title: Challenging the limits in pancreatic surgery: A case report.
abstract: BACKGROUND
  Today, pancreatic surgery can be performed with low mortality and tolerable morbidity in specialized centers. Nevertheless, due to its anatomical localization and proximity to important vascular structures, surgical resection of the pancreas remains challenging in many cases.
  
  
  METHODS
  Here, we present the case of a young woman who presented in our department with abdominal pain and a tumor mass located at the pancreatic head. She had undergone explorative laparotomy elsewhere before, in which the pancreatic tumor mass was reported to be unresectable due to infiltration of the mesenteric root. However, biopsies obtained had not revealed malignancy. Moreover, postoperatively a stenting of the portal vein had been performed due to portal vein thrombosis and varices. Upon admission in our clinic, computed tomography revealed a tumor of the pancreatic head, occlusion of the portal vein stent and, more importantly, extravascular dislocation of the stent with perforation into the stomach. Upon explorative laparotomy we initially performed a mesenterico-caval shunt to release portal hypertension. Secondly, the dislocated stent was successfully removed upon gastrotomy, and finally, a partial pancreaticoduodencectomy was performed. Interestingly, the histopathological analysis revealed granulocytic epithelial lesions (GELs) confirming a type-2 autoimmune pancreatitis without evidence for malignancy. The postoperative course was uneventful and the patients was dismissed without any remaining symptoms.
  
  
  CONCLUSIONS
  This interesting and unique case underlines the complexity in diagnosis of pancreatic tumors with unsolved dignity and differential diagnosis of pancreatitis and pancreatic cancer. Furthermore, it demonstrated the challenges in pancreatic surgery for exceptional and uncommon conditions demanding complex surgical approaches.
authors.affiliation: Department of General and Visceral Surgery, University of Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany.
authors.forename: Johannes
authors.initials: J
authors.lastname: Lemke
authors.affiliation: Department of Diagnostic and Interventional Radiology, University of Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany.
authors.forename: Stefan A
authors.initials: SA
authors.lastname: Schmidt
authors.affiliation: Department of General and Visceral Surgery, University of Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany.
authors.forename: Marko
authors.initials: M
authors.lastname: Kornmann
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, University of Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany.
authors.forename: Karl-Heinz
authors.initials: KH
authors.lastname: Orend
authors.affiliation: Department of General and Visceral Surgery, University of Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany. Electronic address: doris.henne-bruns@uniklinik-ulm.de.
authors.forename: Doris
authors.initials: D
authors.lastname: Henne-Bruns
keywords: Autoimmune pancreatitis; Case report; Mesenterico-caval shunt; Pancreatic surgery; Pancreaticoduodenectomy