Distal transection of the superior mesenteric vein significantly increases the risk of anastomotic stenosis during pancreaticoduodenectomy for cancer.

• Non-tumorous stenosis rate was 40.9% for distal vs. 1.7% for proximal transection (p < 0.01).
• Symptomatic complications like ascites and gastrointestinal bleeding were also higher in the distal group (15.9% vs. 1.2%, p < 0.01).

Surgeons should be cautious of the higher stenosis risk when performing distal transections in these patients.

• Distal transection is a distinct technical risk factor, independent of resection length.