Revascularization techniques for complete portomesenteric venous occlusion in patients undergoing pancreatic resection

Pancreatic pathologies causing portomesenteric occlusion complicate extirpative pancreatic resection due to portomesenteric hypertension and collateral venous drainage. Patients with portomesenteric occlusion undergoing pancreatectomy were identified between 2007 and 2020 at Stanford University Hospital. Demographic and clinical data, technique and perioperative factors, and post-operative outcomes were analyzed. Of twenty-seven (27) patients undergoing venous revascularization during pancreatectomy, most (15) were for pancreatic neuroendocrine tumor. Occlusions occurred mostly at the portosplenic confluence (15). Median occlusion length was 4.0 cm [3.1–5.8]. Regarding revascularization strategy, mesocaval shunting was used in 11 patients, in-line venous revascularization with internal jugular conduit in three patients, traditional venous resection and reconstruction in 9 patients, and thrombectomy in two patients. Median cohort operative time and estimated blood loss were 522 min [433–638] and 1000 mL [700–2500], respectively. Median length of stay was 10 days [8–14.5] with overall readmission rate of 37%. Significant complications occurred in 44% of patients despite only one (4%) perioperative mortality. Despite the technical complexity for managing portomesenteric occlusions, early revascularization strategies including mesocaval shunting or in-line venous revascularization are feasible and facilitate a safe pancreatic resection for surgically fit patients.