Ex-vivo small bowel auto-transplantation with a prior pancreaticoduodenectomy (Whipple’s procedure): a report of a rare case and review of literature

Abstract

Background

Mesenteric tumors involving the superior mesenteric vessels are rare and challenging to treat, particularly in patients with prior complex abdominal surgery. When conventional resection risks extensive bowel loss, ex-vivo small bowel autotransplantation (EV-SBAT) offers a means to achieve R0 resection while minimizing warm ischemia. Evidence supporting its feasibility after pancreaticoduodenectomy remains extremely limited.

Case presentation

A 38-year-old woman with a history of pancreaticoduodenectomy presented with vague and persistent mid-abdominal pain. CT scan revealed a 134 × 76 × 145 mm mesenteric mass encasing the superior mesenteric artery and vein, with progression despite systemic chemotherapy and no evidence of distant metastasis. Given the need for R0 resection and lack of alternative curative options, a multidisciplinary team elected to perform EV-SBAT. Tumor resection, vascular, and gastrointestinal reconstruction were successfully achieved despite surgically altered anatomy. She was discharged in stable condition on postoperative day 14, and no radiological evidence of recurrence at 6-month follow-up.

Conclusion

This case demonstrates that EV-SBAT is a feasible and rational surgical strategy for selected patients with locally advanced mesenteric tumors, even after prior pancreaticoduodenectomy. To our knowledge, this is the first reported case of EV-SBAT performed in a patient with prior Whipple surgery, highlighting both the technical challenges and the feasibility of this approach. Careful patient selection, multidisciplinary decision-making, and meticulous operative planning are essential to achieving acceptable outcomes in this highly complex setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-026-03595-8.

Background

Mesenteric tumors, encompassing a wide spectrum of both benign and malignant neoplasms, can present diagnostic and therapeutic challenges. The mesentery, a peritoneal fold connecting the intestine to the posterior abdominal wall, contains a rich network of blood vessels (including the superior and inferior mesenteric arteries and veins) and lymphatics, which are essential for intestinal viability and function [1, 2]. Given its intricate and vital anatomy, the resection of tumors involving major mesenteric vessels often necessitates extensive bowel resection, resulting in short bowel syndrome, severe malnutrition, long-term total parenteral nutrition dependence, and a diminished quality of life [3]. Management of mesenteric tumors involving the major intestinal blood vessels represents one of the most complex and challenging scenarios in gastrointestinal surgery. Traditional surgical approaches often face significant limitations, as achieving complete tumor resection without compromising the blood supply to a substantial portion of the intestine remains a formidable challenge. In recent years, ex vivo small bowel autotransplantation (EV-SBAT) has emerged as a promising therapeutic option for complex mesenteric tumors encasing or invading critical vascular structures [4, 5]. Despite the initial successes of this technique in a limited number of mesenteric tumor cases, available data regarding its efficacy and safety, particularly in patients with a history of major abdominal surgeries such as pancreaticoduodenectomy (Whipple procedure), remain rare [6].

This case presents a unique management approach of a patient with a prior pancreaticoduodenectomy, who underwent intestinal autotransplantation. The previous Whipple procedure made this surgery more complicated.

Case presentation

Patient information

A 38-year-old woman presented with persistent mid-abdominal pain associated with abdominal distention. She had a history of an abdominal mass first identified in 2020, during which periodic evaluations revealed a pancreatic head neuroendocrine tumor. In June 2020, she underwent a pancreaticoduodenectomy. In April 2023, imaging detected a large mesenteric mass encasing the superior mesenteric vessels. Over the following two years, she received systemic chemotherapy, including Sandostatin, capecitabine, everolimus, and temozolomide. She had no other comorbidities and no drug allergies.

Clinical findings

She was hemodynamically stable with a distended, mildly tender abdomen. No peritonitis or obstruction was present. Initial laboratory tests were within the normal reference range except hemoglobin and alkaline phosphatase (ALP), which were 8.9 g/dL and 360 U/L, respectively (Table 1).

Table 1.

This table shows laboratory test results recorded preoperatively, on postoperative day 1, and on the final day of hospitalization

	Preoperative	1st day after surgery	14th day after surgery
WBC	4900	7600	4600
RBC	3.37	3.53	3.5
Hb	8.9	9.4	10.0
HCT	27.9	29.0	30.9
MCV	82.8	82.1	88.3
MCH	26.4	26.6	28.6
MCHC	31.9	32.4	32.4
Platelet	175,000	100,000	202,000
AST	19	106	17
ALT	13	18	10
ALP	360	133	193

ALP alkaline phosphatase, ALT alanine aminotransferase, AST aspartate aminotransferase, HB hemoglobin, HCT hematocrit, MCH mean corpuscular hemoglobin, MCHC mean corpuscular hemoglobin concentration, MCV mean corpuscular volume, RBC red blood cell, WBC white blood cell

