Pancreaticoduodenectomy with mesocaval shunt for locally advanced pancreatic adenocarcinoma

Abstract

Background: Patients with locally advanced pancreatic cancer (LAPC) represent a challenging group to treat given the involvement of major vascular structures. In selected patients with favorable biology, temporary mesocaval shunt can facilitate the resection and allow for a safer procedure with enhanced exposure to the superior mesenteric vessels. Methods: We show 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 in the uncinate causing total occlusion of the superior mesenteric vein (SMV) and encasement of the first jejunal artery. After neoadjuvant therapy and evidence of disease stability, decision was made to perform a PD with temporary mesocaval shunt to divert mesenteric flow to reduce blood loss and prevent bowel ischemia. During the procedure, the main mesenteric collateral (lieocolic vein) was divided to perform the shunt to the inferior vena cava with LIJ interposition. The remaining mesenteric tributaries involved by the tumor were divided. The uncinate dissection was performed with an SMA-first approach. Once the resection was completed, the shunt was stapled from the IVC graft transposed to the upper SMV for reconstruction. Standard reconstruction was performed. Total operative time was 536 minutes. The estimated blood loss was 250cc with no transfusions. No perioperative complications occurred, and the patient was ready for discharge on post-op day 5. Conclusion: In selected patients with LAPC, PD with temporary mesocaval shunt can facilitate resection and venous reconstruction in patients with complete PV/SMV occlusion.