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The order of the anastomoses after Whipple's procedure: a proposed alternative

      The restoration of the gastrointestinal tract continuity after Whipple's procedure has been a field of a constant debate among experts. Traditionally, the usual order of the anastomoses after a pancreaticoduodenectomy is as follow: 1. Pancreaticojejunostomy or Pancreaticogastrostomy 2. Gastrojejunostomy and 3. Hepaticojejunostomy. In our department, we routinely prefer the pancreaticogastrostomy over the pancreaticojejunostomy not only for the “soft pancreas” cases. The pancreatic stump after a meticulous mobilization is invaginated into the posterior gastric wall and a two layer end to side pancreaticogastrostomy is performed. However, in regards to the order of the rest of the anastomoses, we have recently altered our followed technique deviating from the classically described procedure. We anastomose the blind jejunal loop firstly with the stomach (gastrojejunostomy) and subsequently we perform the hepaticojejunostomy more distally in the jejunal loop. The rationale behind this approach was to wean patients off the nasogastric tube earlier and manage to recommence oral feeding sooner in the postoperative period as the stomach is not, at least theoretically, burdened with the bile that the traditional order of the anastomoses would prerequisite. Indeed, we have performed our altered technique in nine consecutive cases and the initial, uncalibrated however, results are at least encouraging. Certainly, appropriate testing of the technique within a properly designed controlled randomized study is definitely needed before more accurate conclusions could be drawn.