Improved superior mesenteric artery exposure and reduced blood loss risk using temporary mesocaval shunt for locally advanced pancreatic cancer

Abstract

Introduction: Patients with locally advanced pancreatic cancer (LAPC) represent a challenging group to resect given their putative unreconstructible nature of vascular encasement. In selected patients with anatomy beyond “borderline,” temporary mesocaval shunt can facilitate the pancreatectomy by enhancing exposure to the superior mesenteric vessels. Methods: This is a video of a pancreaticoduodenectomy (PD) with temporary mesocaval shunt with left internal jugular (LIJ) vein conduit. Results: A 65 year-old woman presented with LAPC originating in the uncinate causing complete occlusion of the superior mesenteric vein (SMV) and encasement of the first jejunal artery. After neoadjuvant therapy, decision was made to perform a PD with temporary mesocaval shunt to divert SMV flow, reduce blood loss and prevent bowel ischemia during the anticipated longer time needed for the retroperitoneal-superior mesenteric artery (SMA) portion of the PD. During the procedure, the main mesenteric collateral (lieocolic vein) was divided flush to use as landing zone to sew the shunt to the inferior vena cava with the LIJ interposition. The remaining SMV tributaries encased by the tumor were divided. The uncinate dissection was performed with an SMA-first approach with the SMV divided and out of the way. Once the resection was completed, the shunt was stapled from the IVC graft and transposed to the upper SMV for final reconstruction. Standard reconstructions were performed. Estimated blood loss was 250cc. No perioperative complications occurred. Conclusion: In LAPC, PD with temporary mesocaval shunt can facilitate margin-negative resection and transfusion-free venous reconstruction in patients with otherwise unreconstructible complete PV/SMV occlusion.