Plate 137
###### Figure 44

A very small opening related to the size of the pancreatic duct is made into the lumen of the jejunum, and interrupted 00000 or 000000 sutures are placed at both angles (Figure 39). The catheter is rotated to the left while the posterior layer of sutures is placed, and it is then inserted into the lumen of the bowel as the anterior layer of sutures finally is completed. The catheter serves as a stent and makes it easier to place the sutures more accurately through the mucosa of the jejunum as well as the pancreatic duct. When this anastomosis has been completed, the capsule of the pancreas is anchored to the serosa to seal off the raw end of the gland against the wall of the jejunum (Figure 40).

Some prefer to insert the open end of the pancreas into the open end of the jejunum, especially when the pancreatic duct is quite small (Figure 41A). The margins near the cut end of the pancreas should be freed for several centimeters in preparation for telescoping the end of the jejunum over it, and all bleeding points should be ligated carefully. The end of the jejunum is usually large enough to admit the end of the pancreas. If not, it may be necessary to incise the full thickness of the jejunum along the antimesenteric border to make the opening large enough to match easily the size of the end of the pancreas. After all bleeding is controlled, the mucosa of the jejunum is sewed to the capsule of the pancreas in a manner similar to an end-to-end anastomosis. A small, soft rubber catheter can be inserted into the lumen of the pancreatic duct to ensure its patency during the completion of the anastomosis. It is subsequently removed before closure of the gastrojejunostomy. An additional one or two layers of interrupted nonabsorbable sutures are placed to pull the jejunal wall up over the capsule of the pancreas for approximately 1 cm (Figure 41B). The common duct and gastric anastomosis to the jejunum are not altered.

The gastrojejunal anastomosis may be made over the entire length of the gastric outlet, ...

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