The surgical management of MEN I pancreticoduodenal neuroendocrine disease remains controversial, particularly when ZES is present. Our approach is a multifaceted procedure which includes a distal pancreatectomy, enucleation of tumors in the head or uncinate, duodenotomy and excision of one or more duodenal gastrinomas with peripancreatic lymph node dissection. This procedure has resulted in eugastrinemia in two-thirds of 36 patients. A subtotal parathyroidectomy and cervical thymedctomy is also done in those patients with concomitant hyperparathyroidism.