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Invited Critique
March 2013

Nullius in Verba: Comment on “Hepaticojejunostomy Using Short-Limb Roux-en-Y Reconstruction”

Author Affiliations

Author Affiliation: Department of Surgery, Stanford University, Stanford, California.

JAMA Surg. 2013;148(3):257-258. doi:10.1001/jamasurg.2013.626

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.

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