Primary Repair Versus Pyloric Exclusion in Adult Traumatic Duodenal Injury: A Systematic Review and Meta-Analysis With a Grade-Restricted Analysis of AAST Grade III Injuries.

BACKGROUND: Whether pyloric exclusion (PE) retains any advantage over primary repair (PR) in adult traumatic duodenal injury is uncertain and confounded by indication. We restricted the comparison to the zone in which both techniques are realistically applicable. METHODS: Five databases were searched through March 2026 for comparative studies of adults with AAST Grade II or higher injuries undergoing operative management. Primary outcomes were duodenal leak/fistula and in-hospital mortality; secondary outcomes were intra-abdominal abscess and hospital and ICU length of stay. Random-effects models used REML estimation with Hartung-Knapp adjustment. A prespecified analysis restricted to AAST Grade III pooled studies reporting outcomes by grade and technique. RESULTS: Twenty-seven studies (3574 patients) were included. PR was not associated with reductions in mortality (RR 0.66, 95% CI 0.39-1.13) or duodenal leak (RR 0.35, 0.09-1.44; I2 = 64.9%). PR was associated with lower intra-abdominal abscess (RR 0.39, 0.23-0.68), although pooled definitions were heterogeneous, and shorter hospital stay (mean difference -9.21 days, -12.72 to -5.69). Restricted to Grade III, the leak estimate was RR 0.97 (0.03-31.42; I2 = 84.0%). No comparative Grade IV-V data were available. CONCLUSIONS: No advantage of pyloric exclusion was demonstrated for any outcome, but absence of demonstrated benefit is not evidence of absent benefit: prediction intervals were wide and grade-specific data sparse. These findings are consistent with, rather than establish, the contemporary preference for primary repair. Because no comparative data isolate Grade IV-V or combined pancreaticoduodenal injuries, the residual indication for pyloric exclusion remains undefined rather than refuted.