Ex-Vivo Small Bowel Auto-transplantation with a Prior Pancreaticoduodenectomy (Whipple’s Procedure): A Report of a Rare Case and Review of Literature

Ex-Vivo Small Bowel Auto-transplantation with a Prior Pancreaticoduodenectomy (Whipple’s Procedure): A Report of a Rare Case and Review of Literature | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Ex-Vivo Small Bowel Auto-transplantation with a Prior Pancreaticoduodenectomy (Whipple’s Procedure): A Report of a Rare Case and Review of Literature Mohammad Eslamian, Pouria Abedini, Erfan Sheikhbahaei, Alireza Firouzfar, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8278340/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Feb, 2026 Read the published version in BMC Surgery → Version 1 posted 15 You are reading this latest preprint version Abstract Background Mesenteric tumors involving the superior mesenteric vessels are rare and challenging to treat. When conventional resection risks extensive bowel loss, ex-vivo small bowel autotransplantation offers a means to achieve R0 resection while minimizing warm ischemia. Surgical complexity is further increased in patients with prior major abdominal operations such as pancreaticoduodenectomy. 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 vessels. The tumor progressed despite chemotherapy, prompting consideration of ex-vivo small bowel autotransplantation as a definitive surgical solution. Vascular and gastrointestinal reconstruction was successfully completed despite prior Whipple surgery. Histopathological evaluation confirmed recurrence of neuroendocrine carcinoma. She had an uneventful postoperative recovery and was discharged in stable condition on postoperative day 14, with planned follow-up sessions. Conclusion Ex-vivo small bowel autotransplantation is a technically demanding but viable option for unresectable mesenteric tumors involving major vessels, even after complex prior surgery. To our knowledge, this is the first reported case of ex-vivo small bowel autotransplantation performed in a patient with prior Whipple surgery, highlighting both the technical challenges and the feasibility of this approach. Strategic procedural modifications and optimized graft preservation techniques may enhance safety and long-term outcomes. Autotransplantation Pancreaticoduodenectomy Mesentery Neoplasm Small Intestine Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 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, 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 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), are rare ( 6 ). This case presents a unique management of a patient with 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 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. 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 Preoperative 1th 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 175000 100000 202000 AST 19 106 17 ALT 13 18 10 ALP 360 133 193 Diagnostic Assessments A positron emission tomography scan showed an increased uptake of 18F-fluorodeoxyglucose 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 (Fig. 1 ). The lesion demonstrated near circumferential SMA/SMV involvement. 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. 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 ex-vivo small bowel autotransplantation. A mid-line incision was performed, and upon opening the abdominal cavity, the surgical team encountered extensive adhesions from previous surgery. After adhesiolysis, 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. 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 and remained under cold ischemia for 2 hours and 15 minutes. Subsequently, the mesenteric tumor, along with the affected bowel, pancreatic body, para-aortic lymph node, and right colon were resected en bloc. Because of the involvement of the mesentery of jejunal limbs from prior pancreaticoduodenectomy anastomoses, the surgeon had to resect the involved jejunal limbs and reconstructed using uninvolved jejunum. After that, the tumor was meticulously dissected from the SMA and SMV. Both vessels required segmental resection and were reconstructed with end-to-end SMA-to-SMA and SMV-to-SMV anastomoses. Gross tumor size was 18 × 15 × 13 (Fig. 3&4). After achieving R0 resection and successful vascular reconstruction, the preserved bowel was autotransplanted with good vascular pulsations and peristalsis. Gastrointestinal continuity was then restored by duct-to-mucosa pancreaticojejunostomy to restore pancreatic drainage, hepaticojejunostomy for biliary continuity, gastrojejunostomy to reestablish gastric outflow, and ileocolic anastomosis following right hemicolectomy. The operation was completed successfully, with excellent perfusion of the transplanted bowel and stable reconstruction of all gastrointestinal anastomoses. According to our knowledge, this represents the first reported case of ex-vivo intestinal autotransplantation 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. 5 ). 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. Follow-up planning included regular clinical examinations and imaging surveillance for tumor recurrence. The patient underwent regular follow-up with weekly monitoring of her weight and BMI, and serum albumin every two weeks. She was followed up for six months, during which her BMI increased from approximately 18 to 23, owing to regular consumption of nutritional supplements and probiotics. Discussion and Conclusions Mesenteric tumors are exceptionally rare and management varies from careful observation to surgery ( 2 ). As these tumors are close to the main abdominal vasculatures, clamping is inevitable during resection, which can lead to prolonged warm ischemia ( 3 , 7 ). This surgical approach allows the surgeon to explant the small intestine, perfuse it with UW solution, and replace warm ischemia with cold ischemia and prolonging the operative time for meticulous tumor dissection and vascular reconstruction ( 3 ). In this context, Cheng et al., reported a patient with large tumor at the root of mesentery measuring 20×15 cm, comparable to our case with a size of 18×15×13 cm ( 8 ). 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. 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( 9 ). This surgical approach is also associated with high rates of mortality. In a study conducted by Kato et al., the overall survival of patients who underwent ex-vivo resection and visceral autotransplantation was reported to be 70% at 1 year, 59% at 3 years, and 52% at 5 years ( 10 ). In a study performed by Wu and Liang, they suggested isolating and taking out the piece of small intestine, which is free of tumoral cells before proceeding to R0 tumor resection. This change helps protecting 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, surgeon autotransplants the preserved healthy bowel segment back into abdominal cavity ( 11 ). This method may help in reduction of anastomotic leaks, short bowel syndrome occurrence, postoperative ileus, and intestinal ischemia. In our case, we also applied this modified approach by preserving and temporarily isolating the healthy segment of small bowel prior to tumor resection and vascular reconstruction. Experimental research accomplished by Bachholz et al., demonstrated that hydrogen enriched solution significantly improved outcomes of intestinal transplantation by mitigating ischemia-reperfusion injury. This study was done on Lewis rats and utilizing hydrogen enriched solutions resulted in enhanced graft morphology, reduced oxidative stress markers, and decreased proinflammatory cytokines ( 12 ). Hydrogen treatment increased recipient survival rate from 41% to 80% ( 12 ). These findings suggest that incorporating hydrogen-enriched solutions in graft preservation can be a reasonable strategy for optimizing not only intestinal transplantation but also outcomes in other solid organ transplantations. In another study of small intestine autotransplantation performed on outbred hound dogs, the impact of ex-vivo graft irradiation on intestinal function and morphology was evaluated. Overall graft function was well-preserved with normal weight gain by day 30. Histopathological analysis revealed intact intestinal morphology with only mild epithelial apoptosis and no vascular damage, even on longer follow-up. Immunohistochemical assessments indicated less CD3 + T lymphocytes compared to nonirradiated grafts ( 13 ). Based on our review of the available literature, this is the first reported case of ex-vivo small bowel autotransplantation 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 complex reoperative abdominal surgery. In conclusion, ex-vivo small bowel autotransplantation represents 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 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 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. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Fundings No specific funding was received. 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 accuracy Alireza 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. Acknowledgements Not applicable Authors’ information Mohammad Eslamian 1* , Pouria Abedini 2 , Erfan Sheikhbahaei 2 , Alireza Firouzfar 1 , Ali Darakhshandeh 3 , Ahmad Eshaghi Hassanabadi 4 , Behnam Sanei 1 1 Department of General Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran 2 Student Research Committee, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran 3 Department of Medical Oncology-Hematology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran 4 Nursing and Midwife Care Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran Clinical trial number Not applicable. * Corresponding author: Mohammad Eslamian, MD Department of General Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran E-mail: [email protected] Telephone: +98-913-109-1885 ORCID: https://orcid.org/0000-0001-5019-5641 References Kose SI, Singh S, Garg A, Manchanda A, Singh R. Ultrasound and computed tomography in the evaluation of mesenteric lesions: A pictorial review. SA J Radiol. 2023;27(1):2595. Dufay C, Abdelli A, Le Pennec V, Chiche L. Mesenteric tumors: Diagnosis and treatment. J Visc Surg. 2012;149(4):e239–51. Nikeghbalian S, Aliakbarian M, Kazemi K, Shamsaeefar AR, Mehdi SH, Bahreini A, et al. Ex-vivo Resection and Small-Bowel Auto-transplantation for the Treatment of Tumors at the Root of the Mesentery. Int J Organ Transpl Med. 2014;5(3):120–4. Tzakis AG, Tryphonopoulos P, De Faria W, Kato T, Nishida S, Levi DM, et al. Partial abdominal evisceration, ex vivo resection, and intestinal autotransplantation for the treatment of pathologic lesions of the root of the mesentery. J Am Coll Surg. 2003;197(5):770–6. Quintini C, Di Benedetto F, Diago T, Lauro A, Cautero N, De Ruvo N, et al. Intestinal autotransplantation for adenocarcinoma of pancreas involving the mesenteric root: our experience and literature review. Pancreas. 2007;34(2):266–8. Zeng Y, Wu H, Yang J. yin. Small bowel autotransplantation combined with pancreato-duodenectomy for enormous cavernous hemangioma of the small intestine mesentery. Chin Med J (Engl). 2008;121(20):2110–2. Pappas PA, Saudubray JM, Tzakis AG, Rabier D, Carreno MR, Gomez-Marin O, et al. Serum citrulline and rejection in small bowel transplantation: a preliminary report. Transplantation. 2001;72(7):1212–6. Cheng C, Guo S, Kollie DEGB, Zhang W, Xiao J, Liu J, et al. Ex vivo resection and intestinal autotransplantation for a large mesenteric desmoid tumor secondary to familial adenomatous polyposis: A case report and literature review. Med (Baltim). 2018;97(20):e10762. Wu G. Intestinal autotransplantation. Gastroenterol Rep. 2017;5(4):258–65. Kato T, Hwang R, Liou P, Weiner J, Griesemer A, Samstein B, et al. Ex Vivo Resection and Autotransplantation for Conventionally Unresectable Tumors - An 11-year Single Center Experience. Ann Surg. 2020;272(5):766–72. Wu GS, Liang TB. [Gastrointestinal reconstruction by intestinal auto-transplantation after radical resection of neoplasms involving superior mesenteric artery: a preliminary consideration]. Zhonghua Wai Ke Za Zhi. 2022;60(1):27–31. Buchholz BM, Masutani K, Kawamura T, Peng X, Toyoda Y, Billiar TR, et al. Hydrogen-enriched preservation protects the isogeneic intestinal graft and amends recipient gastric function during transplantation. Transplantation. 2011;92(9):985–92. Ishikawa T, Iwanami K, Okuda T, Zhu Y, Fukuda A, Zhang S et al. Intestinal function and morphology after ex vivo irradiated small bowel transplantation. Transplant Proc. 2002;34(3):988–9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 17 Feb, 2026 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 02 Jan, 2026 Reviews received at journal 31 Dec, 2025 Reviewers agreed at journal 23 Dec, 2025 Reviews received at journal 19 Dec, 2025 Reviews received at journal 16 Dec, 2025 Reviews received at journal 13 Dec, 2025 Reviewers agreed at journal 13 Dec, 2025 Reviewers agreed at journal 13 Dec, 2025 Reviewers agreed at journal 11 Dec, 2025 Reviewers agreed at journal 11 Dec, 2025 Reviewers agreed at journal 11 Dec, 2025 Reviewers invited by journal 11 Dec, 2025 Editor assigned by journal 10 Dec, 2025 Submission checks completed at journal 09 Dec, 2025 First submitted to journal 09 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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2","display":"","copyAsset":false,"role":"figure","size":314883,"visible":true,"origin":"","legend":"\u003cp\u003eResected specimen perfusing with University of Wisconsin solution for minimal ischemic injury.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8278340/v1/d3258d01fd3eb5b355bfbfd5.jpeg"},{"id":98441200,"identity":"d6378b8d-b8b4-4a48-a581-7969cde8142d","added_by":"auto","created_at":"2025-12-17 17:05:02","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":255188,"visible":true,"origin":"","legend":"\u003cp\u003eLarge mesenteric tumor resected by ex-vivo surgery.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8278340/v1/9e1e5cd47df0a26338971a58.jpeg"},{"id":98377498,"identity":"0bad5239-14fd-4f1f-9253-d7132bd313e1","added_by":"auto","created_at":"2025-12-17 07:13:19","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":329464,"visible":true,"origin":"","legend":"\u003cp\u003eLarge mesenteric tumor resected by ex-vivo surgery.\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8278340/v1/7a0f4349bfc68842cd1a901d.jpeg"},{"id":98377499,"identity":"cc63d1fa-778e-44c4-b2e6-cd6ddabf1864","added_by":"auto","created_at":"2025-12-17 07:13:19","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1449374,"visible":true,"origin":"","legend":"\u003cp\u003eThis figure shows positive vimentin (A), CD56 (B), and Ki67 (C) indicative of neuroendocrine tumor.\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8278340/v1/8bbc9092f18bc620e1ec6eb9.jpeg"},{"id":103251133,"identity":"cbf6cd30-2967-4cb7-8601-56b448324288","added_by":"auto","created_at":"2026-02-23 16:04:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3346329,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8278340/v1/324b369b-b4e0-4f9e-ab44-2902e8c71a00.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Ex-Vivo Small Bowel Auto-transplantation with a Prior Pancreaticoduodenectomy (Whipple’s Procedure): A Report of a Rare Case and Review of Literature","fulltext":[{"header":"Background","content":"\u003cp\u003eMesenteric 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, essential for intestinal viability and function (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). 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 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). 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 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), are rare (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis case presents a unique management of a patient with prior pancreaticoduodenectomy, who underwent intestinal autotransplantation. The previous Whipple procedure made this surgery more complicated.