Transfusion free radical antegrade modular pancreaticosplenectomy of metastatic neuroendocrine tumor of the pancreas in Jehovah's Witness patient

Abstract

In a popular sense, Jehovah's Witnesses (JW) have their creeds, one of which is refusal of blood transfusion. Such refusal may impinge on their proper management, especially in critical situations. We present a case of successful bloodless multimodality therapy, which was performed for a JW. The patient was a 49-year-old woman and JW who had general weakness 7 days before admission. She was diagnosed with a pancreatic neuroendocrine tumor (PNET) with hepatic metastases. Transcatheter arterial chemoembolization and Sandostatin LAR injection were performed, and then she was given a transfusion-free Radical antegrade modular pancreatosplenectomy sequentially. We gave recombinant human erythropoietin and iron hydroxide sucrose complex daily for five days after surgery. She was discharged at postoperative day 12 without any surgical complications. Multimodality therapy is very important for optimal treatment of PNET. Along with intimate interdepartmental cooperation, careful patient selection and appropriate perioperative management could possibly enhance the surgical outcome.

Keywords: Bloodless medical and surgical procedures; Jehovah's witnesses; Neuroendocrine tumors; Pancreatectomy.

Fig. 1

Abdominal CT scan. (A, B) A huge well-capsulated tumor (indicated by the arrow) is located in pancreatic body and tail, highly enhanced by contrast material. (C-F) Multiple hepatic metastases were found in both lobes. Successful transarterial chemoembolization was done for multiple lesions in liver.

Fig. 2

Surgical dissection plan for radical antegrade modular pancreaticosplenectomy. A, left adrenal gland; C, colon; K, left kidney; P, pancreas; S, spleen.

Fig. 3

(A) Surgical field after removal of specimen showed splenic artery stump, left adrenal gland, and superior mesenteric artery (SMA). Gross specimen consists of distal pancreas with tumor mass and spleen. (B, C) On cross cut section, shows roughly ovoid white gray mass (8 cm × 6.5 cm), 1.5 cm from resection margin. Mass is composed of white gray solid creamy tissue with focal cystic change and necrosis. Mass seems to infiltrate into peripancreatic fat tissue. Several enlarged lymph nodes are found in peripancreatic fat tissue. Small clear tumor cells are spreading with trabecular configuration, and destruction of surrounding exocrine tissue show fibrosis, infiltration of mononuclear cells and disarrangement of parenchymal structure were apparent at splenic side of tumor, indicating diffuse chronic pancreatitis (D: H&E, ×10). Extensive angioinvasion is found (E: Victoria blue H&E, ×20). Tumor cells were positively stained for chromogranin A (F, ×20) and CD53 (G, ×20).