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Restoring one way traffic across the Roux loop: The Nakajo value
Ann Hepatobiliary Pancreat Surg 2018 Feb;22(1):90-2
Published online February 28, 2018
Copyright © 2018 Ann Hepatobiliary Pancreat Surg.

Ashwin Rammohan1, Sripriya Srinivas1, Yahya Al Azri2, Mettu Srinivas Reddy1, and Mohamed Rela1,3

1The Institute of Liver Disease & Transplantation, Global Hospitals & Health City, Chennai, India, 2Department of Hepatobiliary Pancreatic Surgery & Transplantation, Ministry of Health, Muscat, Oman, 3Institute of Liver Studies, King’s College Hospital, London, UK
Received October 13, 2017; Revised October 21, 2017; Accepted October 23, 2017.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Roux-en-Y (RY) hepaticojejunostomy (HJ) is a critical component of complex hepatobiliary operations, and it is the treatment of choice for post-cholecystectomy biliary strictures (PCBS). Complications related to the Roux limb, particularly those leading to cholangitis, can severely compromise outcomes. We present a case of a 54-year-old lady who had previously undergone two HJ procedures for recurrent PCBS. The same Roux limb had been used in each of the operations. Short Roux/Roux reflux syndrome led to recurrent cholangitis in this patient, as proven by the reflux of oral contrast into the biliary tree on imaging. This was effectively treated by lengthening the Roux limb (60 cm) with a redo-jejunojejunostomy, and creation of a Nakajo type valve. One-year post surgery, the patient remains well at follow-up. Enteric reflux into the biliary tree may lead to refractory cholangitis. We present the first ever case in an adult, where a simple and effective modification to the HJ obviated this complication. (Ann Hepatobiliary Pancreat Surg 2018;22:90-92)
Keywords : Biliary strictures; Roux-en-Y anastomosis; Cholangitis; Nakajo valve


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