Appendix as a Biliary Conduit forCholedochal Cysts in Children

Abstract

Biliary conduits are constructed in operations for choledochal

rysts. A wide variety of options are available for biliary tract re-

construction. We present our experience of treating six childrenwith choledochal cysts by using the appendix as a biliary con-

duit. After mobilizing the appendix on its vascular pedicle, non-

refluxing, tunneled anastomosis was made with the 2nd part ofthe duodenum and the appendix. The operative procedure was

simple and less time-consuming. Postoperative evaluation was

done with the help of HIDA scan and ultrasound examination.

Postoperative cholangitis was conspicuously absent in the twoyears of follow-up. One child has been lost to follow-up. From

our preliminary experience, the operation seems simple and sat-

isfuing. Though the long-term efficacy still remains to be proven,

the appendix should prove durable as a functional conduit.

KeywordsCholedochal cyst. appendix

R6sum6

Des n6o-conduits biliaires sont r6alis6s pour traiter les kystes du

chol6doque. Une large vari6t6 de possibilit6s sont disponiblespour la reconstruction de l'arbre biliaire. Nous pr6sentons notre

exp6rience du traitement de six enfants avec des kystes du cho-

l6doque en utilisant I'appendice comme n6o-canal biliaire. AprEs

avoir mobilis6 I'appendice sur son p6dicule vasculaire, une anas-

tomose tunn6lisr6e non refluente 6tait r6alisee entre la deuxidmepartie du duod6num et I'appendice. Le proc6d6 op6ratoire est

A. A. Shah

A. V. Shah

simple et peu consommateur de temps. L'6valuation post-op6ra

toire 6tait faite avec l'aide d'une scintigraphie i HIDA et un

6chographie. Une cholangite post-op6ratoire n'6tait jamais ob

serv6e dans les deux ans de suivi. Un enfant a 6t6 perdu de vut

De iette exp6rience prdliminaire, cette op6ration parait simple tsatisfaisante. Quoiqu'une efficacit6 i plus long terme reste

prouver, I'appendice pourrait €tre un n6o-canal biliaire valable.

Mots-cl6sKyste du chol6doque' appendice

Resumen

En las operaciones por quiste del col6doco es necesario recor

struir la via biliar para lo que hay varias opciones disponible

Presentamos nuestra experiencia en el uso del ap6ndice com

conducto biliar en 6 niflos con quiste del col6doco. Tras moviliz;

el ap6ndice con su pediculo vascular se realiz6 una anastomos

tunelizada entre la segunda porci6n del duodeno y el ap6ndic,

El procedimiento operatorio fue fdcil y breve. La evaluaci6n post

operatoria se hizo con ayuda de HIDA y estudio ecogr6fico. N

hubo colangitis postoperatoria en los 2 af,os de seguimientr

Hemos perdido de vista uno de los niflos. De esta experienci

preliminar deducimos que esta operaci6n parece Simple y satil

factoria aunque la eficacia a largo plazo no ha sido arin probad

El ap6ndice parece ser un conducto biliar funcional.

Palabras clave

Quiste del col6doco. ap6ndice

AffiliationDepartment of Pediatric Surgery K. M. School of Postgraduate Medicine and Research, N. H. L. MunicipalMedical College, V. S. Hospital, Ahmedabad, India

CorrespondenceDr. Anirudh V. Shah. "Anicare", 13, shantisadan society. Nr. Parimal Garden, Nr. Doctor House.

Ellisbridge, Ahmedabad, 380006 . lndia . E-mail: anirudhshah@icenet.net, amarshah-22@hotmail.com

Received: January 8, 2004 .Accepted after Revision: March 14, 2004

BibliographyEurJ Pediatr Surg 2005; 15: 728-731. @ Georg Thieme Verlag KG Stuttgart ' New York'DOI 10.105s/s-2004-827220 .

