Cleveland Clinic Surgeons Perform Ex Vivo Tumor Resection and Intestinal Autotransplantation for Retroperitoneal Schwannoma
A 38-year-old patient underwent a 14-hour ex vivo tumor resection and intestinal autotransplantation at Cleveland Clinic to remove a 15.5 cm retroperitoneal schwannoma encasing the superior mesenteric artery. The procedure involved temporarily removing the small bowel, pancreas, and right colon to extract the mass outside the body, preserving organ function without requiring a donor transplant or lifelong immunosuppressive drugs.
Surgeons Use Ex Vivo Resection and Autotransplantation
- Ex Vivo Resection: Surgeons temporarily removed the patient’s digestive organs from the body to excise a complex abdominal tumor safely without causing catastrophic internal bleeding.
- Intestinal Autotransplantation: Because the patient’s own bowel was put back in after tumor removal, she avoided needing a donor organ and did not require lifelong immunosuppression medications.
- Vascular Reconstruction: Specialists used a harvested right internal iliac artery graft to rebuild the superior mesenteric artery and restore normal blood flow to the digestive tract.
Expanding Tumor Prevents Patient from Eating
The patient’s retroperitoneal schwannoma had been diagnosed five years prior at roughly 9.4 × 8.9 cm, but an initial surgical attempt was abandoned due to vascular involvement. Over the five-year interval, the mass expanded to 13.1 × 11.3 cm on imaging, ultimately preventing the patient’s ability to eat. Masato Fujiki, MD, a liver-intestine transplant surgeon at Cleveland Clinic, noted that such tumors are traditionally deemed unresectable because removing them in standard operations cuts off mesenteric blood flow and causes organ necrosis.
“During the past couple of years, I had been discussing an approach — ex vivo tumor resection with intestinal autotransplantation — with some colleagues,” Dr. Fujiki stated, adding that the operation has only been performed about 30 times over the past two decades. The procedure at Cleveland Clinic is believed to be the first reported intestinal autotransplantation in Ohio and ranks among a small number performed in the United States.
The operation demanded cross-specialty coordination. Surgical oncology teams experienced with the Whipple procedure joined transplant surgeons specializing in organ preservation, vascular reconstruction, and intestinal transplantation. The surgical sequence began with a Whipple procedure and creation of a splenorenal shunt. The head of the pancreas, the entire small intestine, and the right colon were resected en bloc. Ravi Ambani, MD, harvested the right internal iliac artery for a vascular graft. Matthew Walsh, MD, and Robert Naples, DO, performed the pancreaticogastrostomy by connecting the remaining pancreatic tail to the stomach. The iliac artery graft was then connected to the remaining superior mesenteric artery (SMA) to restore arterial inflow.
Intestinal transplant surgeons Mohammed Osman, MD, and Mohamed Maklad, MD, participated in the operative phase and managed the complex postoperative care. On the back table, the team excised the pancreaticoduodenal complex while preserving the main trunks of the superior mesenteric vein and SMA, alongside the first jejunal artery. This ex vivo visibility allowed a precise resection with an estimated blood loss of just 300 mL and zero blood transfusions over the 14-hour procedure. Final pathology confirmed a 15.5 cm retroperitoneal schwannoma with negative surgical margins and negative lymph nodes.
Patients with Retroperitoneal Tumors Should Seek Specialized Evaluation
Patients with retroperitoneal tumors involving major abdominal blood vessels should seek evaluation at specialized academic medical centers before standard surgical options are dismissed.
Postoperative Recovery and Institutional Program Expansion
Despite the technical success of the initial 14-hour operation, the patient developed a pancreatic leak that necessitated a completion pancreatectomy roughly two months later. Cleveland Clinic reported that the patient spent three months in the hospital recovering from the combined procedures. Dr. Fujiki noted that she has since recovered well, is eating well, and is increasing her physical activity.
Cleveland Clinic performs approximately 10 to 15 intestinal transplants annually, placing it among higher-volume programs in the United States, where roughly 100 such transplants occur each year. Dr. Fujiki aims to formalize a dedicated program centered on ex vivo tumor resection and intestinal autotransplantation to serve as an advanced referral pathway for patients with otherwise inoperable vascular-encased abdominal tumors.
References
- Cleveland Clinic Newsroom. “Ex Vivo Tumor Resection and Intestinal Autotransplantation Offer New Option for Complex Abdominal Tumors.” Consult QD.
