While impossible for the laparoscopic surgeon, the open surgeon has the opportunity to palpate the posterior duodenal wall before performing a primary anterior closure. The presence of a simultaneous posterior penetrating ulcer would indicate that the patient has “kissing ulcers.” The concern in patients with this uncommon condition is that the extent of inflammation and the addition of an anterior omental plug may cause a gastric outlet obstruction. If this complication is a possibility, a more definitive ulcer operation should be performed (see below).

Saline solution containing antibiotics (bacitracin or a cephalosporin) is used to irrigate the entire abdomen after simple closure of anterior perforation. The primary subhepatic site of contamination and the sites of peritoneal fluid flow—pelvis and both subdiaphragmatic areas—are particular areas of focus during irrigation. The value of postrepair irrigation, however, remains controversial [8, 11].

Postoperative care after primary suture or omental plug repair of a small anterior perforation of the duodenum has changed considerably. Rather than the old 5–7 days of a nasogastric tube and NPO status, Enhanced Recovery After Surgery (ERAS) pathways are now used in many centers. Gonec et at described a pathway in which no postoperative narcotic analgesics are used, tramadol and diclofenac are substituted, a liquid diet is started on postoperative day one, and the patient is discharged when bowel sounds are present [12, 13].

The 2-cm anterior duodenal perforation with 1-cm thickened edges described in the clinical scenario precludes a primary or omental plug closure in the minds of most general or acute care surgeons. There is a much greater risk of prolapse of the omental plug into the lumen causing a postoperative duodenal destruction. A postoperative leak is more likely, as well, as many omental plugs are quite thin and epithelization of the underside of the plug will be prolonged.

There are two operative options in such a patient or in any patient needing a definitive operation for a complex perforation or scenario as previously described. The first is a Judd-Weinberg pyloroplasty with or without the addition of a truncal vagotomy. E. Starr Judd from the Mayo Clinic described an operation where the large anterior perforation was excised and duodenal closure performed [14]. If done transversely, this resembles a standard pyloroplasty. Joseph Weinberg from UCLA and the Long Beach Veterans Administration Hospital popularized the one-layer transverse closure (instead of the two-layer closure described by Heineke and Mikulicz) of pyloroplasties. The goal of the operation in the patient described would be to first excise the large anterior perforation and surrounding inflammation in either a transverse or longitudinal direction. A transverse direction would be preferred as it might eliminate the need for a Kocher maneuver before closure. If a longitudinal excision is performed, a Kocher maneuver would be mandatory to avoid tension on the transverse suture closure of the duodenum. Silk, Maxon, or PDS suture can be used for the transverse closure, while the historic technique of burying the suture knots has never made much sense to this author. The tips of a DeBakey tissue forceps are then placed between sutures of the transverse closure to see whether any defects remain that need closure. A viable omental pedicle can be sutured as a buttress over the transverse suture line if desired. While this operation is performed uncommonly in the modern era, it is quite simple if a transverse excision has been performed.

The second option is to perform a gastric antrectomy and a partial duodenectomy encompassing the large perforation. The addition of a truncal vagotomy would depend on whether the patient has failed prior anti-Helicobacter therapy, the experience of the surgeon, the patient’s intraoperative hemodynamic status, and whether severe peritonitis is present (truncal vagotomy mandates opening into the posterior mediastinum). The antrectomy is performed up to the “crow’s foot” division of the anterior nerve of Latarjet, while the partial duodenectomy should be limited to just beyond the area of inflammation distal to the perforation. Also, the anterior wall of the duodenum should be where the longest area of the excision is performed to avoid the medially based pancreatic duct of Santorini.

An end-to-end gastroduodenostomy is not commonly performed after the resection because of the inflammation in the subhepatic space. When inflammation is modest and the duodenectomy has been limited, it is a reasonable choice. The first step would be to excise a portion of the lesser curve of the stomach using a suture or staple closure (Schoemaker modification). This should narrow the gastric outlet to a size larger (by at least 1–2 cm) than that of the duodenal lumen. A Kocher maneuver is then performed to avoid tension on the 2-layer handsewn end-to-end gastroduodenostomy. The oversizing of the gastric end avoids narrowing of the anastomosis.