Background <p>Although the clinical efficacy of body composition assessment has been explored in many other cancer types, few studies have focused on periampullary cancer. Furthermore, despite the global rise in minimally invasive pancreaticoduodenectomy (PD), its safety and feasibility in patients with sarcopenic obesity remain unclear. We aimed to investigate the impact of body composition assessment on outcomes after PD and to evaluate the safety of minimally invasive PD in patients with sarcopenic obesity.</p> Methods <p>Between 2015 and 2023, we included patients who underwent PD performed by surgeons who had surpassed the learning curve and were histologically diagnosed with periampullary cancer. Body composition was assessed using the axial images at the L3 vertebra level obtained from contrast-enhanced computed tomography.</p> Results <p>Among 717 patients, 558 (77.8%) underwent open PD and 159 (22.2%) received minimally invasive PD. In multivariate logistic regression analysis, sarcopenic obesity (odds ratio [95% confidence interval]: 1.84 [1.23–2.77]; <i>P</i> = 0.003) was identified as an independent predictor of complications after PD, whereas high body mass index (≥ 25&#xa0;kg/m²) and sarcopenia were not. Among patients with sarcopenic obesity, the open and minimally invasive PD groups demonstrated comparable short-term surgical outcomes—including complication rates—as well as oncologic outcomes such as the number of harvested lymph nodes and R0 resection rates.</p> Conclusion <p>This study demonstrated that computed tomography-derived body composition variables could be helpful in predicting complications after PD. Additionally, minimally invasive PD could be carefully performed by experienced surgeons even in patients with sarcopenic obesity.</p>