Is the appendix graft suitable for routine biliary surgery in children?

• Published in: Journal of pediatric surgery Vol. 35; no. 9; pp. 1312 - 1316
• Main Authors: Delarue, A., Chappuis, J.P., Esposito, C., Valla, J.S., Bonnevalle, M., Allal, H., Robert, M.
• Format: Journal Article Conference Proceeding
• Language: English
• Published: Philadelphia, PA Elsevier Inc 01.09.2000; Elsevier
• Subjects: Adolescent; Appendix - transplantation; Appendix graft; biliary atresia; Biliary Atresia - surgery; Biliary Tract Diseases - surgery; biliary trauma; Biological and medical sciences; Child, Preschool; choledochal cyst; Choledochal Cyst - surgery; Common Bile Duct - injuries; Europe - epidemiology; Female; France - epidemiology; Gastroenterology. Liver. Pancreas. Abdomen; Humans; Infant; Liver, biliary tract, pancreas, portal circulation, spleen; Liver. Biliary tract. Portal circulation. Exocrine pancreas; Male; Medical sciences; Other diseases. Semiology; Postoperative Complications - epidemiology; Postoperative Complications - mortality; Reconstructive Surgical Procedures - methods; Reoperation; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the digestive system; Treatment Outcome; France; Europe; biliary atresia; choledochal cyst; Appendix graft; biliary trauma; Human; Reconstruction; Indication; Multicenter study; Plastic surgery; Biliary tract disease; Appendix; Retrospective; Treatment; Surgery; Digestive diseases; Graft; Safety; Technique; Child
• DOI: 10.1053/jpsu.2000.9313
• ISSN: 0022-3468

Background/Purpose: The appendix graft (AG) is used widely for urinary tract replacement in children. Biliary tract replacement is less common. The purpose of this retrospective multicentric study was to evaluate the safety of appendix grafting for biliary reconstruction. Methods: The files of 33 patients treated at 7 European pediatric centers were reviewed. Indications included choledochal cyst (CC) in 5 cases, biliary trauma (BT) in 1, and biliary atresia (BA) in 27. In CC and BT patients, the graft was inserted isoperistaltically between the proximal biliary duct and second duodenum. In all but one of the BA patients, the graft was placed antiperistaltically by patching its cecal end onto the porta hepatis. Results: Postoperatively, all CC and BT patients initially became asymptomatic but developed laboratory evidence of anicteric cholestasis within 1 year. The most common manifestation was increased gamma-glutamyl-transpeptidase level (GGT), whereas histologic findings showed liver damage (mainly fibrosis). Reoperation has been carried out in 4 CC and 1 BT patients within a mean period of 19 months after appendix grafting. The graft procedure was converted to hepaticojejunostomy (HJ) in 4 and to choledocoduodenostomy in 1. Surgical exploration showed kinking in 1 patient and stenosis in 1. In the remaining 3 cases, there was no discernible cause of cholestasis, and appendix histology findings were normal. In all 5 reoperated patients, liver function findings returned to normal within 1 month. Reoperation is scheduled for the remaining CC patient who currently requires ursodesoxycholic medication to maintain normal liver function and presents histologic evidence of “de novo” sclerosing cholangitis. Results of appendix grafting also were poor in the 27 BA patients. Procedure-related perioperative complications occurred in 4 (15%) including 1 early death from graft necrosis. Another early death resulted from intestinal hemorrhage. Jaundice cleared in only 8 (28%). Conclusions: The findings of this study suggest that the AG is unsuitable for routine biliary repair in children. It should be used only as a salvage technique when conventional HJ repair is contraindicated. Because of the high risk of graft dysfunction, we recommend screening tests to detect biochemical or histologic cholestasis in any patient previously treated with appendix grafting. J Pediatr Surg 35:1312-1316. Copyright © 2000 by W.B. Saunders Company.