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Modification of the Roux-en-Y Procedure
Modification of the Roux-en-Y Procedure KENNETH
w.
WARREN, M.D.
The Roux-en-Y procedure was conceived and applied for the purpose of diverting the bile or other upper gastrointestinal contents to a lower segment of the jejunum in a fashion to minimize or prevent reflux of the gastrointestinal contents into the liver or the pancreas or other organs. This procedure has many advocates, and it is certainly ingenious and works well in many instances. It is a more demanding procedure than an end-to-side cholecystojejunostomy or hepaticojejunostomy in that it involves the division of the mesentery. Another hazard of the Roux-en-Y procedure which is not generally appreciated is that it is possible to attach the wrong end of the divided upper jejunum to the gallbladder or common bile duct. This directs the flow of food and gastric and duodenal contents directly into the biliary system. Although this occurs infrequently, we have seen several patients in whom this mistake has been made. Another disadvantage of the Roux-en-Y procedure is that many surgeons do not appreciate that the diverting limb of the upper jejunum must be at least 16 inches in length in order to prevent reflux of gastrointestinal contents into the biliary system. In a large experience with secondary operations in which the Roux-en-Y procedure had been performed on patients who were subsequently referred to the Lahey Clinic, it has been our observation that the diverting limb almost never was 16 inches in length. Experimental work has been done showing the necessity of using such a long limb of jejunum in order to prevent reflux. Since it is possible to perform a cholecystojejunostomy or a choledochojejunostomy utilizing a loop of jejunum without dividing the mesentery and since the opening which is made in the loop of jejunum can be fashioned to fit the caliber of the fundus of the gallbladder or the choledochus, it has been customary at this clinic to employ this type of procedure and to utilize an entero-enterostomy to minimize or prevent the reflux of gastrointestinal contents into the biliary system. This procedure has also given satisfactory results. It has the same disadvantage with respect to the length of the diverting loop and also the hazard that some or most of the gastrointestinal contents continue to flow past the anastomosis of the jejunum to the gallbladder or common duct despite the entero-enterostomy. 611
612
KENNETH W. WARREN
It has been our feeling, and many surgeons agree, that it is the caliber of the opening which determines whether or not cholangitis will develop rather than whether or not a Roux-en-Y procedure or an end-to-side anastomosis between the biliary tract and jejunum was employed. For several years I employed a very simple modification of the Rouxen-Y procedure. If a cholecystojejunostomy is to be performed, the loop of proximal jejunum is brought anterior to the hepatic flexure of the colon, utilizing a sufficient length of the jejunum to prevent any tension upon the anastomosis. The jejunum is then anastomosed to the gallbladder, or to the common bile duct in continuity and occasionally to the common duct following division of the choledochus. This procedure is usually accomplished by a row of interrupted sutures of fine silk for the seromuscular coat and then a layer of interrupted sutures of fine chromic catgut. The anterior aspect of the anastomosis is reinforced by interrupted sutures of fine silk. An entero-enterostomy is then performed. The opening in the proximal loop of jejunum is made within 2 inches of the previously fashioned cholecystojejunostomy or choledochojejunostomy, and the opening in the limb of jejunum distal to the cholecystojejunostomy or choledochojejunostomy is made at a point 16 inches beyond the previous anastomosis. This entero-enterostomy is made in the usual fashion, utilizing interrupted sutures of fine black silk for the seromuscular coat and a continuous interlocking suture of fine chromic catgut for the posterior row, continued anteriorly after the fashion of Connell. The anterior part of the entero-enterostomy is reinforced with interrupted sutures of fine silk. In order to secure the physiologic advantages of the Roux-en-Y procedure without the hazard of dividing the mesentery of the jejunum, the proximal limb of the jejunum between the entero-enterostomy and the cholecystojejunostomy or choledochojejunostomy is then occluded by placing interrupted sutures of fine silk through both walls of the jejunum. These are tied loosely as mattress sutures in such fashion as to occlude completely the proximal limb of the jejunum at this site. Great care is taken not to strangulate the tissue included in these mattress sutures. Thus, the gastrointestinal contents are forced through the entero-enterostomy and can reflux into the biliary system only by antiperistaltic activity. Since the distal limb extending from the cholecystojejunostomy or choleclochojejunostomy to the entero-enterostomy is 16 inches long, very little if any of the gastric contents will reflux into the biliary system (Fig. 1). We have had no complications from this procedure. It is a simpler procedure than the classical Roux-en-Y and it may have some merit. The ultimate result probably depends upon the maintenance of sufficient caliber of the anastomosis between the biliary tree and the jejunum more than upon the occlusion of the proximal limb. The only possibility of error in this regard is that the surgeon might occlude the distal rather than the proximal limb. Considerable care is always observed to prevent such an error.
