The diagrams in Figures 32A and 32B outline two of the many variations of reconstruction after removal of the duodenum and head of the pancreas that have been developed. When total pancreatectomy is performed, only the common duct and end of the stomach, or the first portion of the duodenum if the entire stomach is preserved, are anastomosed to the Roux-en-Y arm of the jejunum. The bile and pancreatic ducts are arranged to empty their alkaline juices into the jejunum before the acid gastric juice as a measure of protection against peptic ulceration. The mobilized jejunum can be used safely in a variety of ways for the several anastomoses required. The end of the jejunum can be closed and anchored up into the region of the gallbladder bed, followed by direct anastomosis with the dilated common duct and pancreatic duct within a very short distance of the closed end of the jejunum. The jejunum is then anastomosed to the partly closed end of the gastric pouch (Figure 32A). Some prefer to implant the open end of the pancreas directly into the open end of the jejunum (Figure 32B). Unless the pancreatic duct is quite large, this is perhaps a simpler procedure than that in Figure 32A. Alternatively, a pancreaticogastrostomy may be performed. The common duct then is anastomosed to the jejunum and at an easy point of approximation to the stomach. Figures 33 and 34 demonstrate details of the technique shown in Figure 32A. The end of the jejunum then should be anchored to the tissues medial to the common duct or even up into the lower portion of the closed liver bed. Great care should be taken, however, that sutures do not include the right hepatic artery, which may curve upward into this area. The end of the common duct is then anchored with interrupted 0000 sutures to the serosa of the jejunum. Sutures of 0000 size are used to fix either side of the end of the common duct to maintain the wall under slight tension as a row of interrupted sutures is placed to anchor it to the serosa of the jejunum. The fixed angle sutures are allowed to remain for traction (Figure 33), while an incision is made into the adjacent jejunal wall a little shorter than the diameter of the lumen of the common duct (Figure 33). A series of interrupted 4-0 or 5-0 absorbable sutures is used to accurately approximate the mucosa of the jejunum to the common duct. Placement of the interrupted sutures in the closure of the anterior layer is then performed (Figure 34). The catheter also ensures a sizable stoma. This is a single-layer anastomosis. The peritoneum, which tends to be thickened over the region of the common duct, is anchored with interrupted sutures to the serosa of the jejunum, starting beyond the angles of the anastomosis and extending anteriorly parallel with the anastomosis (Figure 35), which holds the divided end of the pancreas (Figure 36). The posterior capsule of the pancreas is anchored with interrupted 000 sutures to the serosa of the jejunum (Figure 37). There should be no tension and preferably some redundancy of the jejunum between the several sites of anastomosis. The patency and size of the pancreatic duct are determined by inserting a soft rubber catheter. With the catheter in place to serve as a stent, the margins of the duct are freed for a short distance to facilitate an accurate anastomosis to the jejunal mucosa (Figure 38).