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Is the appendix graft suitable for routine biliary surgery in children?
A Delarue1, J P Chappuis, C Esposito
1Service de Chirurgie Pédiatrique, Hôpital d'Enfants de la Timone, Marseille, France.
Insights
Appendix grafting (AG) is not recommended for routine pediatric biliary reconstruction due to high rates of graft dysfunction and complications. AG should be reserved as a salvage technique, and patients require monitoring for cholestasis.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Hepatobiliary Surgery
Background:
- The appendix graft (AG) is commonly used for urinary tract reconstruction in children.
- Its application in biliary tract replacement is less frequent and its safety profile is not well-established.
Purpose of the Study:
- To evaluate the safety and efficacy of appendix grafting for biliary reconstruction in pediatric patients.
- To assess the long-term outcomes and complications associated with AG in biliary surgery.
Main Methods:
- Retrospective multicenter study reviewing 33 pediatric patients from 7 European centers.
- Indications included choledochal cyst (CC), biliary trauma (BT), and biliary atresia (BA).
- Graft insertion techniques varied based on indication: isoperistaltic for CC/BT, antiperistaltic for BA.
Main Results:
- Patients with CC and BT developed cholestasis within a year, requiring reoperation in 5 cases (4 converted to hepaticojejunostomy).
- Appendix grafting in biliary atresia patients showed poor outcomes, with 15% perioperative complications including graft necrosis and intestinal hemorrhage.
- Only 28% of biliary atresia patients achieved jaundice clearance.
Conclusions:
- Appendix grafting is unsuitable for routine pediatric biliary repair and should be a salvage option only when conventional hepaticojejunostomy is contraindicated.
- High risk of graft dysfunction necessitates screening for biochemical or histologic cholestasis in all patients who have undergone AG for biliary reconstruction.
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.