al aspect of the duodenal C loop. There is little danger of injuring these vessels, since one needs to stay several millime­ters away from the C loop to avoid injuring the common duct. There is both a posterior and an anterior pancreaticoduo­denal arcade, and as long as one of these arcades is left intact, there is no concern about duodenal viability.

C loop. The pancreatic duct is identified and sutured with a mattress suture of 3-0 silk (3). The remnant at this point is small, unless the head of the pancreas is markedly enlarged; in the latter case, a relatively broad remnant of pancreas is left behind. It is in these patients that further symptoms are occasionally seen. In most instances, however, most of the pancre­atic tissue can be shaved away from the duodenal C loop without risk of injury to the common duct or vascular supply to the duodenum. The remnant is drained with two closed suction Silastic drains brought out through stab wounds in the left upper quadrant.

tal vein is then identified along the superior border of the neck of the pancreas. It is helpful to loop the neck of the pan­creas with a small Penrose drain so that, during the resection of the head of the pancreas, these venous structures and the superior mesenteric artery location are clearly identified. The dilated pancreatic duct is then identified by aspirating with a 20-gauge needle and a 10-ml syringe. If difficulty in identifying the dilated pancreatic duct is encountered, intraoperative ultrasound may be of help. Once the dilated duct has been identified by needle aspiration, using the electrocautery the entire pancreatic duct is filleted open from the tail to the neck (1).

patients, progressively more of the head of the pancreas is excised, starting along the course of the opened proximal pancre­atic duct (1). Most of the head of the pancreas can be cored out

In patients with chronic pancreatitis, and abdominal pain, with a small fibrotic gland with a dilated pancreatic duct, the Puestow procedure is an excellent operation. One should be certain during the performance of the lateral pancreaticoje­junostomy that a Bakes dilator can be passed through the open pancreatic duct down through the ampulla into the duo­denum. If there is an enlarged head of the pancreas, a substantial inflammatory mass, and/or one cannot pass a Bakes dila­tor easily through the proximal pancreatic duct, through the ampulla and into the duodenum, then a local head resection and lateral pancreaticojejunostomy (the Frey procedure) is an excellent operation. Many patients, however, have a very large inflammatory mass in the head of the pancreas but no dilated pancreatic duct. These patients can be treated with the duodenal-preserving pancreatectomy, or the Beger procedure. This operation has gained significant popularity in Europe and, in many areas, is the most frequently performed operation for chronic pancreatitis. It has been slow to catch on in the United States, and is not nearly as frequently performed as the Puestow procedure, the Frey procedure, and the pylorus­preserving pancreaticoduodenectomy. It is an operation that requires a good deal of experience to perform.