INTERPOSED JEJUNAL SEGMENT WITH NIPPLE VALVE TO PREVENT REFLUX IN BILIARY RECONSTRUCTION

BACKGROUND: Resection is the accepted management of a choledochal cyst . However, the debate continues regarding the optimal method of biliar y reconstruction. The Roux-en-Y limb is used most frequently, but conc erns have been raised about this method due to associated peptic ulcer disease, cholangitis, and poor growth. A method of reconstruction usi ng an interposed segment of jejunum with a nipple valve placed between the common bile duct and the duodenum has been proposed. STUDY DESIGN : We have reviewed a series of 12 children requiring biliary reconstru ction for choledochal cyst (11 children) and biliary stricture (one ch ild). All had reconstruction with a nipple valve, and ten had an inter posed segment of jejunum. RESULTS: Ah of the children are alive and ha ve had follow-up evaluation from six months to 8.5 years (median of th ree years). Sequential examinations with ultrasound and biliary excret ion scans have shown no evidence of obstruction, and liver function te sts have remained normal. Three children have had cholangitis. One chi ld had a brief episode in the perioperative period. The second child h ad cholangitis 16 months postoperatively, and the third child had mult iple episodes of cholangitis. These latter two children were unique. O ne had Alonso-Lej type IV choledochal cyst with intrahepatic dilatatio n, which persisted after reconstruction. The other had a prior diversi on with a Roux-en-Y limb from the gallbladder after resection of a cho ledochal cyst and had multiple episodes of cholangitis before reconstr uction. These episodes are now controlled with chronic antibiotic supp ression. Postoperative complications were limited to two episodes of o bstruction of the small bowel requiring lysis of adhesions. No child h as had peptic ulcer disease. These children have grown well after reco nstruction, except for three with multiple anomalies or chronic pancre atitis. CONCLUSIONS: Biliary reconstruction with a jejunal interpositi on containing a nipple valve can be performed safely with a low incide nce of complications. It offers a more physiologic method of reconstru ction and a low incidence of postoperative cholangitis.