title: Hepaticojejunostomy using short-limb Roux-en-Y reconstruction.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  Retrospective medical record review of all patients who underwent short-limb RYHJ by 2 surgeons (N.N.N. and S.D.C.).
  
  
  METHODS
  Tertiary care, university-affiliated teaching hospital.
  
  
  METHODS
  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.
  
  
  METHODS
  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
  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.
authors.affiliation: Division of Transplantation, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA.
authors.forename: Seth I
authors.initials: SI
authors.lastname: Felder
authors.forename: Vijay G
authors.initials: VG
authors.lastname: Menon
authors.forename: Nicholas N
authors.initials: NN
authors.lastname: Nissen
authors.forename: Daniel R
authors.initials: DR
authors.lastname: Margulies
authors.forename: Simon
authors.initials: S
authors.lastname: Lo
authors.forename: Steven D
authors.initials: SD
authors.lastname: Colquhoun
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000713:Anastomosis, Roux-en-Y / Q000379:methods*; D002648:Child; D005260:Female; D006500:Hepatic Duct, Common / Q000601:surgery*; D006801:Humans; D007582:Jejunostomy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult