Digital Pancreatoscopy for Extent of Disease and Guided Biopsies of Downstream Intraductal Papillary Mucinous Neoplasms of the Pancreas

Abstract

Evaluation of intraductal papillary mucinous neoplasms (IPMNs) remains a challenge, especially in regards to determining malignant potential. Certain high-risk features, such as main duct involvement, presence of mural nodules, and dilation of the main pancreatic duct suggest a higher likelihood of malignancy. We propose that direct visualization with digital pancreatoscopy can aid in risk stratification and assess extent of disease and main duct involvement. A 68 year old female was evaluated at our center for idiopathic recurrent acute pancreatitis, persistent abdominal pain, and unintentional weight loss. Past medical history was notable for recently diagnosed diabetes and prior cholecystectomy for presumed biliary pancreatitis. Liver function tests were normal. An MRI showed dilated main pancreatic duct and enlarged pancreatic head with a main duct stricture. Endoscopic examination demonstrated a fish mouth appearance of the ampulla. EUS showed marked dilated upstream main pancreatic duct with echogenic material filling the downstream duct. An ERCP was performed. Pancreatogram revealed dilated main duct and side branches with a filling defect in the head of the pancreas. A pancreatic sphincterotomy was performed. Pancreatoscopy demonstrated thick fluid and a lesion with fish-egg-appearing growths intermixed with villous fronds limited to the downstream duct in the head of the pancreas. The extent of the pancreatoscopy exam was confirmed with concurrent fluoroscopic examination. Guided biopsies were obtained from the lesion. A 5 Fr by 13 cm pancreatic stent was successfully placed at the end of the procedure. Pathology revealed fragments of low-grade papillary mucinous epithelium. Based on these features, the patient underwent pancreaticoduodenectomy with partial gastrectomy (Whipple). The final surgical pathology revealed IPMN of the pancreas, with low and high grade dysplasia, and foci which were suspicious for microinvasion. She had 13 negative lymph nodes. IPMNs have malignant potential, with risk varying from 15-60% depending on the presence of high risk features. Digital pancreatoscopy is a useful tool for visualizing main duct or mixed-type IPMN and for guiding biopsies in the downstream pancreatic duct. Digital pancreatoscopy can aid in visualizing the extent of tumor which determines the extent of surgical resection. Watch the video: https://goo.gl/fWj683