Diagnostic assessments

A positron emission tomography scan showed an increased uptake of 18 F-fluorodeoxyglucose in a retroperitoneal lesion measuring 3.1 × 1.9 cm in May 2023. Two years later, in June 2025, computed tomography (CT) of the abdomen showed a large mesenteric mass measuring approximately 134 × 76 × 145 mm located at the root of the mesentery. Preoperative CT-scan demonstrated that the mesenteric mass had near-circumferential involvement of both the SMA and SMV. The SMA was seen coursing through the central portion of the tumor, while the SMV was partially encased by the mass. These features confirmed the necessity of en bloc resection with vascular reconstruction (Fig. 1). Due to the progression and poor chemotherapy response, surgery was planned. The main indications for surgery were progressive weight loss, intolerance to per oral (PO) intake, involvement of the mesenteric vessels, and tumor progression despite chemotherapy.

Fig. 1.

Preoperative contrast-enhanced computed tomography demonstrating a large, well-circumscribed soft-tissue mass located at the root of the mesentery, with involvement of the mesenteric vessels

Therapeutic intervention and surgical procedure

Extensive SMA/SMV involvement and altered anatomy from prior Whipple surgery precluded conventional resection. The multidisciplinary surgical team decided to proceed with an EV-SBAT. The surgical steps were as follows:

1. A mid-line incision was performed, and upon opening the abdominal cavity, extensive adhesions from the previous surgery were encountered and carefully lysed. A healthy 210-cm segment of small intestine free of tumoral involvement was first isolated. Before clamping the main abdominal vessels, 5000 units of heparin were infused intravenously.

2. The resected specimen was transferred to a sterile, isolated environment and continuously perfused with University of Wisconsin (UW) solution to minimize ischemic injury (Fig. 2). The bowel was kept at a temperature of 4 °C under cold ischemia for 2 h and 15 min.

3. Subsequently, the mesenteric tumor, along with the affected bowel, a 1 cm margin of pancreatic body, para-aortic lymph node, and right colon were resected en bloc. Gross tumor size was 18 × 15 × 13 cm (Fig. 3A). Because of the involvement of the mesentery of jejunal limbs from prior pancreaticoduodenectomy anastomoses, the surgeon had to resect the involved jejunal limbs (Fig. 3B).

4. The tumor, which had encased the SMA (approximately 3 cm distal to its origin from the aorta) and SMV (about 1 cm distal to its confluence with the splenic vein), was then resected. During the cold phase the graft SMA and SMV were carefully prepared for anastomosis after complete tumor dissection.

5. Vascular reconstruction was subsequently performed with end-to-end SMA-to-SMA and SMV-to-SMV anastomoses were performed. An additional intraoperative video shows vascular continuity of the SMA, SMV, and portal vein after reconstruction [see additional file 1]. After achieving R0 resection and successful vascular reconstruction, the preserved bowel was autotransplanted and reconstructed using uninvolved jejunum with good vascular pulsations and peristalsis (Fig. 3C). The warm ischemic time, defined as the period from removal of the isolated bowel from the UW solution until completion of vascular anastomosis and reperfusion, was 20 min.

6. Gastrointestinal continuity was then restored by duct-to-mucosa pancreaticojejunostomy to restore pancreatic drainage (as the pancreatic tail was preserved and only a 1 cm margin of the body was removed), hepaticojejunostomy for biliary continuity, gastrojejunostomy to reestablish gastric outflow, and ileocolic anastomosis following right hemicolectomy [see additional file 2]. The operation was completed successfully, with excellent perfusion of the transplanted bowel and stable reconstruction of all gastrointestinal anastomoses.

Fig. 2.

Ex vivo resected small bowel segment perfused with University of Wisconsin (UW) solution for graft preservation and minimization of ischemic injury

Fig. 3.

A Large mesenteric tumor resected by ex-vivo surgery. B Neuroendocrine tumor before complete resection, demonstrating extensive mesenteric involvement. C Intestinal graft prepared and ready for autotransplantation

According to our knowledge, this represents the first reported case of EV-SBAT performed in a patient with a history of Whipple surgery. The altered anatomy from the prior surgery significantly increased the technical complexity, particularly during reconstruction of gastrointestinal continuity.

Histopathological examination confirmed metastatic neuroendocrine carcinoma, depositing in the mesentery, but the small intestine itself was free of tumoral cells. The tumor was positive for CD56 and vimentin, with a Ki67 proliferation index of approximately 40%, consistent with a high-grade tumor (Fig. 4).

Fig. 4.

