Pancreatic fistula remains the Achilles heel and a common complication of pacreatoduodenectomy . Novel approaches continue to be put forward to reduce its incidence.Pancreatic fistula can be defined as any measurable volume of fluid on or after post operative day 3 with amylase content greater than 3 times the serum amylase activity. Although mortality rates are greatly reduced due to current advances in radiologic imaging and interventional radiologic techniques, antibiotics and critical care medicine , it still continues to cause significant morbidity, prolonged hospital stay, and increased hospital cost. The risk of PF formation appears to be multifactorial involving demographics (seen more in males), preoperative, intraoperative, and pathologic factors.Gender , diabetes, preoperative glucose levels, length of operation, bowel preparation, biliary stenting (endoscopic versus percutaneous), anastomotic technique (invaginated versus duct -to -mucosa), intraperitoneal drain choice (passive gravity versus closed suction) and pathology (pancreatitis, duodenal cancer) may influence PF formation.Invaginated anastomosis, closed suction drainage, and percutaneous biliary stenting all have seen to increase the risk of PF whereas pancreatitis, endoscopic biliary stenting, and female gender has seen to confer protection against PF. The influence of the individual surgeon on PF is also an extremely important factor to consider.Another factor which appears to be consistent is the texture of the gland itself.Studies show that patients with a firmer gland texture show reduced risk of fistulas than those who have a softer or normal gland texture. One should continue to investigate the risk and make use of controllable factors for better outcome after pancreatic surgery.