rssN 0939-7248

Zusammenfassung

Bei der Operation von Choledochuszysten muss eine biliiire Ab_leitung mit Zwischenschaltung anderer Organe durchgeftihrtwerden. Zur Rekonstruktion der Gallenwege werden vielfiiltigeTechniken angegeben. In der vorliegenden Arbeit werden 6 I(in-der mit einer Choledochuszyste vorgestellt, bei denen die Ap-pendix zur Gallenableitung verwandt wurde. Nach Mobilisie-rung der Appendix mit ihrer vaskuldren Versorgung wurde einnicht refluxiver Tunnel mit dem zweiten Teil des Duodenumsangelegt und die Appendix mit dem Choledochus verbunden.Das operative Verfahren war einfach und wenig zeitaufwdndig.Postoperativ wurden mithilfe des HIDA-Scans und des Ultra-

schalls die I(inder nachuntersucht. Bei allen war, zumindest zweiJahre nach dem Eingriff, keine postoperative Cholangitis zu be-obachten. Ein I(ind konnte nicht weiter nachuntersucht werden.Schlussfolgerungen: Von unseren begrenzten Erfahrungen herkann die Operation mit Interposition einer Appendix zwischenCholedochus und unterem Duodenum bei Vorliegen einer Chole-dochuszyste empfohlen werden. Allerdings muss noch geprtiftwerden, ob die Appendix selbst als ein brauchbares, funktionel-les und vor allem dauerhaftes Ersatzrohr geeignet ist.

SchliisselwiirterCholedochuszyste . Appendix . Galleableitung

Introduction

The use of intestinal segments to reconstruct the biliary systemafter surgery for biliary atresia or choledochal cyst is not new.I(asai et al. [9] first described hepaticoportoenterostomy, whichinvolved the use of a Roux-en-y jejunal loop. Later, many modifi-cations were made to the technique by l(asai and others [4,5,10,11,171, but a major problem ofthese techniques has been as-cending cholangitis. Ascending cholangitis has been noted in upto 50-90% of cases with a high incidence of morbidity [12]. Theauthors describe here their experience with the use ofthe appen-dix as a biliary conduit for biliary reconstruction following exci-sion of choledochal cysts in six children. The operation is easierand it achieves an anatomic reconstruction that is close to nor-mal.

Materials and Methods

Six patients between 4 and g months of age with choledochalcysts type I were studied from March 2000 to September 2001.Three patients presented with conjugated hyperbilirubinemia,while one presented with a perforated choledochal cyst withbiliary peritonitis. Two were diagnosed incidentally on abdomi-nal ultrasound.

In addition to clinical examination, hematological tests for a fullblood count, renal lunction tests, liver function tests, and a coag-ulation profile were carried out. An ultrasound examination wasdone in all cases for the evaluation of the extra- and intrahepaticducts. Magnetic resonance cholangiopancreatography was donepreoperatively in all cases to rule out biliopancreatic ductanomalies.

The abdomen was opened through a supraumbilical right trans-verse incision. The right colon and hepatic flexure was mobilizedto bring the cecum under the liver. The appendix was then de-tached, preserving the vascular pedicle. The stump was ligatedand buried, using purse string sutures. The tip of the appendixwas cut open so as to form a tube from the appendix. This wasirrigated with a solution of providone iodine and saline. Thececal end of the appendix was anastomosed with the commonhepatic duct with interrupted 5-0 dexon or vicryl sutures. Thedistal end of the appendix was anastomosed to the duodenum

with interrupted 5 - 0 dexon or vicryl sutures after forming a tun-nel between the mucosa and the muscularis. The seromuscularlayers were closed over it using interrupted 5-0 dexon sutures(Figs.1 and 2). Adrainwas placed in the sub-hepatic space. post-operatively it has been our practice to give prophylactic antibiot-ics for a period of six weeks. We used a combination of trimetho-prim and sulphamethoxazole (cotrimoxazole 1.2mg/kg once dai-ly in all our patients. Hematological and biochemical investiga-tions were repeated two weeks after surgery and subsequentlyat six weeks during the first follow-up. An ultrasound was doneat 3 months and supplemented with a Tc HIDA scan in threepatients. Repeat ultrasound scans were done on a yearly basisfor the first two years. Hematological and biochemical investi-gations were repeated every 6 months for the first two years.Follow-up was done every 6 months up to a period of two years,following which the children will be reviewed on a yearly basis(Table 1 ).

