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The best thing to do w/ a .pdf is to go back to the original / source document for any but the most trivial of modifications.
Enfocus used to make a stand-alone program, Tailor which would allow fairly arbitrary editing of a .pdf, even re-flowing text, but they've since switched to making PitStop, a plug-in for Adobe Acrobat which allows one to edit arbitrarily, if not elegantly.
Next best option is to use a tool which will parse a .pdf into its own native format --- most drawing programs will do this --- at one point in time, I was maintaining a compleat book in Macromedia FreeHand (had to import it as a .pdf since the book was typeset using a proprietary typesetting program which we discontinued use of at my previous employer). This will re-encode all the text from whatever encoding was used in the .pdf into the native format used by the drawing program, so all text should be proofed character-for-character. There's also the Markzware plug-in pdf2dtp which will import a .pdf into either Quark XPress or Adobe InDesign which works quite well (but still requires proof-reading).
For simple edits, one should be able to make do w/ one of the programs billed as a .pdf editor, but for the most part, they're more useful for filling out forms or annotations.
Inkscape is a free drawing program which is able to import .pdfs, but will require a fair bit of work for any but the most trivial of edits (and will still require careful proof-reading).
William
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