Despite poor long-term survival, surgery is the only recognized potentially curative treatment for malignant disease of the pancreatic head.23,24 However, enrollment criteria, the upper limit of surgical aggressiveness, and reconstructive options are still debated.25 In the last few decades, the general goal of enhancing the curative effectiveness of surgical resection has led to extending the excision of the pancreatic head to the regional connective, lymphatic, and neural tissues and to including, in select cases, more or fewer extended segments of portal and mesenteric vessels.6,11,26- 30 Despite increasing the operative morbidity, this aggressive approach has led to a wider recruitment of patients for potentially curative surgery. However, until recently, elderly patients have been excluded by this trend because of the overall unfavorable long-term outcomes that have caused this approach to be considered unadvisable for patients with short life expectancies.22,31- 45 Reduced mortality (<5%) and morbidity (<30%) suggest that pancreaticoduodenectomy should be offered to all patients with resectable disease, with no upper age limit.4,6,12,18,20 Furthermore, populations of developed countries are aging, and age is considered an etiological risk factor for pancreatic adenocarcinoma. It is likely that adequate treatment for elderly patients with pancreatic adenocarcinoma will become a topic of discussion in the next few years. Elements affecting pancreatic operative morbidity and mortality have been divided into patient-related, regional-related, and procedure-related factors.35 Patient-related parameters, such as medical comorbidities, have been stressed as the main reasons for higher complication rates in elderly patients.18,20,31,36,37 The significantly higher number of associated medical diseases detected in our group A patients was confirmed by statistical analysis as affecting early outcome. Nevertheless, while an identical aggressive approach was adopted, no difference in surgical complications was evidenced between the 2 groups of patients (30% vs 29%; P = .99). Careful preoperative monitoring, including evaluation of surgical stress compliance, routine postoperative intensive care, use of parenteral support, and octreotide prophylaxis are the main tools adopted successfully in our experience to reduce morbidity and to contain the number of medical complications leading to death. While the rate of surgical complications and that of reintervention did not differ between the 2 groups, a significantly higher operative mortality was observed in group A patients. Such an unfavorable outcome was exclusively attributable to the exceedingly high mortality rate registered in elderly patients undergoing reoperation because of surgical complications, mainly because of PJA-complicated leakage. This leakage remains the most feared complication of pancreatoduodenectomy.15,23,35- 40 Several studies have shown that rates of PJA leakage are influenced by the texture of the pancreatic remnant.13,21,23,41,42 When this correlation was analyzed in our series, although no correlation was shown to exist between age and texture of the pancreatic remnant, a soft pancreatic stump was an independent factor directly affecting PJA leakage. Experienced surgeons are well aware that hard parenchyma can be anchored tightly to the seromuscular coat of the jejunal loop,21,43,44 while soft and friable parenchyma are easily injured by stitches, making a safe anastomosis difficult to achieve.