From an institutional review of 103 pancreaticoduodenal resections (PDRs) performed during the period 1968-1981, risk factors and selection criteria of this procedure were evaluated. A total of 43.7% of the patients were operated on for benign lesions, mainly right-sided chronic pancreatitis (35%); 56.3% of the interventions were performed for malignant disease, mainly carcinoma of the periampullary region. Despite the absence of any selection, the hospital mortality in 103 consecutive PDRs only reached 10.6% for the whole group (11/103 patients) and 8.3% for the elective group (8/96 patients). Mortality was significantly influenced by age barrier over 65 years (p less than 0.0001) and by urgent degree of surgery (p less than 0.03). All three patients with renal insufficiency had a fatal outcome after PDR. A total of 19.4% of the patients (20/103 patients) developed a surgical complication. The most important complication was pancreatic fistula (15/103 patients, 14.5%) responsible for all digestive-related fatal outcomes (six patients). Surgical treatment of pancreatic fistula (10 patients) is compromised by a high morbidity and a high mortality rate (50%). Postoperative morbidity as well as the incidence of the pancreatic fistula were significantly influenced by the age of the patients over 65 years (p less than 0.01 and less than 0.001, respectively), and by the serum bilirubin level over 6 mg/dl (p less than 0.002). The poor quality of the pancreatic tissue (p less than 0.03) and the urgent degree of the intervention (p less than 0.03) also raised the incidence of pancreatic leakage. Morbidity rate was more important in the malignant disease group (p less than 0.05). Corrected 5-year actuarial survival after PDR is excellent for ampullary cancer, moderate for chronic pancreatitis, and extremely poor for pancreatic and bile duct carcinoma. The decision to perform PDR should be taken after evaluation of the aforementioned risk factors: the emergency, age, serum bilirubin, quality of pancreatic tissue and renal insufficiency, underlying disease, and psycho-social status of the patient.