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The three joins made during a Whipple | CION Cancer Clinics
Once the diseased organs are removed, the surgeon joins three things to a loop of small bowel: the remaining pancreas, the bile duct and the stomach. These joins, called anastomoses, let digestive juice, bile and food flow into the gut again. This page explains how each join is made, which one is most delicate, and how your team checks they are healing. CION Cancer Clinics’ surgical oncologists in Hyderabad can talk this through with you.
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Medically reviewed by Dr. Muralidhar MuddusettyConsultant Surgical Oncologist · MBBS (AIIMS), MS (Surgery, AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh) · last reviewed September 2026, next review due September 2027
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On this page
- What are the three joins made during a Whipple?
- How is each join put together?
- What can go wrong at each join?
- What do the long names for the joins mean?
- How does the team know the joins are healing?
- What do families often worry about with the joins?
- What can this page not tell you?
- Common questions about the joins in a Whipple
The short answer
What are the three joins made during a Whipple?
After the diseased organs are removed, the surgeon brings up a loop of small bowel and joins three things to it: the remaining pancreas, the bile duct and the stomach. These joins let pancreatic juice, bile and food flow into the gut again.
Why the joins are needed at all
Before surgery, pancreatic juice and bile both drained into the duodenum, and food passed through it from the stomach. The duodenum is removed in a Whipple. Without new connections, digestive juice would have nowhere to go and food could not leave the stomach. Rebuilding this plumbing is the second half of the operation, and it takes real time and care.
What the surgeon uses to make them
Each join is sewn with fine stitches, stitch by stitch, so the edges heal together. The surgeon may place a thin plastic tube, called a stent, across the pancreas join to keep it open while it heals. One or two drains are usually left near the joins so any leaking fluid can be seen and removed.
Your operation note may call these joins anastomoses. That is simply the medical word for a surgical join.In the order they are made
How is each join put together?
The pancreas join
The cut end of the pancreas is sewn to the loop of small bowel, or in some techniques to the back of the stomach. This join carries digestive juice. It is the most delicate of the three, because pancreatic tissue can be soft and hold stitches poorly.
The bile duct join
A little further along the same loop, the bile duct from the liver is sewn to the bowel. Bile now drains straight into the gut. This join usually heals well, though the duct can be narrow in some people.
The stomach join
Further down again, the stomach, or the short cuff of duodenum below it, is joined to the bowel. Food now passes from the stomach into the small bowel beyond the other two joins, where it mixes with bile and pancreatic juice.
Not sure whether this applies to you?
Ask an oncologistWhen healing is slow
What can go wrong at each join?
Most joins heal without trouble. These are the problems your team watches for, and why they check drains, blood tests and eating so closely.
Pancreas join leak
Pancreatic juice seeps out where the join has not sealed. This is the most widely known complication of a Whipple. Many leaks are small and settle with the drain left in longer.
Signs the team looks for
- Cloudy or changed drain fluid
- Fever or tummy pain
Bile join leak
Less common. Green-brown fluid may appear in the drain. Many settle with the drain alone. Some need a small tube placed through the skin by a radiologist.
Slow stomach join
The stomach can be slow to empty through its new join. You may feel full, feel sick or vomit. This usually eases with time, but it can lengthen the hospital stay.
Narrowing, much later
Months or years on, the bile join can scar and narrow. Yellowing of the eyes or skin, or fever with shivering, should be reported.
This is uncommon, and it can usually be opened up again.On your operation note
What do the long names for the joins mean?
- Pancreaticojejunostomy
- The pancreas joined to the small bowel. Sometimes written as PJ.
- Pancreaticogastrostomy
- The pancreas joined to the back of the stomach instead. Some surgeons prefer this.
- Hepaticojejunostomy
- The bile duct joined to the small bowel. Sometimes written as HJ.
- Gastrojejunostomy or duodenojejunostomy
- The stomach, or the duodenum just below it, joined to the small bowel.
- Drain amylase
- A test of the drain fluid for a pancreatic enzyme. A high level can point to a leak from the pancreas join.
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In the days after
How does the team know the joins are healing?
They watch three things closely: the drains, your blood tests and how you manage food. None of these alone gives the full picture, so they are read together each day on the ward round.
