Importance
When performing biliary reconstruction, one of the long-standing
tenets of surgery is that Roux-en-Y (RY) reconstruction should use
a long hepatic limb to decrease the risk for postoperative cholangitis.
However, this practice is not well supported and may also make postoperative
biliary endoscopy difficult. While some authors recommend Roux limbs
of up to 75 cm, we have routinely used a Roux length of 20 cm to facilitate
possible postoperative endoscopic access.
Objective
To review our experience with short-limb RY hepaticojejunostomy
(HJ) and examine the short-term and long-term outcomes following this
procedure, as well as the success of future biliary interventions.
Design
Retrospective medical record review of all patients who underwent
short-limb RYHJ by 2 surgeons (N.N.N. and S.D.C.).
Setting
Tertiary care, university-affiliated teaching hospital.
Participants
One hundred patients who underwent RYHJ were identified, with
30 of those patients being excluded owing to creation of an RYHJ to
intrahepatic bile ducts with concomitant liver resection.
Main Outcomes and Measures
Patient records were reviewed to determine the incidence of
postoperative cholangitis and biliary stricture. Secondary outcomes
were the need for postoperative biliary endoscopy and success rates
for endoscopic biliary interventions.
Results
Seventy patients underwent short-limb RYHJ over an 11-year period
(2001-2012). Indications included benign stricture (n = 18),
malignant stricture (n = 12), choledochal cyst (n = 5),
choledocholithiasis (n = 3), idiopathic cholangitis (n = 2),
and deceased donor or live donor liver transplant (n = 30).
Seven patients, including 4 liver transplant patients, developed clinical
or radiographic evidence of postoperative biliary stricture, and all
patients underwent successful endoscopic cholangiography. Four of
these patients required dilation and/or stone extraction, which were
accomplished endoscopically in all cases.
Conclusions and Relevance
Short-limb RYHJ is safe and associated with a low incidence
of postoperative complications. In addition, biliary intervention,
when indicated, can be performed endoscopically with a high degree
of success. In the absence of any evidence demonstrating longer limbs
to be superior, we recommend using short-limb RY reconstruction for
HJ.