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient information\u003c/h2\u003e \u003cp\u003eA 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.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eClinical Findings\u003c/h3\u003e\n\u003cp\u003eShe was hemodynamically stable with a distended, mildly tender abdomen. No peritonitis or obstruction was present. Initial laboratory tests were within normal reference range except hemoglobin and alkaline phosphatase (ALP), which were 8.9 g/dL and 360 U/L respectively (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThis table shows laboratory test results recorded preoperatively, on postoperative day 1, and on the final day of hospitalization. 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\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1th day after surgery\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14th day after surgery\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4900\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7600\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4600\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRBC\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.37\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.53\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHb\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.9\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHCT\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.9\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.0\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.9\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMCV\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82.8\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82.1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88.3\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMCH\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.4\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.6\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.6\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMCHC\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.9\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.4\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.4\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlatelet\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e175000\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100000\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e202000\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAST\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e106\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALT\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALP\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e360\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e133\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e193\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eDiagnostic Assessments\u003c/h3\u003e\n\u003cp\u003eA positron emission tomography scan showed an increased uptake of 18F-fluorodeoxyglucose 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 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The lesion demonstrated near circumferential SMA/SMV involvement. 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.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eTherapeutic Intervention and Surgical Procedure\u003c/h3\u003e\n \u003cp\u003eExtensive SMA/SMV involvement and altered anatomy from prior Whipple surgery precluded conventional resection. The multidisciplinary surgical team decided to proceed with an ex-vivo small bowel autotransplantation. A mid-line incision was performed, and upon opening the abdominal cavity, the surgical team encountered extensive adhesions from previous surgery. After adhesiolysis, 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. The resected specimen, was transferred to a sterile, isolated environment and continuously perfused with University of Wisconsin (UW) solution to minimize ischemic injury (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The bowel was kept at a temperature of 4°C and remained under cold ischemia for 2 hours and 15 minutes.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSubsequently, the mesenteric tumor, along with the affected bowel, pancreatic body, para-aortic lymph node, and right colon were resected en bloc. Because of the involvement of the mesentery of jejunal limbs from prior pancreaticoduodenectomy anastomoses, the surgeon had to resect the involved jejunal limbs and reconstructed using uninvolved jejunum. After that, the tumor was meticulously dissected from the SMA and SMV. Both vessels required segmental resection and were reconstructed with end-to-end SMA-to-SMA and SMV-to-SMV anastomoses. Gross tumor size was 18 × 15 × 13 (Fig.\u0026nbsp;3\u0026amp;4). After achieving R0 resection and successful vascular reconstruction, the preserved bowel was autotransplanted with good vascular pulsations and peristalsis. Gastrointestinal continuity was then restored by duct-to-mucosa pancreaticojejunostomy to restore pancreatic drainage, hepaticojejunostomy for biliary continuity, gastrojejunostomy to reestablish gastric outflow, and ileocolic anastomosis following right hemicolectomy. The operation was completed successfully, with excellent perfusion of the transplanted bowel and stable reconstruction of all gastrointestinal anastomoses.