Plate 137

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, or the outlet may be partly closed and the stoma limited in size. The full thickness of the gastric wall, including the staples, is excised to provide a stoma three to four fingers wide (Figure 42). Any retained gastric contents are aspirated, and all bleeding points in the mucosa of the gastric wall are controlled. The serosa of the jejunum near the mesenteric border then is anchored to the posterior wall of the stomach from one curvature to the other with 000 silk (Figure 43). The jejunum should be approximated loosely so that there is some laxity between the anastomosis of the pancreas and the gastric wall in the region of the lesser curvature. An opening about two fingers wide is made in the jejunum, and the gastrojejunal mucosa is approximated with interrupted 0000 absorbable sutures (Figure 43). The gastrojejunal anastomosis is then completed with a layer of interrupted 0000 nonabsorbable sutures, with the knots buried on the inside. The second layer of the gastrojejunal anastomosis is then completed with a layer of interrupted 000 sutures from one curvature to the other (Figure 44). The opening in the mesocolon should be approximated to the jejunal wall (Figure 44) to prevent prolapse of small bowel up through this opening. The opening about the region of the ligament of Treitz should be closed with ooo silk. A gastrostomy tube and feeding jejunostomy may be indicated in the malnourished patient. Closed-suction drains are placed adjacent to the choledochojejunostomy and pancreaticojejunostomy.

The abdominal wall is closed in the routine manner. In the presence of emaciation or in the older age group, it may be advisable to close the fascia with figure-of-eight stitch or by the addition of numerous retention sutures.

It is of paramount importance, especially in the jaundiced patient, to make certain that the blood volume is restored at all times. Fluid balance is sustained by administration of 5% Ringer's lactate solution. Blood sugar and amylase levels are obtained. The hourly urine output should be watched carefully and should be maintained at 30 to 40 mL/h. The administration of intravenous fluids should be balanced throughout the 24-hour period. Urinary output and the replacement of gastric drainage will determine the amount of fluids required.

The patient's weight must be watched carefully, and an adequate daily caloric and vitamin intake assured. Blood sugar levels should be determined at regular intervals. If a feeding jejunostomy tube has been inserted, tube feedings by continuous infusion may be started 24 to 48 hours after surgery. Initial infusion rate should be slow and gradually increased. The output from the closed suction drains should be monitored and determination of amylase concentration performed after starting oral intake, usually 5 to 7 days after surgery. The drains are removed if there is no bile in the drain fluid and if the amylase is less than that of serum.