When should total pancreatectomy be utilized in the treatment of adenocarcinoma of the pancreas? The rationale for total pancreatectomy comes from a tendency for pancreatic cancer to be multicentric (approximately 30% of patients), the absence of a pancreaticoenterostomy and its attendant morbidity, and the argument that total pancreatectomy is a better cancer procedure (more complete lymphadenectomy, wider soft tissue resection). In spite of these theoretical advantages, any impact on morbidity, mortality, or ultimately on survival has not been realized. Indeed, with the current operative mortality of pancreatic remnant-preserving resections being less than 5%, with the realization of the metabolic consequences of total pancreatectomy, and with the introduction of adjuvant chemo-radiation therapy, extended lymphadenectomy, and the concept of regional pancreatectomy, justification for total pancreatectomy for cancer of the head of the pancreas is questionable. The current data suggest that total pancreatectomy should be used only in selected individuals.