The upper jejunum was transected after division and ligation of duodeno-jejunal mesenteric flexure. The second (D2) and third (D3) part of the duodenum were divided carefully from the parenchyma of the head of the pancreas. Haemostasis was achieved via mono/bipolar diathermy and single haemostatic sutures of the pancreatic tissue. In three cases D2 was dissected 1 cm below the papilla of Vater (Figure

1a). In the remainder, both duodenal bulb and D2 were removed. In these latter two cases an anastamosis was formed between the isolated ampulla (Figure 1b) or surrounding mucosal patch to the side of a jejunal loop (Figure 1c). This was performed using absorbable polyfilament 4/0 interrupted sutures (Figure 1b,c). Figure 1 Lacerations of D2-3 or D1-2-3 parts PD-0332991 in vitro of duodenum not suitable for reconstruction with simple suture or Roux-en-Y closure. Duodenal reconstruction was achieved by distal and total duodenectomy with sparing pancreatic parenchyma.

The distal duodenectomy with the end-to-end junction between the duodenum and jejunum at approximately ALK inhibitor review 1 cm below the papilla (a). Total duodenectomy with end-to-end anastomosis between the duodenal cuff and the jejunum (b, c). The papilla was implanted to the side of the jejunum with (c) or without mucosal islet (b). Biliary stent (marked by arrow) prevented postoperative stricture of the anastomosis due to oedema (b). Pyloric exclusion (black arrow) as well as the T-tube enterocholangiostomy (white arrow) were performed to prevent anastomotic leak. The adjunct enterogastrostomy was not present in the figure (c). An end-to-end anastamosis between the jejunum and duodenal cuff was performed using sero-muscular absorbable polyfilament 3/0 sutures. In one case the procedure was supplemented by a retrocolic gastroenterostomy, T-tube duodenocholangiostomy and stapled pyloric exclusion (Table 1, Figure 1c). The naso-jejunal feeding tube (8 Ch, 140 cm) as well as a naso-gastric decompression tube (12 Ch, 80 cm) was inserted intra-operatively in all cases. Table 1 Clinical features and surgical strategy

in the patients underwent pancreatic sparing duodenectomy as an emergency procedure Patient N° Sex Age Cause of surgery Duodenal resection Supplemented Amrubicin procedures 1. M 57 Road traffic, blunt abdominal trauma, complex pancreatico-duodenal injury partially D1, D2-4 enterogastrostomy, T-tube cholangioenterostomy, pyloric exclusion, cholecystectomy 2. M 81 Gut bleeding, giant peptic ulcers of duodenum localised in D1 and D2/3 surrounded the papilla partially D1, D2-4 bile stent inserted transpapillary 3. F 72 Ischemic necrosis of jejuno-dodenal flexure partially D2, D3-4 resection of the middle part (50 cm) of small intestine 4. F 49 Foreign body (chicken bone) perforation of D3 partially D2, D3-4 none 5.