\u003c/p\u003e \u003cp\u003eAccording to our knowledge, this represents the first reported case of ex-vivo intestinal autotransplantation 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.\u003c/p\u003e \u003cp\u003eHistopathological 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.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eFollow-up and outcomes\u003c/h3\u003e\n\u003cp\u003eThe 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. Follow-up planning included regular clinical examinations and imaging surveillance for tumor recurrence. The patient underwent regular follow-up with weekly monitoring of her weight and BMI, and serum albumin every two weeks. She was followed up for six months, during which her BMI increased from approximately 18 to 23, owing to regular consumption of nutritional supplements and probiotics.\u003c/p\u003e "},{"header":"Discussion and Conclusions","content":"\u003cp\u003eMesenteric tumors are exceptionally rare and management varies from careful observation to surgery (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). As these tumors are close to the main abdominal vasculatures, clamping is inevitable during resection, which can lead to prolonged warm ischemia (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). This surgical approach allows the surgeon to explant the small intestine, perfuse it with UW solution, and replace warm ischemia with cold ischemia and prolonging the operative time for meticulous tumor dissection and vascular reconstruction (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In this context, Cheng et al., reported a patient with large tumor at the root of mesentery measuring 20×15 cm, comparable to our case with a size of 18×15×13 cm (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). 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.\u003c/p\u003e\u003cp\u003eAlthough 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(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). This surgical approach is also associated with high rates of mortality. In a study conducted by Kato et al., the overall survival of patients who underwent ex-vivo resection and visceral autotransplantation was reported to be 70% at 1 year, 59% at 3 years, and 52% at 5 years (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn a study performed by Wu and Liang, they suggested isolating and taking out the piece of small intestine, which is free of tumoral cells before proceeding to R0 tumor resection. This change helps protecting 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, surgeon autotransplants the preserved healthy bowel segment back into abdominal cavity (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This method may help in reduction of anastomotic leaks, short bowel syndrome occurrence, postoperative ileus, and intestinal ischemia. In our case, we also applied this modified approach by preserving and temporarily isolating the healthy segment of small bowel prior to tumor resection and vascular reconstruction.\u003c/p\u003e\u003cp\u003eExperimental research accomplished by Bachholz et al., demonstrated that hydrogen enriched solution significantly improved outcomes of intestinal transplantation by mitigating ischemia-reperfusion injury. This study was done on Lewis rats and utilizing hydrogen enriched solutions resulted in enhanced graft morphology, reduced oxidative stress markers, and decreased proinflammatory cytokines (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Hydrogen treatment increased recipient survival rate from 41% to 80% (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). These findings suggest that incorporating hydrogen-enriched solutions in graft preservation can be a reasonable strategy for optimizing not only intestinal transplantation but also outcomes in other solid organ transplantations.\u003c/p\u003e\u003cp\u003eIn another study of small intestine autotransplantation performed on outbred hound dogs, the impact of ex-vivo graft irradiation on intestinal function and morphology was evaluated. Overall graft function was well-preserved with normal weight gain by day 30. Histopathological analysis revealed intact intestinal morphology with only mild epithelial apoptosis and no vascular damage, even on longer follow-up. Immunohistochemical assessments indicated less CD3\u003csup\u003e+\u003c/sup\u003e T lymphocytes compared to nonirradiated grafts (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBased on our review of the available literature, this is the first reported case of ex-vivo small bowel autotransplantation 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 complex reoperative abdominal surgery. In conclusion, ex-vivo small bowel autotransplantation represents 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.