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The gallbladder is removed in a routine manner and the liver bed may be closed with interrupted sutures. A noncrushing clamp is applied across the common duct and the duct is divided (Figure 11). The next step is to excise the rest of the duodenum down to and slightly beyond the ligament of Treitz (Plate 134, Figures 27 and 28).

A long arm of jejunum is prepared by dividing several vascular arcades (Figure 12). The mobilized jejunum is brought through an opening made in the mesocolon of the transverse colon (Figure 12). This opening is made at either side of the middle colic vessels, depending upon how easily the jejunal loop can be brought up to the region of the common duct. The jejunum is closed with a running 00 absorbable suture or a stapler, and this layer is inverted with a layer of 00 silk mattress or interrupted sutures. Following a gastrojejunal anastomosis, the jejunal loop is anastomosed without tension to the common duct (Figure 2). Alternatively, some prefer to anastomose the biliary duct to the jejunum, followed by an anastomosis with the gastric pouch (Figure 3). It is not necessary to make the stoma the full width of the stomach. A stoma of 3 to 5 cm can be made at the greater curvature end (Figure 13). The jejunum should be anchored to the entire gastric outlet, regardless of how much has been closed off by sutures. The jejunum between the stomach and the common duct should be quite loose and free of tension (Figure 14). All openings in the mesocolon about the arm of the jejunum should be closed with interrupted sutures to avoid angulation of the arm of jejunum or the possibility of an internal hernia. Closed-system suction catheters made of Silastic are used.

The incision is closed in the routine manner. A subcuticular close of the skin may be used, or the skin may be approximated with interrupted sutures or clips.

Constant gastric suction is maintained until bowel function returns within a few days. Blood sugar levels are determined every 4 to 6 hours until stable control is attained. The amount of insulin may not exceed 25 to 30 units daily in some patients. An insulin drip may be necessary in the initial days after surgery. Blood losses must be replaced. Oral pancreatic replacement therapy is started as soon as tolerated. Frequent nutritional evaluation is essential in postoperative care.

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