MODIFICATION OF THE ROUX-EN-Y PROCEDURE
613
Figure 1. Loop cholecystojejunostomy with diverting entero-enteroRtomy and occlusion of the proximal limb of the jejunum between the entero-enterostomy and the choledochojejunostomy by a series of fine silk mattress sutures.
The same procedure is employed in total gastrectomy and is performed in the same fashion except that the entero-enterostomy is made much larger in order to act as a modified reservoir. This procedure is probably more valuable in total gastrectomy than it is in decompression of the biliary tree (Fig. 2). At this clinic we frequently decompress the duct of Wirsung or a pancreatic cyst by anastomosis of the duct of Wirsung or the cyst to a loop of jejunum. Here again the same procedure can be employed, It should be emphasized that the length of the loop of jejunum employed, regardless of whether it is the classical Roux-en-Y or the modification described in this paper, is more important than the choice of the procedure. Very fine suture material should be used on the milliner's needle if the mattress suture is to be employed to occlude the proximal
614
KENNETH W. WARREN
Figure 2. Loop end-to-side esophagojejunostomy with a long entero-enterostomy and occlusion of the proximal limb of the jejunum between the entero-enterostomy and the esophagojejunostomy on the proximal side. Thus, the gastrointestinal contents, the bile and the pancreatic secretions are forced through the entero-enterostomy and can reach the esophagus only by reflux. Since the distal limb between the esophagojejunostomy and the entero-enterostomy is 16 inches in length, reflux is minimal.
limb of the jejunum. Occlusion of the proximal limb should never be performed with a gross ligature. Our interest in publishing this simple modification of the Roux-en-Y procedure was occasioned by several observations. Within a period of 24 hours, I operated on two patients who had had a Roux-en-Y procedure performed to relieve obstruction of the biliary tract. In one instance the proximal limb of the jejunum had been anastomosed to the gallbladder, and in the other the proximal limb of the jejunum approximately 12 inches beyond the ligament of Treitz had been completely closed by inverting the stump. The patient obviously had complete obstruction of the jejunum
MODIFICATION OF THE ROUX-EN-Y PROCEDURE
615
and required a reconstruction of the originally planned Roux-en-Y enteroenterostomy. I would not like to convey the impression that this procedure is done routinely. I employ it in every case of total gastrectomy, but many patients who require decompression of the obstructed biliary tract have an end-toside cholecystojejunostomy or choledochojejunostomy and a diverting entero-enterostomy.
CONCLUSION
A simple modification of the Roux-en-Y procedure is described. When this modification is employed, the necessity of dividing the mesentery of the jejunum is avoided, and the possibility of attaching the wrong limb of the divided jejunum to the biliary tract, esophagus or pancreas is mini- . mized. It is emphasized that, regardless of whether the classical Roux-en-Y or this modification is employed, the distal limb of the jejunum should be 16 inches in order to minimize reflux. It is also my conviction that the patency of the cholecystojejunostomy, choledochojejunostomy, pancreaticojejunostomy or esophagojejunostomy is much more important than the utilization of the Roux-en-Y or this modification.
w.
