Since the first pancreatic allograft in 1966, pancreatic transplantations have been performed by numerous surgical teams throughout the world. Initial results were disappointing with a high percentage of technical failures and rejection. Over-optimistic enthusiasm for islet-cell allografts also retarded the development of pancreatic transplantation. Despite this slow start, results of pancreatic transplantation from 1995 onward have been very satisfactory and equivalent to or even better than the results of other solid organ transplants. This success has been due to better graft selection, improved surgical techniques and preservation solutions, and especially to improvements in immunosuppressive protocols. More than 19,000 pancreatic transplantations have now been performed throughout the world including both combined kidney-pancreas transplantations and pancreas-only transplantations. The most satisfactory results occur in the setting of dialysis-dependent renal failure due to diabetes; simultaneous combined kidney and pancreas transplantation is performed with the total pancreas implanted into the bowel and with venous drainage into the portal system. The long-term risks and constraints of chronic diabetes with renal failure must be weighed against the risks of a complex surgical procedure, significant post-operative complications, and the need for long-term immunosuppressive therapy.