The drains
Nurses measure how much fluid comes out and note its colour. The fluid is often tested for pancreatic enzyme in the first few days. Clear, small and falling amounts are reassuring. The surgeon removes the drains once the fluid shows the joins are sealing.
Blood tests and temperature
A rising infection marker, a fever or a fast pulse can be early signs of a leak or a collection of fluid near a join. If these appear, a CT scan is often the next step to look for fluid that needs draining.
Eating again
Food and drink are started slowly. Sips, then fluids, then soft food. If the stomach join is slow, eating is paused and extra nutrition is given until it recovers.
Commonly believed
What do families often worry about with the joins?
"A leak means the surgeon made a mistake."
Leaks happen even in very experienced hands. How soft the pancreas is and how narrow its duct is play a large part, and neither can be changed. What matters is that a leak is spotted early and managed well.
"If the drain is still in, he is not getting better."
Drains are often kept in as a precaution. A drain left longer is doing its job, carrying fluid safely out of the body. Many people go home with a drain and have it removed at a clinic visit.
"Once he is eating, the joins have fully healed."
Eating is a good sign, but joins keep strengthening for weeks. Fever, new tummy pain or vomiting after going home still need a call to the team.
"The stitches will dissolve and the joins will come apart later."
The stitches hold the edges only while the tissue grows together. By the time they dissolve, the body has formed its own seal.
Being straight with you
What can this page not tell you?
This page cannot tell you how your own joins will heal, or which technique your surgeon will use. Surgeons differ in how they sew the pancreas join, whether they use a stent, and whether drains are placed. There is no single right method, and studies comparing techniques have not settled which is ahead.
Questions worth asking
Ask how the pancreas join will be made, and why. Ask whether you are likely to go home with a drain. Ask what signs at home should make you call, and who answers at night. Ask whether the team feels your pancreas is likely to be soft, as that changes how closely they watch.
Whether a Whipple suits you at all is a decision for your treating team, based on your scans, your fitness and your wishes.Questions we are asked
Common questions about the joins in a Whipple
Which join is most likely to leak?
The pancreas join. Pancreatic juice is strong enough to break down tissue, and a soft pancreas holds stitches less firmly. The bile join and stomach join leak far less often. This is why drain fluid is tested for pancreatic enzyme in the first days after surgery.
Will I go home with a drain?
Some people do, especially if drain fluid is still coming out or shows a small leak. The nurses will teach your family how to empty it, note the amount and keep the site clean. It is usually removed at a follow-up visit once the fluid settles.
What is the stent the surgeon mentioned?
A thin, soft plastic tube placed across the pancreas join or bile join to keep it open while it heals. Some are left inside and pass out naturally in the stool later. Others come out through the skin. Your surgeon will tell you which kind, if any, was used.
Why is my father not allowed to eat yet?
The joins need time to seal, and the stomach is often slow to wake up after a large operation. Food is started gradually to avoid vomiting and strain. If eating is delayed, nutrition is given another way, through a vein or a feeding tube, so healing is not held back.
Can the joins cause problems years later?
Occasionally. The bile join can narrow over time, causing yellow eyes, itching or fever with shivering. Some people get infections of the bile ducts. These are uncommon and usually treatable. Report any such symptoms to your surgical team rather than waiting for the next routine visit.
Does a keyhole Whipple use different joins?
No. The same three joins are made, whether the operation is open, keyhole or robot-assisted. Only the way the surgeon reaches them changes. Ask your centre which approach they use for the joins, and how often they do it that way.
Will I feel the joins inside me?
Not as distinct points. You will feel general soreness in the upper tummy while everything heals, which is managed with pain relief. New or sharply worsening pain, especially with fever, is different. Tell the ward team straight away, or call if you are already home.
Can we do anything to help the joins heal?
Yes, in simple ways. Walking as soon as the team allows, breathing exercises, and good nutrition before and after surgery all help the body heal. Stopping smoking well before the operation matters too. Follow the eating plan you are given rather than rushing onto heavy meals.
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Sources
- Cancer Research UK — Surgery for pancreatic cancer
- American Cancer Society — Surgery for pancreatic cancer
- NHS — Pancreatic cancer: treatment
- Macmillan Cancer Support — Pancreatic cancer
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
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