WARREN, M.D.
The Roux-en-Y procedure was conceived and applied for the purpose of diverting the bile or other upper gastrointestinal contents to a lower segment of the jejunum in a fashion to minimize or prevent reflux of the gastrointestinal contents into the liver or the pancreas or other organs. This procedure has many advocates, and it is certainly ingenious and works well in many instances. It is a more demanding procedure than an end-to-side cholecystojejunostomy or hepaticojejunostomy in that it involves the division of the mesentery. Another hazard of the Roux-en-Y procedure which is not generally appreciated is that it is possible to attach the wrong end of the divided upper jejunum to the gallbladder or common bile duct. This directs the flow of food and gastric and duodenal contents directly into the biliary system. Although this occurs infrequently, we have seen several patients in whom this mistake has been made. Another disadvantage of the Roux-en-Y procedure is that many surgeons do not appreciate that the diverting limb of the upper jejunum must be at least 16 inches in length in order to prevent reflux of gastrointestinal contents into the biliary system. In a large experience with secondary operations in which the Roux-en-Y procedure had been performed on patients who were subsequently referred to the Lahey Clinic, it has been our observation that the diverting limb almost never was 16 inches in length. Experimental work has been done showing the necessity of using such a long limb of jejunum in order to prevent reflux. Since it is possible to perform a cholecystojejunostomy or a choledochojejunostomy utilizing a loop of jejunum without dividing the mesentery and since the opening which is made in the loop of jejunum can be fashioned to fit the caliber of the fundus of the gallbladder or the choledochus, it has been customary at this clinic to employ this type of procedure and to utilize an entero-enterostomy to minimize or prevent the reflux of gastrointestinal contents into the biliary system. This procedure has also given satisfactory results. It has the same disadvantage with respect to the length of the diverting loop and also the hazard that some or most of the gastrointestinal contents continue to flow past the anastomosis of the jejunum to the gallbladder or common duct despite the entero-enterostomy. 611
612
KENNETH W. WARREN
It has been our feeling, and many surgeons agree, that it is the caliber of the opening which determines whether or not cholangitis will develop rather than whether or not a Roux-en-Y procedure or an end-to-side anastomosis between the biliary tract and jejunum was employed. For several years I employed a very simple modification of the Rouxen-Y procedure. If a cholecystojejunostomy is to be performed, the loop of proximal jejunum is brought anterior to the hepatic flexure of the colon, utilizing a sufficient length of the jejunum to prevent any tension upon the anastomosis. The jejunum is then anastomosed to the gallbladder, or to the common bile duct in continuity and occasionally to the common duct following division of the choledochus. This procedure is usually accomplished by a row of interrupted sutures of fine silk for the seromuscular coat and then a layer of interrupted sutures of fine chromic catgut. The anterior aspect of the anastomosis is reinforced by interrupted sutures of fine silk. An entero-enterostomy is then performed. The opening in the proximal loop of jejunum is made within 2 inches of the previously fashioned cholecystojejunostomy or choledochojejunostomy, and the opening in the limb of jejunum distal to the cholecystojejunostomy or choledochojejunostomy is made at a point 16 inches beyond the previous anastomosis. This entero-enterostomy is made in the usual fashion, utilizing interrupted sutures of fine black silk for the seromuscular coat and a continuous interlocking suture of fine chromic catgut for the posterior row, continued anteriorly after the fashion of Connell. The anterior part of the entero-enterostomy is reinforced with interrupted sutures of fine silk. In order to secure the physiologic advantages of the Roux-en-Y procedure without the hazard of dividing the mesentery of the jejunum, the proximal limb of the jejunum between the entero-enterostomy and the cholecystojejunostomy or choledochojejunostomy is then occluded by placing interrupted sutures of fine silk through both walls of the jejunum. These are tied loosely as mattress sutures in such fashion as to occlude completely the proximal limb of the jejunum at this site. Great care is taken not to strangulate the tissue included in these mattress sutures. Thus, the gastrointestinal contents are forced through the entero-enterostomy and can reflux into the biliary system only by antiperistaltic activity. Since the distal limb extending from the cholecystojejunostomy or choleclochojejunostomy to the entero-enterostomy is 16 inches long, very little if any of the gastric contents will reflux into the biliary system (Fig. 1). We have had no complications from this procedure. It is a simpler procedure than the classical Roux-en-Y and it may have some merit. The ultimate result probably depends upon the maintenance of sufficient caliber of the anastomosis between the biliary tree and the jejunum more than upon the occlusion of the proximal limb. The only possibility of error in this regard is that the surgeon might occlude the distal rather than the proximal limb. Considerable care is always observed to prevent such an error.
