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Objectives: To evaluate the safety of nonoperative management (NOM), to examine the diagnostic sensitivity of computed tomography (CT), and to identify missed diagnoses and related outcomes in patients with blunt pancreatoduodenal injury (BPDI). Design: Retrospective multicenter study. Setting: Eleven New England trauma centers (7 academic and 4 nonacademic). Patients: Two hundred thirty patients (>15 years old) with BPDI admitted to the hospital during 11 years. Each BPDI was graded from 1 (lowest) to 5 (highest) according to the American Association for the Surgery of Trauma grading system. Main Outcome Measures: Success of NOM, sensitivity of CT, BPDI-related complications, length of hospital stay, and mortality. Results: Ninety-seven patients (42.2%) with mostly grades 1 and 2 BPDI were selected for NOM: NOM failed in 10 (10.3%), 10 (10.3%) developed BPDI-related complications (3 in patients in whom NOM failed), and 7 (7.2%) died (none related to failure of NOM). The remaining 133 patients were operated on urgently: 34 (25.6%) developed BPDI-related complications and 20 (15.0%) died. The initial CT missed BPDI in 30 patients (13.0%); 4 of them (13.3%) died but not because of the BPDI. The mortality rate in patients without a missed diagnosis was 8.8% (P=.50). There was no correlation between time to diagnosis and length of hospital stay (Spearman r=0.06; P=.43). The sensitivity of CT for BPDI was 75.7% (76% for pancreatic and 70% for duodenal injuries). Conclusions: The NOM of low-grade BPDI is safe despite occasional failures. Missed diagnosis of BPDI continues to occur despite advances in CT but does not seem to cause adverse outcomes in most patients. [ABSTRACT FROM AUTHOR]