When dealing with large, penetrating duodenal ulcers, one is confronted with three major problems: control of pain, hemorrhage and obstruction.
These are a direct result of the posterior penetrating lesion and are best managed by a procedure that excludes the ulcer from the duodenal stump.
The procedure developed consists of obtaining an adequate normal duodenum, distal to the indurated margin of the ulcer, in order to secure an adequate duodenal stump closure.
The critical step in this procedure is to recognize any opening into either the common duct or the pancreatic ducts.
A careful dissection and identification of all openings in the common and pancreatic ducts must be done.
In the event the base or margin of the ulcer crater communicates with either the biliary or pancreatic ducts, more specific operative techniques will be necessary. This entails a resection procedure or some manipulation of the ductal opening that will return
Ferguson WH. Management of Large Penetrating Duodenal Ulcer. Arch Surg. 1969;99(5):582-584. doi:10.1001/archsurg.1969.01340170034008