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Managing the Unmanageable: A Two-Staged Palliative Resection to Control Life-Threatening Duodenal Bleeding Due to Recurrent Paraganglioma

Unusual clinical course, Management of emergency care, Clinical situation which can not be reproduced for ethical reasons

Levi Y. Smucker, Ashley N. Hardy, Peter J. O'Neil, Roderich E. Schwarz

Department of Surgery, Indiana University School of Medicine, South Bend, IN, USA

Am J Case Rep 2018; 19:386-391

DOI: 10.12659/AJCR.907760

Available online:

Published: 2018-04-02

BACKGROUND: This report presents therapeutic decision-making and management of refractory, life-threatening duodenal bleeding in a young man with recurrent metastatic retroperitoneal paraganglioma.
CASE REPORT: The patient had been symptom free for 8 years after radioactive MIBG (metaiodobenzylguanidine) therapy. Failure of endoscopic or angiographic bleeding control led to urgent need to evaluate possible endocrine functional status, tumor curability, safety of incomplete resection, intra- and postoperative support needs, and anticipated recovery potential and postoperative function. Aside from these considerations, impact of tumor biology, alternative therapeutic options, current management guidelines, and ethical challenges of resource utilization for such complex palliative operative intervention were reviewed.
CONCLUSIONS: Based on the observed outcomes after an urgent presentation of an unusual tumor-related complication, palliation-intent therapy was justifiable even if significant treatment-related risks were expected and complex resources were required.

Keywords: Emergency Treatment, Endocrine Surgical Procedures, Gastrointestinal Hemorrhage, Palliative Care, Paraganglioma, Extra-Adrenal