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eALP, alkaline phosphatase\u003c/p\u003e\n\u003cp\u003eALT, alanine aminotransferase\u003c/p\u003e\n\u003cp\u003eAST, aspartate aminotransferase\u003c/p\u003e\n\u003cp\u003eCT, computed tomography\u003c/p\u003e\n\u003cp\u003eHCT, hematocrit\u003c/p\u003e\n\u003cp\u003eHB, hemoglobin\u003c/p\u003e\n\u003cp\u003eMCH, mean corpuscular hemoglobin\u003c/p\u003e\n\u003cp\u003eMCHC, mean corpuscular hemoglobin concentration\u003c/p\u003e\n\u003cp\u003eMCV, mean corpuscular volume\u003c/p\u003e\n\u003cp\u003eRBC, red blood cell\u003c/p\u003e\n\u003cp\u003eSMA, superior mesenteric artery\u003c/p\u003e\n\u003cp\u003eSMV, superior mesenteric vein\u003c/p\u003e\n\u003cp\u003eUW, University of Wisconsin\u003c/p\u003e\n\u003cp\u003eWBC, white blood cell\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of the participant\u0026rsquo;s clinical details and images was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFundings\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo specific funding was received.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003ePouria Abedini, Erfan Sheikhbahaei, and Ahmad Eshaghi Hassanabadi: Prepared the manuscript, contributed to the conception and design of the report.\u003c/p\u003e\n\u003cp\u003eMohammad Eslamian: Performed the surgery, managed the patient\u0026rsquo;s postoperative care, provided clinical details, and verified data accuracy\u003c/p\u003e\n\u003cp\u003eAlireza Firouzfar and Ali Darakhshandeh: Prepared imaging studies and figures, assisted with manuscript revision.\u003c/p\u003e\n\u003cp\u003eBehnam Sanei: Edited the manuscript and performed a comprehensive review of the literature.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; information\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMohammad Eslamian\u003csup\u003e1*\u003c/sup\u003e, Pouria Abedini\u003csup\u003e2\u003c/sup\u003e, Erfan Sheikhbahaei\u003csup\u003e2\u003c/sup\u003e, Alireza Firouzfar\u003csup\u003e1\u003c/sup\u003e, Ali Darakhshandeh\u003csup\u003e3\u003c/sup\u003e, Ahmad Eshaghi Hassanabadi\u003csup\u003e4\u003c/sup\u003e, Behnam Sanei\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDepartment\u0026nbsp;of\u0026nbsp;General\u0026nbsp;Surgery,\u0026nbsp;School of Medicine,\u0026nbsp;Isfahan\u0026nbsp;University\u0026nbsp;of Medical\u0026nbsp;Sciences, Isfahan, Iran\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eStudent Research Committee, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eDepartment of Medical Oncology-Hematology, School of Medicine, Isfahan\u0026nbsp;University\u0026nbsp;of Medical\u0026nbsp;Sciences, Isfahan, Iran\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003eNursing and Midwife Care Research Center, School of Nursing and Midwifery, Isfahan\u0026nbsp;University\u0026nbsp;of Medical\u0026nbsp;Sciences, Isfahan, Iran\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eClinical trial number\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e*\u003c/sup\u003e\u003cstrong\u003e\u0026nbsp;Corresponding author:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMohammad Eslamian, MD\u003c/p\u003e\n\u003cp\u003eDepartment\u0026nbsp;of\u0026nbsp;General\u0026nbsp;Surgery,\u0026nbsp;School of Medicine,\u0026nbsp;Isfahan\u0026nbsp;University\u0026nbsp;of Medical\u0026nbsp;Sciences, Isfahan, Iran\u003c/p\u003e\n\u003cp\u003eE-mail: [email protected]\u003c/p\u003e\n\u003cp\u003eTelephone: +98-913-109-1885\u003c/p\u003e\n\u003cp\u003eORCID: https://orcid.org/0000-0001-5019-5641\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKose SI, Singh S, Garg A, Manchanda A, Singh R. Ultrasound and computed tomography in the evaluation of mesenteric lesions: A pictorial review. SA J Radiol. 2023;27(1):2595.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDufay C, Abdelli A, Le Pennec V, Chiche L. Mesenteric tumors: Diagnosis and treatment. J Visc Surg. 2012;149(4):e239\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNikeghbalian S, Aliakbarian M, Kazemi K, Shamsaeefar AR, Mehdi SH, Bahreini A, et al. Ex-vivo Resection and Small-Bowel Auto-transplantation for the Treatment of Tumors at the Root of the Mesentery. Int J Organ Transpl Med. 2014;5(3):120\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTzakis AG, Tryphonopoulos P, De Faria W, Kato T, Nishida S, Levi DM, et al. Partial abdominal evisceration, ex vivo resection, and intestinal autotransplantation for the treatment of pathologic lesions of the root of the mesentery. J Am Coll Surg. 2003;197(5):770\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuintini C, Di Benedetto F, Diago T, Lauro A, Cautero N, De Ruvo N, et al. Intestinal autotransplantation for adenocarcinoma of pancreas involving the mesenteric root: our experience and literature review. Pancreas. 2007;34(2):266\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZeng Y, Wu H, Yang J. yin. Small bowel autotransplantation combined with pancreato-duodenectomy for enormous cavernous hemangioma of the small intestine mesentery. Chin Med J (Engl). 2008;121(20):2110\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePappas PA, Saudubray JM, Tzakis AG, Rabier D, Carreno MR, Gomez-Marin O, et al. Serum citrulline and rejection in small bowel transplantation: a preliminary report. Transplantation. 2001;72(7):1212\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng C, Guo S, Kollie DEGB, Zhang W, Xiao J, Liu J, et al. Ex vivo resection and intestinal autotransplantation for a large mesenteric desmoid tumor secondary to familial adenomatous polyposis: A case report and literature review. Med (Baltim). 2018;97(20):e10762.