During a 12-year period, 313 patients with duodenal injuries were treated. Primary repair, pyloric exclusion, and gastrojejunostomy were used in 128 patients (41%) with severe duodenal and pancreaticoduodenal injuries, to reduce "duodenal" morbidity and mortality. The duodenal fistula rate was 2.2% overall, and 5.5% in the patients undergoing exclusion. Only two deaths were due to fistulas. Forty-two patients underwent upper gastrointestinal tract examinations after operation. In patients examined 21 days or more after operation, 94% had a patent pylorus. Marginal ulceration was infrequent (four patients), as were complications associated with the procedure (3%). Pyloric exclusion with gastrojejunostomy is a quick and simple procedure that allows return of pyloric patency and is associated with a low incidence of duodenal fistulas. When fistulas do develop, they are usually easily controlled and are associated with a low mortality. We believe pyloric exclusion with gastrojejunostomy to be the procedure of choice in patients with severe duodenal and pancreaticoduodenal trauma.