Original Article

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.

!NTRODUCTION

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: anirudhshah@icenet.net

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

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Append,ix as a biliary

Table 1: Details of patients

Patient Age in Sex SpecialNo. months Ix.

Associated Presentationsymptoms

Liver Postbiopsy operative

1. Male

Male

Male

HIDA

HIDA

HIDA

UmbilicalHernia

SitusInversus

None

Jaundice &Acholic Stools

Jaundice &Acholic StooIs

Jaundice &Acholic Stools

Fibrotic BiliaryAtresia with

CirrhosisFibrotic Biliary

Atresia withCirrhosis

Fibrotic BiliaryAtresia with

cirrhosis

Uneventful Normal

Fever for 2 Lost topostop days follow up

Uneventful Normal

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.

DISCUSSION

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

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,n,ah et al

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.le

Appendix 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.

REFERENGES

1. Kasai M, Kimura S, Asakura Y, et al. Surgicaltreatment ofbiliary atresia. J Pediatr Surg 1g68; B:

665-675.Suruga K, Komo S, Miyano T, et al. Treatment ofbiliary atresia. Microsurgery for hepatic porto-enterostomy. Surgery 1976; 80: 558-562.Lilly JR, Altman RP. Hepatic portoenterostomy (theKasai operation) for biliary atresia. Surgery 1975;78:76-86.Freund H, Berlatzky Y, Schiller M. The ileocaecalsegment: An antireflux conduit for hepatic porto-enterostomy. J Pediatr Surg 1979; 14:169-171.Kaufman BH, Luck SR, Raffensperger JG. Theevolution of a valved hepato-duodenal-intestinalconduit. J Pediatr Surg 1981; L6:279-283.Endo M, Katsumata K, Yokoyama J, et al. Extendeddissection of the porta-hepatis and creation of anintussuscepted ileo-colic conduit for biliary atresia.J Pediatr Surg 1983; 18:784-793.Lilly JR, Karrer FM. Contemporary surgery forbiliary atresia. Pediatr Clin North Am 1985; 32:1233-t246.Kimura K, Chikara T, Kyoichi O. Choledochal cystetiologic considerations and surgical managementin 22 cases. Arch Surg 1978; 113: 159-163.Chiba T. Bile duct reconstruction with an ileocecalintestinal graft to prevent postoperative ascendingcholangitis. Jpn J Soc Pediatr Surg 1974; 10: 611-618.Freund H, Berlotzkky Y, Schiller M. The ileocecalsegment: An anti-reflux conduit for hepaticportoenterostomy. J Pediatr Surg 1979; 14:169-17L.Kaufman BH, Luck SR, Raffensperger JG:Evolution of a valved intestinal conduit. J PediatrSurg 1981; 16:279-283.Donahoe PK, Hendren WH. Roux-en-Y on-lineintussusception to void ascending cholangitis inBiliary Atresia. Arch Surg 1983; 118: 1091-1094.Reynolds M, Luck SR, Raffensperger JG. The valvedconduit prevents ascending cholangitis: A follow-up. J Pediatr Surg 1985; 20: 696-702.Shin WKT, Zhang JZ. Antirefluxing Roux-en-YBiliary drainage for hepatic portoenterostomy:Animal experiments and clinical experience. JPediatr Surg 1985; 20:689-692.Lilly Jr, Stenllin G. Catheter decompression ofhepatic portocholecystostomy. J Pediatr Surg 1982;17: 904-950.Gupta DK, Rohatgi M. Use of appendix in biliaryatresia. Indian J Pediatr 1989;56: 479-82.Delarue A, Chappuis JP, Esposito C, et al. Is theappendix graft suitable for routine biliary surgeryin children? J Pediatr Surg 2000; 35: 1312-16.Grosfeld JL, Weinberger M, Clatworthy HW.Vascularized appendiceal transplants in Biliary andurinary tract replacement. J Pediatr Surg 1971; 6:630-638.Greenholz SK, Lilly JR, Shikes RH, etatresia in the newborn. J Pediatr SurgLI47-tt48.Weinberg RW. Appendix ureteroplasty.1976; 48:234.

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