Small Bowel Autotransplantation for Pancreatic Adenocarcinoma Involving the Superior Mesenteric Artery
Biolchini F1, Mastrangelo L1, Landolfo G1, Billi P2, Talarico F1, Lazzari A1, Selleri S1, Lerro MF1, Martuzzi F1, D’Imperio N2, Jovine E1
1Division of Surgery and 2Division of Gastroenterology, 'Maggiore' Hospital. Bologna, Italy
ABSTRACT
Background The presence of vascular involvement due to adenocarcinoma of the head of the pancreas is still considered by some authors a contraindication for surgery. Recently an improved survival after pancreatectomy with associated resection of the superior mesenteric vein or the portal vein was demonstrated, while the involvement of the superior mesenteric artery still remains an absolute contraindication for surgery.
Aim The authors described a case of small bowel autotransplantation in a 60-year old woman affected by an adenocarcinoma of the head of the pancreas with infiltration of the superior mesenteric artery.
Methods Intraoperatively, a neoplastic involvement of the common hepatic artery was detected, thus, a revascularization of the liver by an anastomosis of the common hepatic artery with the left gastric artery, was necessary. Then, the stomach, duodenum, pancreas, spleen, small bowel, right colon, extrahepatic bile duct, cephalad superior mesenteric vein and proximal superior mesenteric artery were resected, with en-bloc dissection of the paraaortic lymph nodes. The resected organs were flushed with chilled Celsior solution, placed in an ice-cold bath and, then, the total pancreatectomy was performed. Only the small bowel was autotransplanted by anastomozing the portal vein to the superior mesenteric vein and by anastomozing the superior mesenteric artery of the small bowel with the proximal superior mesenteric artery with the interposition of a cadaveric graft. Then, the gastrointestinal continuity was completed.
Results The intervention was 12 hours long, while the cold ischemia time was about 2 hours. The patient started normal oral feeding after 4 days. In the 6th postoperative day, the patient developed a massive hemoperitoneum due to the dissection of the common hepatic artery and reintervention was necessary. Unfortunately, the patient died 10 days after the first intervention for a multi organ failure.
Conclusions Small bowel autotransplantation could represent the only therapy in patients affected by pancreatic carcinoma with involvement of the superior mesenteric artery, at least in selected cases.
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