Distal splenorenal and mesocaval shunting at the time of pancreatectomy: an important adjunct to the operative management of selected patients

Abstract

Background: We previously provided proof that pancreatic resection in the setting of complex vascular involvement can be safely performed. When the tumor involves the portal-superior mesenteric-splenic vein (PV-SMV-SV) confluence with abutment of the SMA, a mesocaval shunt (MCS) may be created with/without distal splenorenal shunt (DSRS). This achieves wide exposure of the vascular structures involved and allows for a safe pancreatectomy. We report our experience with these procedures. Methods: All patients with pancreatic resection and either DSRS and/or MCS were identified from our institutional database. Demographics, stage, neoadjuvant treatment, operative details and outcomes were reviewed. Results: Twenty-eight patients were resected with the aid of shunting procedures (25 adenocarcinomas, 2 neuroendocrine cancers, 1 solid pseudopapillary tumor), including 23 standard or extended pancreaticoduodenectomies and 5 total pancreatectomies. Shunts consisted of 11 MCS, 15 DSRS and 2 MCS/DSRS. Eight MCS were temporary. Median operative time was 8.8 hours (6.3-13), median estimated blood loss was 925 mL (100-3500) and median length of hospital stay was 11.5 days (7-35). Two patients experienced Clavien-Dindo grade III or above complications. No 90-day mortalities or reoperations encountered. Median follow up was 12.2 months (0.5-97). Overall survival was 29 months for patients with adenocarcinoma. Of the permanent shunts performed, all but one DSRS was patent at follow up. Conclusion: Shunting facilitates safe resection in pancreatic tumor patients who may otherwise be deemed inoperable. In the era of more effective systemic therapy, it's critically important to know which patients are candidates for extended resections and how to safely perform them.