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Background: Soft tissue tumors at the mesenteric root are often not resectable by conventional means because of major vascular involvement; if benign and symptomatic, intestinal allo-transplantation is a potential option.Aim: To describe initial experience with a planned surgical approach to ‘inoperable’ tumors at the root of the mesentery within the setting of an intestinal transplant program.Methods: We undertook retrospective review of patients with ‘inoperable’ tumors at the mesenteric root, operated upon over a 2-year period. The operative approach consisted of:1. Early mesenteric vascular dissection and segmental control.2. Estimation of potential bowel loss with conventional tumor resection, based on segmental vascular sacrifice.3. If residual small bowel length with tumor resection was estimated to be > 180 cm, conventional resection was planned.4. Where bowel salvage was not possible with conventional resection, the tumor and the entire mid-gut was excised en-bloc. If auto-transplantation was a technical option, the specimen was flushed with cold preservative solution with ex-vivo tumor resection, followed by vascular reconstruction and auto-transplantation of the intestine.5. In the absence of malignancy, patients with extreme short bowel syndrome, following macroscopically complete tumor resection, were evaluated for intestinal allo-transplantation.Results: Eight patients met criteria for inclusion. Their characteristics are in Table 1. Five of the 8 patients are currently alive; 7 of the 8 patients, including all 5 survivors have had complete tumor resection with macroscopically clear margins. The three deaths occurred after failed/aborted resection in 1, after successful ex-vivo resection, due to possible cardiac causes in a second, and after ‘swine H1N1 influenza’ 7 weeks after successful intestinal allo-transplantation in the third patient. One patient has full graft function after intestinal allo-transplantation and one is currently awaiting intestinal transplant. Two of the five survivors require parenteral nutrition. Three patients, including both the auto-and allo-transplant are on full oral feeds. Conclusions: Our preliminary experience is consistent with the surgical challenge of large tumors at the mesenteric root involving the superior mesenteric vessels. We believe ex-vivo resection with auto-transplantation may be an option in carefully selected cases. However, our data indicate the need for extreme caution. Rapid access to intestinal transplant is critical for success. While our aggressive approach challenges conventional limits of resectability for these difficult tumors, the potential morbidity of this approach must be carefully considered in the context of the often benign clinical course of mesenteric desmoid tumors.

Table 1: Patient Characteristics

Patient number	Age	Sex	Diagnosis	Procedure	Outcome	Comments
1	30	Male	Desmoid	Aborted resection	Died	Abdominal wall and para-spinal fixity at operation
2	54	Male	Lipo-sarcoma	Ex-vivo resection; auto-transplant	Alive	Full oral feeds
3	59	Male	Fibromatosis	Conventional resection	Alive	Full oral feeds
4	53	Female	Leiomyosarcoma	Ex-vivo resection; auto-transplant	Died	On full oral feeds at discharge; no autopsy
5	37	Male	Fibromatosis	Ex-vivo resection	Died	Extreme short bowel; intestinal allo-transplant; died of 'swine H1N1' influenza
6	28	Female	Fibromatosis	ex-vivo resection; failed auto-transplant; allo-transplant	Alive	Mesenteric ischemia after auto-transplant; full graft function after allo-transplant
7	43	Male	Desmoid	Conventional resection	Alive	Complete enterectomy; awaiting allo-transplant
8	31	Female	Desmoid; FAP	Conventional resection	Alive	Short bowel, on stable tpn