If a patient hits the steering wheel of his car, he can crush both his duodenum and his pancreas against his spine. The combination of a leaking duodenum and traumatic pancreatitis usually kills him. Diagnosis and treatment are difficult, and may be delayed for days because both organs lie at the back of his abdomen behind his peritoneum. These injuries are difficult even for the most skilled surgeon, and you will have to manage the patient as best you can. Fortunately, injuries of the duodenum are rare.
The patient’s injured duodenum leaks into his peritoneal cavity or behind it and causes a deep seated pain in his epigastrium and back, which gets steadily worse. This is accompanied by severe vomiting, fever, toxaemia, and sometimes by shock. His epigastrium becomes tender, silent, and a little distended. When you open it, you find an oedematous red mass behind his stomach. The tear itself is difficult to find, and you may need to lift his duodenum and pancreas forwards from the right (Kocher’s manoeuvre).
You should be able to suture small tears into the peritoneal cavity, and some of the tears behind it. If you cannot do this, the unsatisfactory alternatives are: (1) A duodeno jejunostomy, which is difficult, (2) a gastroenterostomy which does not divert bile from the wound, or (3) a Foley catheter which does not provide enough drainage.