Histopathological and immunohistochemical findings of the mesenteric tumor showing positive staining for vimentin (A), CD56 (B), and Ki-67 (C), consistent with neuroendocrine carcinoma

The decision to perform this surgery was made after a multidisciplinary tumor board discussion involving surgical oncology, medical oncology, radiology, and gastroenterology specialists. The patient had a progressive mesenteric neuroendocrine carcinoma encasing the SMA and SMV, with increasing abdominal pain, intolerance to oral intake, and clinical despite systemic chemotherapy. Because of the neuroendocrine nature of the tumor, palliative or debulking surgery was not considered beneficial, as achieving R0 resection remains the only potentially curative option for localized digestive neuroendocrine carcinoma [7]. Imaging studies confirmed localized disease without distant metastasis, supporting the feasibility of a curative intervention. Although the Ki-67 index was high (40%), the absence of systemic spread and the patient’s good performance status justified an aggressive surgical approach. Given the tumor’s rapid progression, failure of medical therapy, and the patient’s deteriorating nutritional condition, no other viable treatment option existed. The goal of surgery was R0 resection, restoration of bowel continuity, and prevention of total parenteral nutrition dependence. Thus, EV-SBAT represented the only feasible and potentially life-saving approach.

Follow-up and outcomes

The patient had an uneventful postoperative course except suffering from postoperative diarrhea, which was controlled using pancreatin and loperamide. She was discharged on the 14th postoperative day in stable condition, tolerating oral intake and improvement in abdominal discomfort. During the follow-up period, she underwent abdominopelvic CT scan and Gallium-68 positron emission tomography (PET) scan, both of which demonstrated no evidence of local recurrence or distant metastasis (Fig. 5). Serial monitoring of serum ALP, and liver function tests, revealed no abnormal trends. The patient was started on adjuvant therapy with intramuscular Sandostatin LAR 30 mg and oral Everolimus as part of the multidisciplinary treatment plan. She was followed up regularly with clinical examinations, nutritional assessment, and laboratory testing. Over a six-month period, her BMI increased from approximately 18 to 23, supported by nutritional supplements and probiotics. The patient remains disease-free at 6 months, and we have acknowledged the limitation of short follow-up duration, with ongoing long-term follow-up planned every 6 months.

Fig. 5.

Contrast-enhanced abdominopelvic CT scan at 6-month follow-up. A The liver demonstrates mild fatty changes; SMA, SMV, and portal vein are patent and free of tumor involvement. B The base of the mesentery and intra-abdominal organs show no evidence of residual or recurrent tumor

Discussion and conclusions

To verify the novelty of this case, a structured literature search was conducted in PubMed, Scopus, and Google Scholar databases for studies published up to December 2025, with the following search strategy of (“intestinal autotransplantation” OR “small bowel autotransplantation” OR “visceral autotransplantation” OR “autologous intestinal transplantation”) AND (“pancreaticoduodenectomy” OR “Whipple”). Only English-language articles describing ex-vivo or autologous intestinal transplantation in patients with prior pancreaticoduodenectomy were considered. Reports involving multivisceral transplantation, simultaneous intestinal autotransplantation and Whipple procedure, or partial bowel resections without reimplantation were excluded. The search yielded no previously reported cases of EV-SBAT following pancreaticoduodenectomy, confirming the uniqueness of the present case.

Mesenteric tumors are exceptionally rare and management varies from careful observation to surgery [2]. Tzakis et al. established the feasibility of intestinal autotransplantation for complex abdominal tumors, demonstrating that acceptable graft function and survival could be achieved in highly selected cases [8]. In the present case, the tumor was large (18 × 15 × 13 cm) and completely encased both the SMA and SMV. Conventional resection was impossible due to vascular involvement and altered anatomy from prior pancreaticoduodenectomy. As these tumors are close to the main abdominal vasculature, clamping is inevitable during resection, which can lead to prolonged warm ischemia [3, 9]. This surgical approach allows the surgeon to explant the small intestine, perfuse it with UW solution, and replace warm ischemia with cold ischemia, thereby prolonging the operative time for meticulous tumor dissection and vascular reconstruction [3].The patient benefited from this strategy by avoiding massive bowel resection, which would have severely impacted her postoperative nutrition and quality of life.

This scenario is comparable to the report by Cheng et al., who described ex-vivo resection for a large tumor at the root of mesentery measuring 20 × 15 cm [10]. However, our case presented additional complexity due to prior Whipple surgery, which altered the normal anatomy of gastrointestinal system. These cases reveal the feasibility of this method for large mesenteric tumors across different tumor types and clinical contexts. In the absence of distant metastasis, curative-intent surgery with R0 resection was favored despite the high Ki-67 index, following multidisciplinary assessment of oncologic risk and anticipated clinical benefit [7].