MODIFICATION OF THE ROUX-EN-Y PROCEDURE
613
Figure 1. Loop cholecystojejunostomy with diverting entero-enteroRtomy and occlusion of the proximal limb of the jejunum between the entero-enterostomy and the choledochojejunostomy by a series of fine silk mattress sutures.
The same procedure is employed in total gastrectomy and is performed in the same fashion except that the entero-enterostomy is made much larger in order to act as a modified reservoir. This procedure is probably more valuable in total gastrectomy than it is in decompression of the biliary tree (Fig. 2). At this clinic we frequently decompress the duct of Wirsung or a pancreatic cyst by anastomosis of the duct of Wirsung or the cyst to a loop of jejunum. Here again the same procedure can be employed, It should be emphasized that the length of the loop of jejunum employed, regardless of whether it is the classical Roux-en-Y or the modification described in this paper, is more important than the choice of the procedure. Very fine suture material should be used on the milliner's needle if the mattress suture is to be employed to occlude the proximal
614
KENNETH W. WARREN
Figure 2. Loop end-to-side esophagojejunostomy with a long entero-enterostomy and occlusion of the proximal limb of the jejunum between the entero-enterostomy and the esophagojejunostomy on the proximal side. Thus, the gastrointestinal contents, the bile and the pancreatic secretions are forced through the entero-enterostomy and can reach the esophagus only by reflux. Since the distal limb between the esophagojejunostomy and the entero-enterostomy is 16 inches in length, reflux is minimal.
limb of the jejunum. Occlusion of the proximal limb should never be performed with a gross ligature. Our interest in publishing this simple modification of the Roux-en-Y procedure was occasioned by several observations. Within a period of 24 hours, I operated on two patients who had had a Roux-en-Y procedure performed to relieve obstruction of the biliary tract. In one instance the proximal limb of the jejunum had been anastomosed to the gallbladder, and in the other the proximal limb of the jejunum approximately 12 inches beyond the ligament of Treitz had been completely closed by inverting the stump. The patient obviously had complete obstruction of the jejunum
MODIFICATION OF THE ROUX-EN-Y PROCEDURE
615
and required a reconstruction of the originally planned Roux-en-Y enteroenterostomy. I would not like to convey the impression that this procedure is done routinely. I employ it in every case of total gastrectomy, but many patients who require decompression of the obstructed biliary tract have an end-toside cholecystojejunostomy or choledochojejunostomy and a diverting entero-enterostomy.
CONCLUSION
A simple modification of the Roux-en-Y procedure is described. When this modification is employed, the necessity of dividing the mesentery of the jejunum is avoided, and the possibility of attaching the wrong limb of the divided jejunum to the biliary tract, esophagus or pancreas is mini- . mized. It is emphasized that, regardless of whether the classical Roux-en-Y or this modification is employed, the distal limb of the jejunum should be 16 inches in order to minimize reflux. It is also my conviction that the patency of the cholecystojejunostomy, choledochojejunostomy, pancreaticojejunostomy or esophagojejunostomy is much more important than the utilization of the Roux-en-Y or this modification.