Iatrogenic duodenal injuries are uncommon. Their clinical importance lies in the significant morbidity and mortality they cause if diagnosed late or treated improperly. The aim of this study is to show efficacy of pyloric exclusion with biliary diversion compared to primary repair over tube duodenostomy for treating iatrogenic duodenal injuries when discovered late (more than 48 hours). A retrospective study was conducted in the period between April 2013 and December 2014 in Ain shams university, general surgery department Cairo, Egypt. Patients admitted with delayed iatrogenic duodenal injuries were selected. 16 patients were included in the study. Six patients were treated with drainage, primary repair over tube duodenostomy and feeding through TPN and the other 10 patients underwent drainage, primary repair with omental patch, pyloric exclusion via gastrotomy and gastrogejunostomy and biliary diversion using Ttube. Demographics, clinical presentation data, laboratory and radiological investigations, operative management, post-operative morbidity and mortality were analyzed. The study included 16 patients, 10 males and 6 females with mean age 42±7.5. The causes of injury were post laparoscopic cholecystectomy (n = 4), after ERCP (n = 9), after right nephrectomy (n = 2) and during CBD exploration one patient. Delayed diagnosis was due to injuries not identified during the first operation, injuries treated conservatively and refusal of reoperation by patients and their relatives. 10 patients were treated by pyloric exclusion and biliary diversion after drainage and repair of injury with one death and four complications (one duodenal fistula and 3 retroperitoneal abscesses that indicated reoperation). The other 6 patients were treated with drainage of collection, primary repair of duodenal injury over tube duodenostomy, nasogastric tube for decompression of stomach and feeding by TPN with four deaths and two complications (two prolonged duodenal fistulae). Conclusion: Iatrogenic duodenal injuries are uncommon. They have significant morbidity and mortality if diagnosed late or treated improperly. Pyloric exclusion with biliary diversion gives the best results in cases discovered late. Key words: delayed duodenal injuries, pyloric exclusion, biliary diversion, duodenal fistula.