INTRODUCTION: The utility of pancreaticoduodenectomy (PD) for high-grade traumatic injuries remains unclear and data surrounding its use are limited. We hypothesized that PD does not result in improved outcomes when compared with non-PD surgical management of grade IV-V pancreaticoduodenal injuries. METHODS: This is a retrospective, multicenter analysis from 35 level 1 trauma centers from January 2010 to December 2020. Included patients were ≥15 years of age with the American Association for the Surgery of Trauma grade IV-V duodenal and/or pancreatic injuries. The study compared operative repair strategy: PD versus non-PD. RESULTS: The sample (n=95) was young (26 years), male (82%), with predominantly penetrating injuries (76%). There was no difference in demographics, hemodynamics, or blood product requirement on presentation between PD (n=32) vs non-PD (n=63). Anatomically, PD patients had more grade V duodenal, grade V pancreatic, ampullary, and pancreatic ductal injuries compared with non-PD patients (all p<0.05). 43% of all grade V duodenal injuries and 40% of all grade V pancreatic injuries were still managed with non-PD. One-third of non-PD duodenal injuries were managed with primary repair alone. PD patients had more gastrointestinal (GI)-related complications, longer intensive care unit length of stay (LOS), and longer hospital LOS compared with non-PD (all p<0.05). There was no difference in mortality or readmission. Multivariable logistic regression analysis determined PD to be associated with a 3.8-fold greater odds of GI complication (p=0.010) compared with non-PD. In a subanalysis of patients without ampullary injuries (n=60), PD patients had more anastomotic leaks compared with the non-PD group (3 (30%) vs 2 (4%), p=0.028). CONCLUSION: While PD patients did not have worse hemodynamics or blood product requirements on admission, they sustained more complex anatomic injuries and had more GI complications and longer LOS than non-PD patients. We suggest that the role of PD should be limited to cases of massive destruction of the pancreatic head and ampullary complex, given the likely procedure-related morbidity and adverse outcomes when compared with non-PD management. LEVEL OF EVIDENCE: IV, Multicenter retrospective comparative study.