Perioperative Complications and Outcomes after Intestinal Autotransplantation for Neoplasms Involving the Superior Mesenteric Artery



Intestinal autotransplantation (IATx) is a novel surgical technique for neoplasms arising from the pancreas, duodenum, mesentery, or retroperitoneum with involvement of the superior mesenteric artery (SMA). The value of this aggressive procedure remains to be defined. We describe its surgical indications, postoperative complications, and clinical outcomes after IATx.


Fifteen patients aged 20 to 67 years (mean 44.9 years) underwent IATx in our program from January 2011 to January 2018. In all patients, selection and harvesting of a healthy bowel autograft were initially carried out, and an extended en bloc resection of neoplasms was performed afterward.


Of the 15 patients, there was one early death from a pancreatic leak and two late deaths either from disease recurrence or sudden cardiac arrest. Ten patients developed 23 postoperative complications. Of these, one patient lost his bowel autograft due to arterial thrombosis 48 h later. Delayed gastric emptying, pleural effusions, pancreatic fistula, and relaparotomy were the most common complications. In our series, four of nine patients with invasive malignant neoplasms had evidence of disease recurrence at 13, 13, 16, and 18 months after IATx. At a median follow-up of 29.9 months, 11 patients undergoing successful IATx remained alive with a well-functioning bowel graft.


Our results indicate that IATx is technically feasible with acceptable perioperative morbidity and mortality. This procedure should be considered in selected patients presenting with locally invasive neoplasms involving the SMA.

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  1. 1.

    Christians KK, Pilgrim CH, Tsai S, Ritch P, George B, Erickson B, Tolat P, Evans DB. Arterial resection at the time of pancreatectomy for cancer. Surgery 2014; 155: 919–926.

    Article  Google Scholar 

  2. 2.

    Dufay C, Abdelli A, Le Pennec V, Chiche L. Mesenteric tumors: diagnosis and treatment. J Visc Surg 2012; 149: e239–251.

    CAS  Article  Google Scholar 

  3. 3.

    Werner J, Combs SE, Springfeld C, Hartwig W, Hackert T, Buchler MW. Advanced-stage pancreatic cancer: therapy options. Nat Rev Clin Oncol 2013; 10: 323–333.

    CAS  Article  Google Scholar 

  4. 4.

    Mollberg N, Rahbari NN, Koch M, Hartwig W, Hoeger Y, Buchler MW, Weitz J. Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis. Ann Surg 2011; 254: 882–893.

    Article  Google Scholar 

  5. 5.

    Bockhorn M, Burdelski C, Bogoevski D, Sgourakis G, Yekebas EF, Izbicki JR. Arterial en bloc resection for pancreatic carcinoma. Br J Surg 2011; 98: 86–892.

    CAS  Article  Google Scholar 

  6. 6.

    Fairweather M, Gonzalez RJ, Strauss D, Raut CP. Current principles of surgery for retroperitoneal sarcomas. J Surg Oncol 2018; 117: 33–41.

    Article  Google Scholar 

  7. 7.

    Tzakis AG, De Faria W, Angelis M, Verzaro R, Pinna A. Partial abdominal exenteration, ex vivo resection of a large mesenteric fibroma, and successful orthotopic intestinal autotransplantation. Surgery 2000; 128: 486–489.

    CAS  Article  Google Scholar 

  8. 8.

    Tzakis AG, Pararas NB, Tekin A, Gonzalez-Pinto I, Levi D, Nishida S, Selvaggi G, Garcia J, Kato T, Ruiz P. Intestinal and multivisceral autotransplantation for tumors of the root of the mesentery: Long-term follow-up. Surgery 2012; 152: 82–89.

    Article  Google Scholar 

  9. 9.

    Kato T, Lobritto SJ, Tzakis A, Raveh Y, Sandoval PR, Martinez M, Granowetter L, Armas A, Brown RS Jr, Emond J. Multivisceral ex vivo surgery for tumors involving celiac and superior mesenteric arteries. Am J Transplant 2012; 12: 1323–1328.

    CAS  Article  Google Scholar 

  10. 10.

    Quintini C, Di Benedetto F, Diago T, Lauro A, Cautero N, De Ruvo N, Romano A, Di Sandro S, Ramacciato G, Pinna AD. Intestinal autotransplantation for adenocarcinoma of pancreas involving the mesenteric root: our experience and literature review. Pancreas 2007; 34: 266–268.

    Article  Google Scholar 

  11. 11.

    Zeng Y, Wu H, Yang JY. Small bowel autotransplantation combined with pancreato-duodenectomy for enormous cavernous hemangioma of the small intestine mesentery. Chi Med J 2008; 121: 2110–2112.

    Article  Google Scholar 

  12. 12.

    Tzvetanov IG, Bhati CS, Jeon H, Glover AE, Oberholzer J, Benedetti E. Segmental intestinal autotransplantation after extensive enterectomy for removal of large intra-abdominal desmoid tumors of the mesentery root: initial experience. Surgery 2012; 151: 621–624.

    Article  Google Scholar 

  13. 13.

    Wu G, Zhao Q, Wang W, Shi H, Wang M, Zhang J, Li Z, Fan D. Clinical and nutritional outcomes after intestinal autotransplantation. Surgery 2016; 159: 1668–1676

    Article  Google Scholar 

  14. 14.

    Wu G, Wang X, Zhao Q, Wang W, Shi H, Wang M, Zhang J, Li Z, Fan D. Intestinal autotransplantation for neoplasms originating in the pancreatic head with involvement of the superior mesenteric artery. Langenbeck’s Arch Surg 2016; 401: 1249–1257.

    Article  Google Scholar 

  15. 15.

    Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traveso W, Buchler M; International Study Group on Pancreatic Fistula Definition. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005; 138: 8–13.

    Article  Google Scholar 

  16. 16.

    Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Buchler MW. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007; 142: 761–768.

    Article  Google Scholar 

  17. 17.

    Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Yeo CJ, Buchler MW. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007; 142: 20–25.

    Article  Google Scholar 

  18. 18.

    Payne RF, Pain JA. Duct-to-mucosa pancreaticogastrostomy is a safe anastomosis following pancreaticoduodenectomy. Br J Surg 2006; 93: 73–77.

    CAS  Article  Google Scholar 

  19. 19.

    Xiong JJ, Tan CL, Szatmary P, Huang W, Ke NW, Hu WM, Nunes QM, Sutton R, Liu XB. Meta-analysis of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Br J Surg 2014; 101: 1196–1208.

    CAS  Article  Google Scholar 

  20. 20.

    Menahem B, Guittet L, Mulliri A, Alves A, Lubrano J. Pancreaticogastrostomy is superior to pancreaticojejunostomy for prevention of pancreatic fistula after pancreaticoduodenectomy: an updated meta-analysis of randomized controlled trials. Ann Surg 2015; 261: 882–887.

    Article  Google Scholar 

  21. 21.

    Hartwig W, Gluth A, Hinz U, Koliogiannis D, Strobel O, Hackert T, Werner J, Buchler MW. Outcomes after extended pancreatectomy in patients with borderline resectable and locally advanced pancreatic cancer. Br J Surg 2016; 103: 1683–1694.

    CAS  Article  Google Scholar 

  22. 22.

    Kulemann B, Hoeppner J, Wittel U, Glatz T, Keck T, Wellner UF, Bronsert P, Sick O, Hopt UT, Makowiec F, Riediger H. Perioperative and long-term outcome after standard pancreaticoduodenectomy, additional portal vein and multivisceral resection for pancreatic head cancer. J Gastrointest Surg 2015; 19: 438–444.

    Article  Google Scholar 

  23. 23.

    Bhayani NH, Enomoto LM, James BC, Ortenzi G, Kaifi JT, Kimchi ET, Staveley-O'Carroll KF, Gusani NJ. Multivisceral and extended resections during pancreatoduodenectomy increase morbidity and mortality. Surgery 2014; 155: 567–574.

    Article  Google Scholar 

  24. 24.

    Onkendi EO, Boostrom SY, Sarr MG, Farnell MB, Nagorney DM, Donohue JH, Kendrick ML, Lombardo KM, Haddock MG, Que FG. Neoadjuvant treatment of duodenal adenocarcinoma: a rescue strategy. J Gastrointest Surg 2012; 16: 320–324.

    Article  Google Scholar 

  25. 25.

    Nikeghbalian S, Aliakbarian M, Kazemi K, Shamsaeefar AR, Mehdi SH, Bahreini A, Malek-Hosseini SA. Ex-vivo Resection and Small-Bowel Auto-transplantation for the Treatment of Tumors at the Root of the Mesentery. Int J Organ Transplant Med 2014; 5: 120–124.

    CAS  PubMed  PubMed Central  Google Scholar 

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The authors would like to thank the surgical team and the nursing staff at Xijing Hospital of Digestive Diseases, the Fourth Military Medical University, for their excellent patient care. The authors thank Mr. Yinglun Wu for help with English grammar.


This work was supported by the grant from the National Natural Science Foundation of China (#81570588).

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Drs. Guosheng Wu, Qingchuan Zhao, and Weizhong conceived and designed this study. The acquisition, analysis, and interpretation of data, as well as manuscript drafting and approval, were performed meaningfully by all listed authors. All authors accept responsibility for the accuracy and integrity of this work.

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Correspondence to Guosheng Wu.

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Wu, G., Zhao, Q., Li, X. et al. Perioperative Complications and Outcomes after Intestinal Autotransplantation for Neoplasms Involving the Superior Mesenteric Artery. J Gastrointest Surg 24, 650–658 (2020).

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  • Intestinal autotransplantation
  • Neoplasms
  • SMA resection
  • Clinical outcomes