Early venous intervention during resection of pancreatic neoplasms with SMV/PV occlusions

Abstract

Introduction: Pancreatic neoplasms with superior mesenteric and/or portal vein (SMV/PV) occlusions present the significant (substantial) surgical challenge of mesenteric hypertension. We present a series of patients who underwent pancreas resection with complete SMV/PV occlusion. Methods: A retrospective review of patients diagnosed with pancreas tumors with concomitant SMV/PV occlusions, and underwent pancreas resection with vascular intervention in the form of portosystemic shunting, resection and thrombectomy was performed. Demographics, perioperative characteristics and outcomes were reviewed. Results: Eleven patients, with a median age of 56, underwent pancreas resection with vascular intervention for pancreas neoplasms with SMV/PV occlusion. The median follow-up was 26 months. Six patients were treated for pancreatic neuroendocrine tumor, two for pancreatic adenocarcinoma, two for solid pseudopapillary tumor and one for a cystic lesion believed to be a large cystic tumor (final pathology revealed sclerosing pancreatitis). Two underwent pancreaticoduodenectomy, 6 left sub- or near total pancreatectomy, and 3 total pancreatectomy. Six underwent early mesocaval shunting, with SMV/PV reconstruction following pancreas resection. Four underwent in-line SMV/PV reconstruction with conduit prior to the bulk pancreatic dissection/reconstruction, and one underwent early tumor thrombectomy. The internal jugular vein was graft of choice in nine patients. Median hospital length of stay was 11 days. Five patients developed complications with Clavien-Dindo grade >III. Six patients required readmission. There were no 90-day mortalities. Conclusion: Despite the technical challenges that arise from the sequelae of SMV/PV occlusion, early mesenteric decompression via mesocaval shunting or immediate in-line SMV/PV reconstruction with graft allows pancreatectomy in the face of SMV/PV occlusion to be performed safely.