Pancreaticoduodenectomy.

Few major abdominal operations have undergone the extent of dramatic change as that associated with pancreaticoduodenectomy in the last 20 years. The precipitous drop in the mortality rate most likely has a multifaceted explanation. Possibilities include the concentration of the operations at specialized centers, the improvement in the quality of critical care and anesthesia, and the improvement in the skill and experience of surgeons performing the procedure. Concomitant with the drop in the morality rate has been an increase in the resectability rate, along with the early encouraging evidence of improved long-term survival. However, many aspects of the technical portion of the procedure, particularly the pancreaticojejunostomy, need to be evaluated in prospective trials. The changes in the mortality and resectability rates make the operation more widely available to a larger number of patients, and the effectiveness of pancreaticoduodenectomy even for palliation is now well established.