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It may be necessary to resect additional stomach to be certain that all of the antrum has been removed. A noncrushing clamp is applied across the gastric pouch to control bleeding and prevent gross soiling, as well as to fix the gastric wall for the placement of sutures (Figure 7). A two-layer anastomosis, end of stomach to side of jejunum, is made with the full width of the gastric outlet (Figure 8). The end of the jejunum should not extend more than 2 cm beyond the anastomosis (Figure 9). All openings in the mesocolon are closed with interrupted sutures to avoid a possible internal hernia and avoid a twist or angulation of the arm of jejunum.

A jejunojejunal anastomosis is done at least 40 cm from the gastrojejunal anastomosis (Figure 10). A two-layer anastomosis is performed, and all openings in the mesenteries are closed to avoid any chance of herniation or obstruction about the anastomosis (Figure 11). A long Levin tube is directed through the anastomosis and may be directed around into the duodenum to ensure decompression of the duodenal stump. Some prefer to perform a temporary gastrostomy, provided the gastric pouch can be attached easily to the overlying peritoneum. The gallbladder, if present, should be compressed to confirm the patency of the ductal system following the procedure. After a thorough search for needles, instruments, and sponges, and affirming a correct count, the abdomen is closed.

The abdominal incision is closed in the routine manner.

The calculated blood losses are replaced, and fluid and electrolyte balance maintained. Systemic antibiotics may be given. The intubation is retained until adequate bowel activity has resumed. Clear liquids followed by six small feedings a day are gradually permitted since slow gastric emptying is often a problem. Careful medical supervision is required to ensure a good result.

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