Even though the surgical techniques and perioperative care have improved, blood transfusions are still often required for the patients undergoing pancreaticoduodenectomy (PD). But complications from blood transfusions, poor prognosis of blood transfused patients, cost, and availability of blood products demand transfusion free (TF) surgery in the PD patients. The purpose of this study is to compare clinical outcome of TF pancreaticoduodenectomy with transfusion-eligible (TE) PD. We had investigated the possibility of blood TF treatments for the patients who underwent PD from December 2005 to August 2007. There were 41 cases of PD performed by one surgeon with the same method: 14 patients of the TF group and 27 patients of the TE group. Most of the TF group patients received perioperative blood augmentation and intraoperative acute normovolemic hemodilution. The results of statistical analysis between TF and TE group showed that there were no statistical differences in intraoperative data and postoperative outcomes, except preoperative hemoglobin levels, type of operations, and transfusion amount. To our best knowledge, this is the first successful PD program in selected patients as a series of operations without blood transfusion. TF PD can be done successfully in selected patients without severe complications.