Venous shunting procedures for borderline resectable pancreatic cancer

Introduction Contemporary vascular resection and reconstruction during pancreatectomy is done when the surgeon cannot safely separate the portal vein (PV), superior mesenteric vein (SMV), or the SMV-PV confluence from the tumor. A temporary mesocaval shunt provides a safe way to deal with cavernous transformation of the portal vein. This technique also allows wide exposure of the mesenteric root, greatly enhancing exposure of the superior mesenteric artery (SMA) and/or celiac artery when dissection directly on the peri-adventicial plane is challenging due to tumor-artery abutment. Splenic vein (SV) ligation facilitates resection/reconstruction of the SMV-PV confluence and also enhances exposure of the SMA and celiac origin. However, if the IMV does not provide for retrograde decompression of the SV, sinistral hypertension may occur. A distal splenorenal shunt (DSRS) can prevent this complication. Methods We describe the technical aspects and indications for venous shunting procedures during pancreaticoduodenectomy (PD). Summary Venous shunting is a valuable strategy during PD in select patients who have cavernous transformation of the PV or tumor abutment of the SMA or celiac axis where safe arterial dissection will require enhanced exposure. The wide exposure of the mesenteric root, along with diversion of mesenteric venous flow optimizes visibility of critical vascular structures, minimizes blood loss and improves the surgeon’s ability to achieve a negative margin of resection.