as Traverso-Longmire procedure/PPPD) has been gaining popularity, especially among European surgeons. The main advantage of this technique is that the pylorus, and thus normal gastric emptying, should in theory be preserved. There is conflicting data as to whether pylorus-preserving pancreaticoduodenectomy is associated with increased likelihood of gastric emptying. In practice, it shows similar long-term survival as a Whipple's (pancreaticoduodenectomy + hemigastrectomy), but patients benefit from improved recovery of weight after a PPPD, so this should be performed when the tumour does not involve the stomach and the lymph nodes along the gastric curvatures are not enlarged. Compared to the standard Whipple procedure, the pylorus preserving pancreaticoduodenectomy technique is associated with shorter operation time and less intraoperative blood loss, requiring less blood transfusion. Post-operative complications, hospital mortality and survival do not differ between the two methods. Morbidity and mortality Pancreaticoduodenectomy is considered, by any standard, to be a major surgical procedure. Many studies have shown that hospitals where a given operation is performed more frequently have better overall results (especially in the case of more complex procedures, such as pancreaticoduodenectomy). A frequently cited study published in The New England Journal of Medicine found operative mortality rates to be four times higher (16.3 v. 3.8%) at low-volume (averaging less than one pancreaticoduodenectomy per year) hospitals than at high-volume (16 or more per year) hospitals. Even at high-volume hospitals, morbidity has been found to vary by a factor of almost four depending on the number of times the surgeon has previously performed the procedure. de Wilde et al. have reported statistically significant mortality reductions concurrent with centralization of the procedure in the Netherlands. One study reported actual risk to be 2.4 times greater than the risk reported in the medical literature, with additional variation by type of institution. Postoperative complications Three of the most common post-operative complications are: delayed gastric emptying, bile leak, and pancreatic leak. Delayed gastric emptying, normally defined as an inability to tolerate a regular diet by the end of the first post-op week and the requirement for nasogastric tube placement, occurs in approximately 17% of operations. During the surgery, a new biliary connection (normally a choledochal-jejunal anastamosis connecting the common bile duct and jejunum) is made. This new connection may leak in 1-2% of operations. As this complication is fairly common, it is normal in this procedure for the surgeon to leave a drain in place at the end.