Introduction: Although preoperative therapy is increasingly administered to patients with pancreatic adenocarcinoma, the role of preoperative therapy for patients with adenocarcinoma of the ampulla of Vater is undefined. Methods: All patients with ampullary cancer who were evaluated between 1999 and 2014 were retrospectively reviewed. Differences in clinicopathologic characteristics, perioperative complications, and overall survival were compared between patients who underwent surgery de novo and those who received preoperative therapy before pancreatoduodenectomy. Results: A total of 142 patients underwent pancreatoduodenectomy: 43 (30.3%) who received preoperative therapy and 99 (69.7%) who did not. Preoperative therapy consisted of chemoradiation (65%), chemotherapy (7%), or both (28%). Patients who underwent surgery first had a lower comorbidity index (p < 0.05) and were more likely to receive postoperative chemotherapy (p < 0.01) and chemoradiation (p < 0.0001). Tumors resected de novo were larger (p < 0.01) and had a different histopathologic subtype distribution (p < 0.01) on final pathology than those resected following preoperative therapy. Six (14.0%) patients demonstrated a complete pathologic response. There were no differences in rates of postoperative complications, mortality, readmission, LR (9.1 vs. 7.0%), median survival (107 vs. 146 months), or 5-year overall survival (60.6 vs. 70.4%). On multivariate cox regression analysis, the receipt of preoperative therapy was not associated with improved survival (odds ratio 1.14, 95% confidence interval (CI) 0.56–2.31). Conclusions: Although these data do not support the routine administration of preoperative therapy to all patients with ampullary cancer, the delivery of preoperative therapy represents an alternative strategy that is associated with excellent short- and long-term outcomes and appears appropriate for a subset of patients.