Author Affiliation: Department of Surgery,
Stanford University, Stanford, California.
Much (perhaps most) of our day-to-day surgical practice is rooted
in tradition and dogma. Hepatobiliary surgeons around the world routinely
construct their Roux limb in preparation for a biliary anastomosis
at anywhere between 40 cm and 70 cm to prevent reflux of enteric contents
into the biliary tree and thus cholangitis. This practice makes basic
sense and most everybody does it—thus, it is not often questioned.
Felder and colleagues1 challenge
this basic tenet of hepatobiliary surgery. They describe a series
of 70 patients over a decade that required Roux-en-Y hepaticojejunostomy
for a breadth of indications. The authors' practice has been to minimize
the distance between the ligament of Treitz and the enteroenterostomy
and to create a short Roux limb of only 20 cm. With a respectable
median follow-up of 49 months, their rate of complications was comparable
with published series using the more standard Roux length. And, notably,
their rate of cholangitis was very low. Certainly these data are vulnerable
to critics of any retrospective case series. But the authors do not
overanalyze or oversell it. And these data are as good or better than
any of the sparse data supporting the tradition of a longer Roux.
Visser BC. Nullius in VerbaComment on “Hepaticojejunostomy Using Short-Limb Roux-en-Y
Reconstruction”. JAMA Surg. 2013;148(3):257-258. doi:10.1001/jamasurg.2013.626