High-resolution optical pancreatoscopy for recurrent main-duct intraductal papillary mucinous neoplasms

Introduction

Main-duct intraductal papillary mucinous neoplasms (IPMNs) have high malignant potential and are generally managed with surgical resection. Even after resection, the rate of recurrence in the remnant pancreas can be as high as 5% for noninvasive IPMNs.¹ Here, we present a case of recurrent main-duct IPMNs diagnosed by intraductal endoscopy and biopsy.

Case

A 73-year-old man with a history of Whipple resection 1 year prior for main-duct IPMNs was found to have abnormal liver tests and biliary ductal dilation on a surveillance MRCP. Prior surveillance MRCP and EUS had revealed pancreatic duct dilation in the remnant pancreas without an obvious mass or intraductal nodularity. Pathological evaluation of the original surgical specimen demonstrated IPMNs with negative margins and no associated high-grade dysplasia. He underwent ERCP to evaluate for a biliary-enteric anastomotic stricture. Informed consent was obtained from the patient for the publication of their information and imaging.

Using a 1T gastroscope, we found evidence of a Whipple reconstruction and a pinpoint stricture was observed at the hepatico-jejunal anastomosis (Fig. 1; Video 1, available online at www.videogie.org). After extensive efforts, access to the bile duct was achieved with an 0.018-inch guidewire, allowing subsequent balloon dilation of the anastomosis and fully covered self-expandable metal stent placement.

Figure 1.

Pinpoint stricture at hepatico-jejunal anastomosis.

In the process of searching for the biliary orifice, the pancreatico-jejunal anastomosis was observed to be widely patent, draining a copious amount of purulent mucin (Fig. 2, Video 1). The gastroscope was advanced seamlessly into the pancreatic duct, and thick mucin was aspirated with some difficulty. This resulted in exposure of the underlying pancreatic duct epithelium, which harbored several discrete areas of hypervascular nodularity that appeared to be the source of mucin production (Fig. 3, Video 1). After dislodging the attached mucin bubbles with endoscopic instruments to expose the underlying lesions, directed biopsy specimens were obtained (Fig. 4, Video 1). Pathologic evaluation revealed IPMNs with moderate dysplasia as well as focal dissecting mucin concerning for mucinous carcinoma (Fig. 5, Video 1).

Figure 2.

Pancreatico-jejunal anastomosis with mucin.

Figure 3.

Hypervascular nodularity in pancreatic duct.

Figure 4.

Underlying lesion in the pancreatic duct.

Figure 5.

H&E staining of focal dissecting mucin (orig. mag. ×20).

The patient therefore underwent a completion pancreatectomy and splenectomy, which he tolerated well. The resected pancreas harbored high-grade dysplasia but no malignancy. The patient remains well over 1 year postoperatively.

Disclosure

The authors disclosed no financial relationships relevant to this publication.

Supplementary data

Video 1

A case of recurrent main-duct intraductal papillary mucinous neoplasms diagnosed by intraductal endoscopy and biopsy.