Mesoportal bypass, interposition graft, and mesocaval shunt: Surgical strategies to overcome superior mesenteric vein involvement in pancreatic cancer

Published:September 17, 2020DOI:



      In pancreatic cancer, extensive tumor involvement of the mesenteric venous system poses formidable challenges to operative resection. Such involvement can result from cavernous collateral veins leading to increased intraoperative blood loss or long-segment vascular defects of not only just the superior mesenteric vein but also even jejunal/ileal branches. Strategies to facilitate margin-free resection and safe vascular reconstruction in pancreatic surgery are important, particularly because systemic control of the tumor is improving with multi-agent chemotherapy regimens.


      We describe a systematic, multidisciplinary assessment for patients with pancreatic cancer that involves the superior mesenteric vein, as well as the preoperative planning of those undergoing operative resection. In addition, detailed descriptions of operative approaches and technical strategies, which evolved with increasing experience at a high-volume center, are presented.


      For the preoperative evaluation of tumor-free, vascular locations for potential reconstruction and collateralization, computed tomographic imaging with high-resolution of vascular structures (used with 3-dimensional or cinematic rendering) allows a precise calibration of radiographic data with intraoperative findings. From an operative perspective, we identified 5 potential strategies to consider for resection: collateral preservation, mesoportal bypass (preresection), mesoportal interposition graft (postresection), mesocaval shunt, and various combinations of these strategies. Many of these techniques use interposition grafts, making it essential to assess autologous veins (preferred conduit for reconstruction) or to prepare cryopreserved vascular allografts (an alternative conduit, which must be thawed and should be matched for size and blood type).