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu G. Intestinal autotransplantation. Gastroenterol Rep. 2017;5(4):258\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKato T, Hwang R, Liou P, Weiner J, Griesemer A, Samstein B, et al. Ex Vivo Resection and Autotransplantation for Conventionally Unresectable Tumors - An 11-year Single Center Experience. Ann Surg. 2020;272(5):766\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu GS, Liang TB. [Gastrointestinal reconstruction by intestinal auto-transplantation after radical resection of neoplasms involving superior mesenteric artery: a preliminary consideration]. Zhonghua Wai Ke Za Zhi. 2022;60(1):27\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBuchholz BM, Masutani K, Kawamura T, Peng X, Toyoda Y, Billiar TR, et al. Hydrogen-enriched preservation protects the isogeneic intestinal graft and amends recipient gastric function during transplantation. Transplantation. 2011;92(9):985\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIshikawa T, Iwanami K, Okuda T, Zhu Y, Fukuda A, Zhang S et al. Intestinal function and morphology after ex vivo irradiated small bowel transplantation. Transplant Proc. 2002;34(3):988\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Autotransplantation, Pancreaticoduodenectomy, Mesentery, Neoplasm, Small Intestine","lastPublishedDoi":"10.21203/rs.3.rs-8278340/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8278340/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMesenteric tumors involving the superior mesenteric vessels are rare and challenging to treat. When conventional resection risks extensive bowel loss, ex-vivo small bowel autotransplantation offers a means to achieve R0 resection while minimizing warm ischemia. Surgical complexity is further increased in patients with prior major abdominal operations such as pancreaticoduodenectomy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 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 vessels. The tumor progressed despite chemotherapy, prompting consideration of ex-vivo small bowel autotransplantation as a definitive surgical solution. Vascular and gastrointestinal reconstruction was successfully completed despite prior Whipple surgery. Histopathological evaluation confirmed recurrence of neuroendocrine carcinoma. She had an uneventful postoperative recovery and was discharged in stable condition on postoperative day 14, with planned follow-up sessions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEx-vivo small bowel autotransplantation is a technically demanding but viable option for unresectable mesenteric tumors involving major vessels, even after complex prior surgery. To our knowledge, this is the first reported case of ex-vivo small bowel autotransplantation performed in a patient with prior Whipple surgery, highlighting both the technical challenges and the feasibility of this approach. Strategic procedural modifications and optimized graft preservation techniques may enhance safety and long-term outcomes.\u003c/p\u003e","manuscriptTitle":"Ex-Vivo Small Bowel Auto-transplantation with a Prior Pancreaticoduodenectomy (Whipple’s Procedure): A Report of a Rare Case and Review of Literature","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-17 07:13:14","doi":"10.21203/rs.3.rs-8278340/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-02T09:49:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-31T21:33:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31150173286825667250221574330958004956","date":"2025-12-23T06:46:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-19T15:59:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-17T03:55:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-13T16:33:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"209680836228378625082657469345405198029","date":"2025-12-13T16:13:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"286593131081625066798972665975377131050","date":"2025-12-13T08:13:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31150173286825667250221574330958004956","date":"2025-12-11T09:41:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"143032688805887918726840805639622749822","date":"2025-12-11T08:27:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22861737706993127663577868589522296942","date":"2025-12-11T08:25:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-11T08:05:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-10T08:38:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-09T19:46:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2025-12-09T19:39:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"47a128c8-2031-4347-a6f9-ae0b700bb3c8","owner":[],"postedDate":"December 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T16:01:52+00:00","versionOfRecord":{"articleIdentity":"rs-8278340","link":"https://doi.org/10.1186/s12893-026-03595-8","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2026-02-17 15:58:22","publishedOnDateReadable":"February 17th, 2026"},"versionCreatedAt":"2025-12-17 07:13:14","video":"","vorDoi":"10.1186/s12893-026-03595-8","vorDoiUrl":"https://doi.org/10.1186/s12893-026-03595-8","workflowStages":[]},"version":"v1","identity":"rs-8278340","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8278340","identity":"rs-8278340","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}