Hepaticojejunostomy using short-limb roux-en-Y reconstruction

Importance: When performing biliary reconstruction, one of the long-standing tenets of surgery is that Rouxen- 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 shortterm 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.