      Herein we share operative strategies to overcome involvement of the superior mesenteric vein in pancreatic cancer. Improvements in preoperative planning and operative technique can address common barriers to resection with curative intent.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ho C.K.
        • Kleeff J.
        • Friess H.
        • Büchler M.W.
        Complications of pancreatic surgery.
        HPB. 2005; 7: 99-108
        • Cameron J.L.
        • He J.
        Two thousand consecutive pancreaticoduodenectomies.
        J Am Coll Surg. 2015; 220: 530-536
        • Neoptolemos J.P.
        • Palmer D.H.
        • Ghaneh P.
        • et al.
        Comparison of adjuvant gemcitabine and capecitabine with gemcitabine monotherapy in patients with resected pancreatic cancer (ESPAC-4): a multicentre, open-label, randomised, phase 3 trial.
        Lancet. 2017; 389: 1011-1024
        • Conroy T.
        • Hammel P.
        • Hebbar M.
        • et al.
        FOLFIRINOX or gemcitabine as adjuvant therapy for pancreatic cancer.
        N Engl J Med. 2018; 379: 2395-2406
        • Tempero M.A.
        • Malafa M.P.
        • Al-Hawary M.
        • et al.
        Pancreatic adenocarcinoma, Version 2.2017, NCCN Clinical Practice Guidelines in Oncology.
        J Natl Compr Canc Netw. 2017; 15: 1028-1061
        • Hackert T.
        • Sachsenmaier M.
        • Hinz U.
        • et al.
        Locally advanced pancreatic cancer: neoadjuvant therapy with FOLFIRINOX results in resectability in 60% of the patients.
        Ann Surg. 2016; 264: 457-463
        • Gemenetzis G.
        • Groot V.P.
        • Blair A.B.
        • et al.
        Survival in locally advanced pancreatic cancer after neoadjuvant therapy and surgical resection.
        Ann Surg. 2019; 270: 340-347
        • Caggiati A.
        • Bergan J.J.
        • Gloviczki P.
        • et al.
        Nomenclature of the veins of the lower limb: extensions, refinements, and clinical application.
        J Vasc Surg. 2005; 41: 719-724
        • Ravikumar R.
        • Sabin C.
        • Abu Hilal M.
        • et al.
        Impact of portal vein infiltration and type of venous reconstruction in surgery for borderline resectable pancreatic cancer.
        Br J Surg. 2017; 104: 1539-1548
        • Glebova N.O.
        • Hicks C.W.
        • Piazza K.M.
        • et al.
        Technical risk factors for portal vein reconstruction thrombosis in pancreatic resection.
        J Vasc Surg. 2015; 62: 424-433
        • Dua M.M.
        • Tran T.B.
        • Klausner J.
        • et al.
        Pancreatectomy with vein reconstruction: technique matters.
        HPB. 2015; 17: 824-831
        • Hirono S.
        • Kawai M.
        • Tani M.
        • et al.
        Indication for the use of an interposed graft during portal vein and/or superior mesenteric vein reconstruction in pancreatic resection based on perioperative outcomes.
        Langenbecks Arch Surg. 2014; 399: 461-471
        • Zhang X.M.
        • Fan H.
        • Kou J.T.
        • et al.
        Resection of portal and/or superior mesenteric vein and reconstruction by using allogeneic vein for pT3 pancreatic cancer.
        J Gastroenterol Hepatol. 2016; 31: 1498-1503
        • Zhao X.
        • Li L.X.
        • Fan H.
        • et al.
        Segmental portal/superior mesenteric vein resection and reconstruction with the iliac vein after pancreatoduodenectomy.
        J Int Med Res. 2016; 44: 1339-1348
        • Terasaki F.
        • Fukami Y.
        • Maeda A.
        • et al.
        Comparison of end-to-end anastomosis and interposition graft during pancreatoduodenectomy with portal vein reconstruction for pancreatic ductal adenocarcinoma.
        Langenbecks Arch Surg. 2019; 404: 191-201
        • Gao W.
        • Dai X.
        • Jiang K.
        • et al.
        Comparison of patency rates and clinical impact of different reconstruction methods following portal/superior mesenteric vein resection during pancreatectomy.
        Pancreatology. 2016; 16: 1113-1123
        • Fishman E.K.
        • Horton K.M.
        Imaging pancreatic cancer: the role of multidetector CT with three-dimensional CT angiography.
        Pancreatology. 2001; 1: 610-624
        • Chu L.C.
        • Johnson P.T.
        • Fishman E.K.
        Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities.
        Abdom Radiol N Y. 2018; 43: 3009-3015
        • Weitz J.
        • Rahbari N.
        • Koch M.
        • Büchler M.W.
        The “artery first” approach for resection of pancreatic head cancer.
        J Am Coll Surg. 2010; 210: e1-e4
        • Hackert T.
        • Werner J.
        • Weitz J.
        • Schmidt J.
        • Büchler M.W.
        Uncinate process first—a novel approach for pancreatic head resection.
        Langenbecks Arch Surg. 2010; 395: 1161-1164
        • Janssen Q.P.
        • Buettner S.
        • Suker M.
        • et al.
        Neoadjuvant FOLFIRINOX in patients with borderline resectable pancreatic cancer: a systematic review and patient-level meta-analysis.
        J Natl Cancer Inst. 2019; 111: 782-794
        • Klaiber U.
        • Leonhardt C.-S.
        • Strobel O.
        • et al.
        Neoadjuvant and adjuvant chemotherapy in pancreatic cancer.
        Langenbecks Arch Surg. 2018; 403: 917-932
        • Bachellier P.
        • Rosso E.
        • Fuchshuber P.
        • et al.
        Use of a temporary intraoperative mesentericoportal shunt for pancreatic resection for locally advanced pancreatic cancer with portal vein occlusion and portal hypertension.
        Surgery. 2014; 155: 449-456
        • Clatworthy W.H.
        • Wall T.
        • Watman W.R.
        A new type of portal-to-systemic venous shunt for portal hypertension.
        Arch Surg. 1955; 71: 588
        • Marion P.
        Mesentero-caval anastomosis.
        J Cardiovasc Surg. 1966; 70: 70
        • Pilgrim C.H.C.
        • Tsai S.
        • Evans D.B.
        • Christians K.K.
        Mesocaval shunting: a novel technique to facilitate venous resection and reconstruction and enhance exposure of the superior mesenteric and celiac arteries during pancreaticoduodenectomy.
        J Am Coll Surg. 2013; 217: e17-e20
        • Chavez M.I.
        • Tsai S.
        • Clarke C.N.
        • et al.
        Distal splenorenal and mesocaval shunting at the time of pancreatectomy.
        Surgery. 2014; 165: 298-306
        • Kumar R.
        • Herman J.M.
        • Wolfgang C.L.
        • Zheng L.
        Multidisciplinary management of pancreatic cancer.
        Surg Oncol Clin N Am. 2013; 22: 265-287
        • Dokmak S.
        • Aussilhou B.
        • Sauvanet A.
        • et al.
        Parietal peritoneum as an autologous substitute for venous reconstruction in hepatopancreatobiliary surgery.
        Ann Surg. 2015; 262: 366-371