['We have observed that leakage from pancreaticojejunostomy is reduced when a surgical microscope is used to construct the pancreaticojejunostomy during pancreaticoduodenectomy. To validate our hypothesis that better vision improves the technical performance of pancreaticojejunostomy, we limited inclusion criteria to those patients at high risk for leak, performed more cases, and used the grading system of the International Study Group of Pancreatic Surgery.', 'From 1988 through 2008, 507 consecutive pancreaticoduodenectomies were performed with pancreaticojejunostomy. A subset of 283 patients at risk for leak had a main pancreatic duct (MPD) ≤3 mm at the surgical margin. Pancreaticojejunostomy was completed with surgical loupes (n = 135) or surgical microscope (n = 148). Incidence of pancreaticojejunostomy leak and delayed gastric emptying was determined using a Web-based calculator for the severity grading scale of the International Study Group of Pancreatic Surgery.', 'Within the 507 pancreaticoduodenectomies, the clinically relevant pancreaticojejunostomy leak for those with an MPD >3 mm (n = 224) was 4%, and with an MPD ≤3 mm (n = 283) it was 16% (p < 0.0001). For these 283 high-risk patients, outcomes were worse in the loupes versus microscope group, ie, clinically relevant pancreaticojejunostomy leak (21% versus 11%; p = 0.021), pancreas-related complications (31% versus 19%; p = 0.018), clinically relevant delayed gastric emptying (19% versus 9%; p = 0.016), and hospital length of stay (12.9 versus 9.5 days; p < 0.0001).'] Does pancreatic anastomotic failure rate after pancreaticoduodenectomy decrease with microsurgery?