Key word,s; extrahepatic biliary atresia, appendix.
The use of intestinal segments toreconstruct the biliary system after surgery forbiliary atresia is not new. Kasai et all firstdescribed Hepaticoportoenterostomy, whichinvolved the use of a Roux-en-Y jejunal loop.Later, many modifications have been made inthe technique by Kasai and others,2-6 but a majorproblem with these techniques has beenascending cholangitis. Ascending cholangitis hasbeen noted in up to 50-90 % of cases with a highincidence of morbidity.7,8 The authors describehere their experience with the use of appendixas a Biliary conduit instead of jejunum for biliaryreconstruction in three children withextrahepatic Biliary Atresia. The operation iseasier and it achieves an anatomic reconstructionwhich is close to normal.
MATERIAL AND METHODS
Three patients with jaundice and acholicstools and hepatomegaly were referred to us were
Paper received: January 2002Paper accepted: April 2002
Address for correspondenceDr. Anirudh V..ShahAnicare, 13, Shantisadan Society,Nr. Parimal Garden, Nr. Doctor House,Ellisbridge, Ahmedabad - 380 006.Email: email@example.com
included in the study. The patient details aregiven in the Table 1.
Clinical examination, and routinebiochemical tests which confirmed the evidenceof obstructive jaundice. An ultrasound of theabdomen did not show any intrahepatic ducts,
Figure 1: Mobilized appendixpedicle. (A)
preserving the vascular
496 IJS VoI. 64, No. 6,2002
Append,ix as a biliary
Table 1: Details of patientsPatient Age in Sex SpecialNo. months Ix.
Liver Postbiopsy operative
Jaundice &Acholic Stools
Jaundice &Acholic StooIs
Jaundice &Acholic Stools
Fibrotic BiliaryAtresia with
Fibrotic BiliaryAtresia with
Fever for 2 Lost topostop days follow up
nor was the gall bladder and the extrahepaticducts visualized. HIDA scan was carried out inall the patients, which suggested no visualizationofthe gall bladder or extrahepatic ducts.
The operative technique involves thedissection of the right colon and hepatic flexure'so as to place the caecum under the liver. Theappendix is then detached preserving thevascular pedicle. (Fig. 1) The caecum is closedin two layers. The tip of the appendix is cut openso as to form a tube from the appendix. This isthen irrigated with solution of povidone iodineand saline. The caecal end ofthe appendix is thenanastomosed at the porta with interrupted 5-0dexon or vicryl sutures. The distal end of theappendix is then anastomosed to the duodenumafter making a sub mucosal tunnel. (Fig. 2) The
Figure 2: The appendix (A) placed between the porta hepatisand the 2nd part of the duodenum. (D)
liver biopsy was suggestive of fibrotic biliaryatresia with biliary cirrhosis.
The postoperative period was uneventfulin all the patients except for the onset of fever inone chiltl which lasted for two postoperative days.There was no evidence of any sudden increase in,jaundice, abd"ominal distension or positive blood
vcultures. AII patients were discharged on the 8ihto the 12th postoperative day. Post operatively,prophylactic antibiotics were continued for sixweeks following the surgery in all the patients.
An ideal biliary conduit is one whichshould allow a free flow of bile from the liver tothe duodenum, without allowing reflux of anyintestinal contents back into the biliary tree.Though the jejunal loop is well known andeffective, it has its own drawbacks. Cholangitisis one of the main problems that the surgeonshave to face in these patients. As many as 50%of patients who have been operated for biliaryatresia suffer from cholangitis. This highincidence has prompted various modificatioils efvthe jejunal grafts to prevent.reflux e.g. using aninterposition grafts, intussuscepted ileocolicinterposition graft, e-11 jejunal nipple valve 11-13,mucosal flap valve,la and sphincter of Oddi valvelsbut inspite of all these modifications theincidence of cholangitis remains significant.Postoperative cholangitis as suggested by Guptaet al 16 when appendix was used as a biliaryconduit was possibly due to the role played bythe presence of lymphoid follicles in the wall ofthe appendix. Jejunal loop has its owndisadvantages i.e. the use of a wide loop whichmay necessitates tailoring, loss of a long jejunalloop out of the intestinal circuit.
The use ofthe appendix on the other hand
IJS VoI. 64, No. 6,2002 497
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is weII suited as a biliary conduit. Theprocurement of the appendix is simple and direct.The conical base and the tapering tip are weIIsuited for biliary replacement in small children.The small caliber, well-vascularized isoperistaltictube can be anastomosed to the duodenum usinga nonrefluxing tunnel. The bile is directed intothe duodenum, which is a physiological area forthe intestinal and biliary contents to be mixed.We have had no febrile episodes to suggestCholangitis in the two patients who are presentlyin follow up. The third child is lost to follow upand presumed to be dead.
Follow up HIDA scans would be doneafter six months to assess the patency and thefunction of the conduit, but tilI then, lack ofclinical evidence of cholangitis and increase inthe intensity of jaundice has eliminated thev possibility of reflux or strictures and ensured. afree flow of bile. Currently in follow up patientsare not free of jaundice, but the intensity hasdecreased considerably. Neither of the patientshave signs of portal hypertension. Of late, thisprocedure has been reported to be used by someresearchers for choledochal cysts and also inBiliary trauma.17 However, they suggest that itshould be used only as a salvage technique whenconventional hepaticojejunostomy repair iscontraindicated.lT We have recently done asimilar procedure in a 6 children withcholedochal cysts, and the results areencouraging.
The use of an appendiceal graft in biliaryreconstruction was first reported by Grosfeld etal in mongrel dogs.18 Greenholz et aI performed
- rn ancillary appendiceal conduit to provide.-biliary drainage of an independent bile duct.leAppendix has also been used as a ureteral conduitand long term patency and function has beendocumented for as long as 11 yearspostoperatively.20 Our initial experience with theuse of appendix as a bilioenteric conduit seemsto be promising.
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