Pancreatoduodenectomy (PD) is the standard treatment for pancreatic and periampullary malignancy and offers the only chance for cure. Improvements in surgical technique and post- operative care with regionalization of services have improved outcomes over time. Mortality rates have decreased to less than 5–6 % in high-volume centers; the morbidity rates are still substantial [1–5]. This potential for significant morbidity with a possible chance of mortality after PD has made its role in benign disease controversial and indicated only in selected cases [6, 7].