Since 1983, 66 cases of periampullary cancer (33:pancreatic head, 16:distal bile duct, and 17:ampulla) were operated on by PPPD procedure. At first, the Traverso procedure was used in 19 cases. Since 1986, we have adopted the Imanaga procedure, by which gastrointestinal continuity was done duodeno-, pancreatico-, and choledochojejunostomy in this order. PPPD by Imanaga procedure has some advantages: (1) better mixture of food with bile and pancreatic juice, (2) better recovery of postoperative body weight, and (3) observation of pancreatic and biliary stomas and early detection of local recurrence by postoperative endoscopy.