Colorectal Quiz: Episode 43
With Dr. Jeffrey Avanzino & Dr. Mark Levitt & Dr. Jason Frischer & Dr. Hira Ahmad · hosted by Dr. Philippa Jalus · Marc Levitt
Cued at 14:44 · stops at 15:29 · press play
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
About 60% of the time there is success with using a split appendix for both Malone and Mitrofanoff; about 40% of the time you cannot make it work.
Flow of fluid through a tube is based on Poiseuille's law: radius to the fourth power and length. A longer appendix or narrower appendix affects flow probability.
In a study of 10 malones done in a row without plicating, five leaked, leading to the decision to plicate all malones.
The longer the appendix, the less likely it will leak and you should not need to plicate.
Plicating all malones is a very effective strategy; no leakage has occurred in several years using this approach.
If appendix is short and stumpy, it is best for the Malone and the Mitrofanoff should be made from small bowel.
If appendix is five to seven centimeters, that is not enough to share and should go for the Mitrofanoff because long term the Mitrofanovs do much better, requiring a neo-Malone.
If appendix is seven centimeters or greater it can be split, requiring minimum two centimeters for Malone and five centimeters minimum for Mitrofanoff.
For patients with appendix 4-7 centimeters, 90% of appendix can be given to urologist with extension of appendiceal stump into cecum using non-cutting endo-TA stapler or hand-sewn non-absorbable braided suture.
Wrapping technique depends on mesentery appearance: broad-based mesentery allows making a window and wrapping through it; adherent single-vessel mesentery allows laying down and wrapping cecum around appendix.
When mesentery parallels the appendix, wrap cecum around appendix like a fundoplication; when mesentery is fenestrated, make one window at the bottom and plicate through that window to avoid crunching the mesentery.
Pay attention to ileocecal valve location when creating Malone and plication to avoid obstruction at the ileocecal valve.
Small bowel volvulus around the appendix has been seen in two or three cases.
Cecum should be positioned underneath the umbilicus without leaving a long-stemmed appendix hanging to reduce volvulus risk.
When doing a neo-Malone, orient the channel so the catheter will enter into the right colon rather than refluxing into the ileum.
If patient is not doing well with flushes or getting significant symptoms like nausea, a contrast study through the Malone should be done to check for reflux into the terminal ileum.
During plication, pass the tube after every stitch to ensure it passes in the desired direction.
Using a 10 French coude catheter as a bougie during plication and checking passage afterward usually prevents single offending stitch problems.
Using a 10 French tube instead of 8, leaving it in for a month, and cathing twice a day has reduced the incidence of stenosis.
Leaving tubes in prevents stenosis but increases the chance of leakage because the valve is no longer as pertinent with a stent across it.
Prolonged stenting increases prolapse rate due to pressure on the appendiceal base pushing up mucosa.
Urologists almost never get stenosis of Mitrofanoff because they cath every four hours; cathing the Malone twice a day has reduced stenosis rate.
For recurrent leakage after two wraps, consider whether appendix length is a problem and whether channel needs lengthening.
Lone Star ring and pins can be placed in umbilicus to get exposure and visualize the Malone hole for catheterization.
Blowing up a balloon on Foley catheter to occlude umbilicus and injecting dye creates pressurized system that will find any micro-hole tract still present.
Ultrasound can be used to find the appendix around the umbilicus, then needle-localize the lumen ultrasound-guided to rescue malones.
Appendicitis in a Malone is impossible unless the hole closes, because there is no obstruction in the pathophysiology.
Appendix should not be removed in first Crohn's or ARM patients, kids with spine issues, absent sacrum, or spina bifida because they may need it for future Malone or Mitrofanoff.
In South Africa, appendix is never taken out as part of laparoscopic appendectomy; it is a United States practice.
Appendix tissue should always be sent to pathology during Malone creation; one case had a carcinoid (neuroendocrine tumor) discovered three months later.
Stricture occurs in 17 to 20% of patients after Malone procedure regardless of approach.
A neo-Malone does just as well as a Malone, so if you can only use the appendix for one channel it should be the Mitrofanoff because an appendix-based Mitrofanoff does much better than a small bowel Monty.
Visualizing a floppy cecum with laparoscope means checking alignment of Treitz ligament before completing case to rule out malrotation.
Most patients (80-90%) do not have any problems post-procedure; only 10 to 20% will have issues with their Malone.