Elsevier

Transplantation Proceedings

Volume 53, Issue 8, October 2021, Pages 2598-2601
Transplantation Proceedings

Intestinal Autotransplantation and In-Situ Resection of Recurrent Pancreatic Head Intraductal Tubulopapillary Neoplasm with Portal Cavernoma: A Case Report

https://doi.org/10.1016/j.transproceed.2021.05.009Get rights and content

HIGHLIGHTS

  • Intraductal tubulopapillary neoplasm is a rare premalignant pancreatic neoplasia.

  • Frequently the proximity of the tumor to the large abdominal vessels precludes conventional resection.

  • Autotransplantation offers a safe and curative resection of otherwise inoperable tumors.

ABSTRACT

Background

Intraductal tubulopapillary neoplasm (ITPN) is a new entity of a rare premalignant pancreatic neoplasia, and a radical curative resection is indicated. As with other tumors of the root of the mesentery, the proximity of the lesion to large splanchnic vessels, abdominal aorta, and inferior vena cava poses major risks of a massive hemorrhage and visceral ischemia using conventional surgical techniques. At times, these lesions are amenable for resection using novel techniques developed from organ transplantation. Multivisceral (allo-) transplantation should be considered when radical resection of a benign tumor is likely to compromise portal flow and possibly precipitate acute liver failure, but it may be associated with a long waitlist time and tumor progression. Autotransplantation offers a safe and curative resection of otherwise inoperable tumors in a bloodless field, an excellent exposure, and prevention of warm ischemic injury to the affected viscera, which are then autotransplanted.

Methods

We describe the en bloc resection of a large and recurrent ITPN of the pancreas, distal stomach, proximal duodenum, transverse colon, superior mesenteric vein, and portal cavernoma, followed by intestinal autotransplantation.

Results

A complete tumor resection was achieved with negative margins, adequate cold preservation of the reimplanted intestine, and without significant hemorrhage. The patient was discharged from the hospital 10 days later. The histopathologic examination revealed free-margin resection of ITPN with an associated invasive carcinoma. The patient received adjuvant chemotherapy with folinic acid, fluorouracil, and oxaliplatin and remains disease-free 20 months after surgery.

Conclusions

Autotransplantation offers curative resection of otherwise unresectable lesions of the root of the mesentery.

Section snippets

Patient Presentation

This report was exempt from an institutional review board approval. The patient was a 24-year-old Israeli man, who 5 years earlier had undergone distal pancreatectomy and splenectomy for ITPN with multifocal high-grade dysplasia. Nearly 30 months later, he developed abdominal pain, diarrhea, exocrine pancreatic insufficiency, diabetes, and bouts of sepsis. Computerized tomography (CT) scan showed a recurrent cystic tumor arising from the head of the pancreas. During preoperative workup for

Discussion

Because of its rarity, limited data are available concerning the natural history of ITPN. Malignant transformation with locally invasive disease was found in 54% of ITPNs and was more common in the presence of a large tumor size and a high Ki-67 proliferative index [6]. Similar to other precancerous pancreatic neoplasia, radical, margin-free resection is indicated for premalignant ITPN and ITPN-associated invasive carcinoma [7,8]. In patients with invasive disease, 5-year survival is 71%, and

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