Pancreaticoduodenectomy in the Presence of Superior Mesenteric Venous Obstruction Leonidas G. Koniaris, M.D., F.A.C.S., Kevin F. Staveley-O’Carroll, M.D., Ph.D., F.A.C.S., Herbert J. Zeh, M.D., F.A.C.S., Eduardo Perez, M.D., Xiao-ling Jin, M.D., Ph.D., Warren R. Maley, M.D., F.A.C.S., Gazi Zabari, M.D., F.A.C.S., David L. Bartlett, M.D., F.A.C.S., Amit Khanna, M.D., M.P.H., Dido Franceschi, M.D., F.A.C.S., Luke O. Schoeniger, M.D., Ph.D., F.A.C.S. The study goal was to determine the technical feasibility and outcomes associated with pancreaticoduodenectomy for periampullary malignancies with near (80%) or complete (100%) superior mesenteric venous (SMV) obstruction. A retrospective examination of 11 patients with high-grade or complete SMV obstruction who underwent pancreaticoduodenectomy at five academic medical centers is reviewed. Pancreaticoduodenectomy for locally advanced periampullary malignancies causing high- grade or complete SMV obstruction is technically feasible. Operative approaches and outcomes are presented. One 30-day death was observed. Median survival of the cohort is 18 months. Survivals exceeding 2 years post-resection have been observed. In a number of cases, significant palliation of pain and of biliary and duodenal obstruction were achieved. Based on this initial series, pancreaticoduodenectomy in the presence of near or total SMV obstruction is feasible, may result in an R0 resection, and may be beneficial in select patients with a periampullary malignancy. We suggest such an approach be considered particularly following completion of neoadjuvant therapy without systemic progression. Further studies and more long-term follow-up at high-volume centers are required, however, to better determine the indications and potential benefit of such an undertaking. ( J GASTROINTEST SURG 2005;9:915–921)  2005 The Society for Surgery of the Alimentary Tract KEY WORDS: Pancreatic, pancreatitis, cancer, Whipple, neoadjuvant, technique Surgical resection remains the best chance of cure and palliation for patients presenting with periampul- lary malignancies. Although historically associated with high perioperative mortality risk, pancreaticodu- odenectomy currently can be performed at a number of high-volume centers with a 1%–4% periprocedural mortality rate. 1–3 Consideration for surgical candi- dacy is generally determined based upon computed tomography (CT) criteria. 4–6 Criteria include absence of metastatic disease, no extension into the superior mesenteric or celiac artery, and no tumor invasion into the portal mesenteric confluence. With im- proved surgical experience, especially over the past decade, reports from many centers with high-volume pancreatic surgeries have challenged the presence of From the Departments of Surgery, University of Miami School of Medicine, Miami, Florida (L.G.K., E.P., X.J., D.F.); Penn State University School of Medicine, Hershey, Pennsylvania (K.F.S.-O.); University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (H.J.Z.); The Johns Hopkins University School of Medicine, Baltimore, Maryland (W.R.M.); University of Louisiana School of Medicine, Shreveport, Louisiana (G.Z.); and University of Rochester School of Medicine, Rochester, New York (A.K., L.O.S.). Reprint requests: Leonidas G. Koniaris, M.D., F.A.C.S., Alan Livingstone Chair in Surgical Oncology, University of Miami Miller School of Medicine, 3550 Sylvester Comprehensive Cancer Center (310T), 1475 N.W. 12th St., Miami, FL 33136. e-mail: lkoniaris@med.miami.edu  2005 The Society for Surgery of the Alimentary Tract 1091-255X/05/$—see front matter Published by Elsevier Inc. doi:10.1016/j.gassur.2005.04.005 915 portomesenteric invasion as a contraindication to pancreaticoduodenectomy. 7–9 Of particular signifi- cance is the report of Tseng and coworkers 10 from the M. D. Anderson cancer center who reported venous resection in 141 cases of pancreaticoduodenectomy from 1990 through 2002. This and other consider- ably smaller series have demonstrated that complete resection in patients with lateral tumor invasion of the superior mesenteric venous (SMV) without venous obstruction can be associated with outcomes approaching that of patients undergoing pancreatico- duodenectomy alone. 7–10 Given the nearly equivalent long-term survival associated with venous resection for periampullary malignancies, the question of extending the benefits