Ann Hepatobiliary Pancreat Surg.  2021 Feb;25(1):122-125. 10.14701/ahbps.2021.25.1.122.

Transient mesoportal shunt: An innovative technique for maintaining portal flow during pancreatoduodenectomy with portal vein resection

• S. GM
• Gnanasekaran S
• Raja K
• Pottakkat B

• KMID: 2513185
• DOI: http://doi.org/10.14701/ahbps.2021.25.1.122

Abstract

Pancreatic cancers exhibit a surgical challenge, in light of frequent vascular involvement. In absence of metastatic spread, vascular invasion is the predominant limiting factor for determining the resectability. With progression of time vascular involvement is no longer considered a surgical contraindication. However these complex procedures are fraught with technical challenges. Portal clamping required for vascular resection and reconstruction results in hepatic ischemia and visceral congestion. In order to mitigate these untoward effects, surgeons have tried diverse techniques including venous shunts. Venous shunting facilitates the resection and allows for an enhanced exposure and a safe procedure. Previously described techniques were either cumbersome or failed to maintain portal flow. We present a technique of transient mesoportal shunt, to facilitate vascular resection during pancreatoduodenectomy. This technique is both simple and maintains portal flow throughout the procedure preventing both hepatic ischemia and visceral congestion.

Keyword

Borderline resectable carcinoma pancreas; Transient mesoportal shunt; Pancreatoduodenectomy; Vascular resection

Figure

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  Fig. 1 Preoperative contrast enhanced CT images. (A) Borderline pancreatic head malignancy involving portal vein confluence region (arrow). (B) Lesion has contact with portal vein of >180° with contour abnormality.

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  Fig. 2 Intraoperative images. (A) Hard tumor noted in the head and uncinate process of pancreas with infiltration into SMV-PV confluence region (white arrow). (B) Tumor was adherent to CHA (yellow arrow), both proximal and distal artery control were taken.

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  Fig. 3 Intraoperative images demonstrating construction of TMPS. (A) TMPS constructed after application of side biting vascular clamps, with a 10 mm- Dacron graft. (B) Schema depicting the construction of TMPS.

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  Fig. 4 Intraoperative images showing tumor bed. (A) Tumor was resected enbloc with a segment of PV-SMV confluence. Arrows depict transected ends of portal vein (a), splenic vein (b), IMV (c), SMV (d). (B) Schema showing operative field after enbloc resection.

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