Penetrating injuries to the pancreas and duodenum are uncommon occurring in 4% and 6% of patients, respectively. Which of the following statement(s) is/are true concerning the management of pancreaticoduodenal injuries?

a. The Kocher maneuver is essential for providing exposure for the duodenum

d. Class III injuries of the head of the pancreas should be treated with simple external drainage rather than resection

Because of the retroperitoneal location of the duodenum and pancreas and the close proximity to a number of viscera and major structures, isolated penetrating injuries to the duodenum and pancreas are rare. Diagnosis of pancreaticoduodenal injuries depends on adequate exposure. A Kocher maneuver whereby the duodenum and head of the pancreas are mobilized from the retroperitoneal position by excising the lateral peritoneal reflection of the duodenum is essential for this exposure. Most penetrating injuries of the duodenum are simple lacerations that can be repaired primarily. Large injuries to the duodenum are more difficult to repair. Injuries of greater than 50% can lead to luminal compromise if repaired primarily. Treatment with a jejunal patch or duodenojejunostomy with a defunctionalized Roux-en-Y limb of jejunum can avoid the need for pancreaticoduodenectomy and its associated substantial mortality. Since many duodenal repairs are tenuous especially in combination with pancreatic injury and the concern about the digestive action of activated pancreatic enzymes on the repair, the technique of pyloric exclusion has been devised and is advocated by some. Pyloric exclusion involves suture or staple closure of the pylorus and restoration of gastrointestinal continuity by performing a gastrojejunostomy. Tube decompression of the duodenum should be performed in severe duodenal injuries but the biliary tract does not require decompression unless there has been an associated biliary tract injury. The management of pancreatic injuries depends on the location with respect to the head, body, and tail of the gland. Class III injuries of the head of the pancreas involve a relatively severe injury. In almost all situations, these injuries should simply be drained without attempts at resection or emergency internal drainage. If a patient develops a pancreatic fistula, the fistula can be controlled by the drain. If the fistula does not resolve with time, the pancreas can be drained internally at a later date.