Background: There are an estimated 37,680 new cases per year and 34,290 deaths per year related to pancreatic cancer according to the National Cancer Institute in 2008. However, there has been a steep decline in perioperative mortality from 20% to less than 5% over the last decade due to experience at high-volume institutes. Blood transfusion may be a factor in long term survival in patients with pancreatic cancer undergoing pancreaticoduodencetomy (PD). A recent study of the effects of perioperative blood transfusion (allogenic vs. autologus) on the immune system in gastric cancer patients revealed a down-regulation of key components of cell-mediated immunity indicating immunosuppression. It is the aim of this study to examine survival in patients with pancreatic adenocarcinoma receiving perioperative blood transfusions with PD. Methods: Data was collected between 1995 and 2007 for patients with pancreatic adenocarcinoma who were treated by PD at our institution. The blood transfusion data was obtained and recorded directly from blood bank records and all transfusions during the same hospital admission. Estimated survival was analyzed using Kaplan-Meier log-rank tests.Results: A total of 185 patients underwent pancreaticoduodenectomy for pancreatic adenocarcinoma between 1995 and 2007. The median survival of patients transfused intraoperatively (N=70) versus not transfused (N=115) was 14 vs. 19 months respectively (p=0.05). Patients were further stratified based on stage. T3 disease was present in 114 patients (62%). Of these, 52 patients were transfused and 62 patients were not transfused with a median survival of 13 and 18 months respectively (p=0.02). Patients with node-positive disease (N=126) had similar survivals whether or not a blood transfusion was given. Patients with node-negative disease had median survival of 18 months when a transfusion was given compared to 54 months when there was no transfusion (p=0.07). In addition, patients transfused intraoperatively were more likely to develop intraabdominal abscesses (p=.03). Conclusion: Patients with pancreatic adenocarcinoma who receive a blood transfusion during pancreaticoduodenectomy have a worse long-term survival than those who do not receive an intraoperative transfusion and are more likely to suffer an intraabdominal abscess. This holds true for T3 disease and trends toward significance in patients who are node-negative and have the best curative potential. Surgical technique and avoidance of intraoperative blood transfusion is of the utmost importance during PD to minimize complications and maximize long-term survival.