Shunting for Portal Vein Reconstruction—A Single-Institution Case Series

During pancreatic head resection (Whipple procedure), the portal vein (PV) and mesenteric veins must often be resected or repaired. Grafts or patches for mesenteric venous reconstruction—homograft, internal jugular vein, or bovine pericardium—can take time to thaw or to be harvested. Therefore, temporary procedural shunting of the mesenteric venous circulation during reconstruction can mitigate bowel edema and ischemia resulting from procedural venous occlusion (Fig). Patient health information was harvested retrospectively from a prospectively maintained database. Data were summarized using standard statistical techniques. Twenty-one patients, 12 women and 9 men, underwent temporary PV shunting during oncologic resection and PV reconstruction from 2010 to 2020. Average age was 64 years. All patients had either pancreatic cancer (95%) or cholangiocarcinoma (5%) and underwent Whipple procedure (81%) or pancreatectomy and splenectomy (19%). Reconstructions consisted of interposition grafting (52% cadaveric aortic homograft and 5% internal jugular vein) or patch angioplasty (38% bovine pericardium and 5% internal jugular vein). No. 12 and No. 14 Argyle shunts were used. In all but two patients, the shunt was easily placed into the superior mesenteric vein (SMV) caudally and the PV cranially. One patient was shunted caudally into the splenic vein as his SMV had chronic nonocclusive thrombus that precluded shunt placement. The other patient lacked sufficient length of the SMV stump to clamp around the shunt, so only the second anastomosis (on the liver side) was performed with the shunt in place. Technical success of the PV reconstruction was 100%, and no intraoperative complications resulted from shunt placement. Postoperatively, one PV reconstruction thrombosed before discharge on day 7, which was managed nonoperatively with anticoagulation. During a mean follow-up of 13.6 months (range, 0.2-112 months), three additional reconstructions occluded (two early at 0.5 month and 1.5 months in patients with aggressive recurrent cancer and one late at 28 months after adjuvant radiation therapy). No other complications, including pseudoaneurysm or graft infection, were noted. Shunting is a well-established technique with which most vascular surgeons are comfortable in practice. Applying it as an adjunct in a novel context for PV reconstruction is safe, is technically straightforward, and may mitigate the deleterious effects of temporary mesenteric venous occlusion required for mesenteric venous reconstruction during oncologic resection.