Results

All children did well in the postoperative period. There was noevidence of cirrhosis in any ol the patients. One child was lost tofollow-up after two weeks. All hematological and biochemicalinvestigations were normal at the two-week check-up. Jaundicehad resolved in all three children who had initially presentedwith hyperbilirubinemia. A Tc HIDA scan was done in three pa-tients operated for choledochal cyst excision with interpositionof the appendix three months after surgery which showed a nor-mal length and caliber of the duct with free flow of the contrastinto the duodenum and no evidence of reflux. Follow-up HIDAscans could not be carried out in all patients because ofeconomicrestraints, but the lack of clinical evidence of cholangitis or jaun-dice eliminated the possibility of reflux or strictures and ensureda free flow ofbile. Repeat ultrasound scans done on a yearly basisshowed no dilatation of the intrahepatic biliary tree or changesofportal vasculature.

We had no febrile episodes to suggest cholangitis in the twoyears of follow-up of our patients. Currently all five patients infollow-up are free ofjaundice.

Shah AA, Shah AV. Appendix as a Biliary ... Eur I pediatr Surg 2005; t5: 128 - 131

Fig.2 Picture show'ing the appendix (A)

placed between thecommon bile ductand the 2nd part ofthe duodenum (D).

Fig.1 Picture showing the mobilized appendlx preservlng tne vascu-

lar pedicle (A).

Discussion

An ideal biliary conduit is one that should allow a free flow of bile

from the liver to the duodenum, without allowing reflux of any

intestinal contents back into the biliary tree. Though the jejunal

loop is well known and effective, it has its own drawbacks'

Cholangitis is one of the main problems that the surgeons have to

face in these patients. As many as 50 % of patients who have been

operated for Biliary Atresia, and about 46% ofpatients operated

for biliary reconstruction after resection of choledochal cysts

have episodes of cholangitis. This high incidence has prompted

various modifications ofthejejunal grafts to prevent reflux' e'g'

using interposition grafts, intussuscepted ileocolic interposition

grafi 1t,+,t01, jejunal nipple valve [3,10,15], mucosal flap valve

irOl, ana sphincter of Oddi valve [13], but in spite of all these

modifications the incidence of cholangitis remains significant'

Jejunal loop has its own disadvantages, i.e' the use of a wide loop

thatmaynecessitatetailoring,stricturesatthesiteofanastomo-sis, and loss ofa longjejunal loop out ofthe intestinal circuit'

The use of the appendix, on the other hand, is well suited as a

biliary conduit. The procurement of the appendix is simple and

direct. The conical base and the tapering tip are well suited for

biliary replacement. The small caliber, well-vascularized tube

can be anastomosed to the duodenum using a nonrefluxing tun-

nel. The bile is directed into the duodenum, which is a physir

logical area for the intestinal and biliary contents to be mixed'

We used prophylactic antibiotics for up to six weeks after su

gery. O'Neill [14] suggests that the chances of postoperative chc

ingitis diminish six weeks after surgery' Decreased incidence

poitoperative cholangitis as suggested by Gupta et al' [8] wh(

itre appenaix was used as a biliary conduit was possibly due

the role played by the presence of lymphoid follicles in the w;

of the appendix.

Grosfeld et al. [7] first reported the use of an appendiceal gri

for biliary reconstruction in mongrel dogs' Greenholz et al' I

performed an ancillary appendiceal conduit to provide bilia

irainage of an independent bile duct' Crombleholme et al' ha

used this technique successfully in patients with biliary atrel

and choledochal cyst [21. The appendix has also been used ar

ureteral conduit and long-term patency and function has be

documented for as long as 11 years postoperatively [18]' Our i

tial experiences with the use of the appendix as a bilioente

mobilized appendix preserving the vascu-

Table 1 Patient details

Patientno. Ageinmonths

rl: :::r:l i:r,l,'l',:]:tl:6rl..ii.::t l'r:l::

25:.13.''a:'].;.:i:i:'t;r..]rei::].

44

Prcsentation LFf ot 6 weekspost op.

Follow-up

HIDA - Normal

Lost to follow-uP

r:tiijiritri.ti:]ii,i.trt tti,li9riiri':i $6 7112 Male lncidental

USG - Normal

Shah AA, Shah AV. Appendix as a Biliary "' Eurl Pediatr Surg 2005: 15: 128-131

ii

conduit in children with choledochal cyst seem to be promisingand long-term follow-up of these children would be interesting.

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