A 74 year-old man, presented relevant weight loss (15 kgs/1 month) and new onset diabetes associated with Ca 19.9 levels of 467 UI/ml. A CT scan identified a 25x20 mm solid lesion in the pancreatic head associated with main pancreatic duct dilatation (6mm). No distant distant metastases neither vascular invasion (cT2) were detected. Ultrasound-endoscopy confirmed the presence of a hypoechoic lesion of 31x26 mm, in contact with the superior mesenteric vein without evidence of its infiltration. Doubtful locoregional nodes were detected (uT2N1) too. A pylorus-preserving pancreaticoduodenectomy was scheduled. Intraoperatively, after pancreatic isthmus section, the presence of suspicious solid tissue involving the spleno-mesenteric venous confluence was found. The superior mesenteric artery was dissected and gently isolated from the superior mesenteric vein. Infiltration was confirmed, portal vein, splenic and inferior mesenteric veins were isolated and pancreaticoduodenectomy en block with spleno-mesenteric venous confluence resection was completed. Venous confluence reconstruction with an end-to end suture was performed.