From a technical standpoint, isolating and preserving a tumor-free segment of small intestine prior to en bloc tumor resection was a key component of the operative strategy. This approach, previously described by Wu and Liang, helps protect the healthy small bowel segment from prolonged warm ischemia and allows the surgical team to work on removing tumor and any involved bowel. After removal and vascular reconstruction, the surgeon autotransplants the preserved healthy bowel segment back into abdominal cavity [11]. Restoration of intestinal perfusion was confirmed intraoperatively by visible pulsations and peristalsis. This method may help reduce anastomotic leaks, short bowel syndrome, postoperative ileus, and intestinal ischemia.

Although this method is applicable for unresectable mesenteric tumors, it is associated with complications such as early graft loss due to SMA and portal vein thrombosis, pancreatic anastomotic leak, delayed gastric emptying, and postoperative hemorrhage [12]. Reported survival rates remain modest, with Kato et al. demonstrating overall survival rates of 70% at 1 year, 59% at 3 years, and 52% at 5 years following visceral autotransplantation [13]. Importantly, despite the well-documented morbidity associated with EV-SBAT, no major vascular, graft-related, or anastomotic complications occurred in the present case. This favorable outcome may be attributed to accurate patient selection, absence of distant metastasis, meticulous control of ischemia times, and preservation of a tumor-free bowel segment prior to en bloc resection. Limiting warm ischemia to 20 min, use of cold UW perfusion, and stepwise vascular reconstruction likely contributed to graft viability and uneventful postoperative recovery. Nevertheless, such outcomes may not be generalizable, and the risk–benefit balance of EV-SBAT must be carefully individualized, particularly in those with aggressive tumor biology or limited physiological reserve.

Experimental studies have suggested that graft preservation strategies may further optimize outcomes in intestinal autotransplantation. Bachholz et al. demonstrated that hydrogen-enriched solution reduced ischemia–reperfusion injury and significantly improved graft morphology and survival rate from 41% to 80% in a rat model of intestinal transplantation [14]. Similarly, experimental work in canine models showed that EV-SBAT with adjunctive graft irradiation preserved intestinal morphology and function, with minimal epithelial injury and reduced immune cell infiltration [15]. While these approaches remain experimental, they highlight potential avenues for improving graft preservation in complex EV-SBAT procedures.

Based on our review of the available literature, this is the first reported case of EV-SBAT in a patient with a prior Whipple procedure. Previous reports have described this technique in primary settings, but none have highlighted its application in patients with surgically altered anatomy. The presence of prior anastomoses and distorted mesenteric vasculature substantially increased the technical difficulty, especially in achieving safe and functional reconstruction of gastrointestinal continuity. This novelty underscores the feasibility of such an approach and expands its potential indications in patients with prior complex abdominal surgeries. Although early postoperative and 6 months of oncologic assessments have been favorable, the limited duration of follow-up precludes definitive conclusions regarding long-term disease control, emphasizing the need for continued surveillance in high-grade tumors.

In conclusion, EV-SBAT represents a technically demanding choice for the management of unresectable mesenteric tumors, particularly in anatomically complex situations such as patients with prior pancreaticoduodenectomy. Advances in surgical strategy, such as isolation and preservation of tumor-free bowel segments prior to R0 resection may reduce complications, including anastomotic leakage, postoperative ileus, and short bowel syndrome.

Abbreviations

ALP

Alkaline phosphatase

ALT

Alanine aminotransferase

AST

Aspartate aminotransferase

CT

Computed tomography

EV-SBAT

Ex-vivo small bowel autotransplantation

HCT

Hematocrit

HB

Hemoglobin

MCH

Mean corpuscular hemoglobin

MCHC

Mean corpuscular hemoglobin concentration

MCV

Mean corpuscular volume

RBC

Red blood cell

SMA

Superior mesenteric artery

SMV

Superior mesenteric vein

UW

University of Wisconsin

WBC

White blood cell

Authors’ contributions

Pouria Abedini, Erfan Sheikhbahaei, and Ahmad Eshaghi Hassanabadi: Prepared the manuscript, contributed to the conception and design of the report.Mohammad Eslamian: Performed the surgery, managed the patient’s postoperative care, provided clinical details, and verified data accuracyAlireza Firouzfar and Ali Darakhshandeh: Prepared imaging studies and figures, assisted with manuscript revision.Behnam Sanei: Edited the manuscript and performed a comprehensive review of the literature.

Funding

No specific funding was received.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study gained ethical approval based on the code of IR.ARU.MUI.REC.1404.109 and all processes done in the study involving human attendance, were in accordance with the ethical standards of the Research Ethics Committees of School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran and with the Declaration of Helsinki and its later amendments. Informed consent was also obtained from all of the patients in this study.

Consent for publication

Written informed consent for publication of the participant’s clinical details and images was obtained from the patient.

Competing interests

The authors declare no competing interests.