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Context Computed tomography is widely used to pre-operatively evaluate patients with ductal carcinoma of the pancreas. Objective To prospectively evaluate the ability of multi-detector computed tomography to predict resectability of pancreatic head cancer. Patients Ninety-one consecutive patients (53 men, 38 women; mean age, 61 years) referred to our department with a diagnosis of cancer of the head of the pancreas underwent a preoperative contrast enhanced triphasic 16- slice multi-detector computed tomography. Sixty-three were considered inoperable because of advanced local disease, metastatic disease, or poor surgical risk. Intervention Of the remaining 28 patients, 23 underwent a Whipple procedure, whereas 5 patients underwent a palliative procedure. Main outcome measures Surgical and pathologic reports were reviewed and compared to CT results. Results Of the 91 patients evaluated, 25% had successful resection of pancreatic head carcinoma; while only 5% had a palliative procedure. When compared to surgical outcome, the positive predictive value of multi-detector computed tomography for resectability was 100%. On the basis of pathologic results, the positive predictive value of multi-detector computed tomography for resectability fell to 83%, Four patients deemed resectable following multi-detector computed tomography had positive margins at pathology. Conclusion The positive predictive value of multi-detector computed tomography for resectable disease is lower when pathologic correlation, as opposed to surgical correlation, is used as the gold standard. Compared to previous studies, there was a lower rate of palliative surgery in our cohort.