Pancreatectomy with en bloc superior mesenteric vein resection and permanent mesocaval shunting for locally advanced pancreatic head cancer

In pancreatic cancer (PC) with superior mesenteric vein (SMV) invasion, radical resection following neoadjuvant chemotherapy (NAC) is often feasible. While temporary mesocaval shunting (MCS) with subsequent portal vein (PV) reconstruction has been reported, PV reconstruction may be omitted in cases with sufficient collateral circulation. We report a case in which permanent MCS without PV reconstruction was employed to manage unexpected bowel congestion despite preoperative imaging suggesting adequate collateral flow. An elderly woman with borderline resectable uncinate PC and SMV invasion underwent pancreaticoduodenectomy with en bloc SMV resection following NAC. Intraoperatively, a 12-cm gap for reconstruction was noticed, and MCS was performed. The patient was discharged without liver dysfunction or hyperammonemia. This case highlights that permanent MCS may offer a salvage technique in select patients with SMV involvement, particularly when venous grafts are not available. It expands the surgical options in anatomically challenging cases.