Single Operator Through-the-Colonoscope Pancreatoscopy in Post-Whipple Anatomy

Abstract

Purpose: A 58-year-old man underwent Whipple pancreatic head resection for intraductal papillary mucinous neoplasm (IPMN) with high-grade dysplasia. Dysplasia was limited to the pancreatic head but IPMN extended throughout the main pancreatic duct. The decision was made not to undergo total pancreatectomy due to concerns for worsening preexisting diabetes. Patient was surveyed regularly with endoscopic ultrasound (EUS) and cross-sectional imaging. EUS showed a small sub-centimeter pancreatic duct nodule vs. mucus ball in the remaining pancreatic duct. Fine-needle aspiration of this area revealed IPMN without dysplasia. Direct pancreatoscopy was then performed to further evaluate the nodule and obtain targeted biopsies. Adult colonoscope was used because duodenoscope had insufficient length to reach pancreatic anastomosis. Pancreatic orifice was identified and dilated to 10Fr. Single-operator SpyGlass system (Boston Scientific, MA) was then introduced through the colonoscope into pancreatic duct. Under direct visualization, the pancreatic duct epithelium was irregular, with papillary-like projections near the anastomosis (Figure). Several small mucus/sludge balls were seen as well. Targeted biopsies of irregular epithelium were obtained. Pathology was consistent with IPMN without dysplasia. Immunohistochemical staining for p53 and Ki67 were negative. Patient is scheduled for repeat pancreatoscopy surveillance in 6 months. Main duct IPMN carries a significant risk of malignant transformation. Total pancreatectomy is a morbid procedure, and often surgeons choose to remove area of dysplasia leaving non-dysplastic IPMN in the remaining duct. We present a through-the-colonoscope application of SpyGlass system that allows for improved surveillance of patients with residual IPMN. This procedure may have wider application in patients after Whipple resection.Figure: Irregular pancreatic duct epithelium.