MetroHealth Medical Center Cleveland, OH, United States
Nabil El Hage Chehade, MD1, Anastasia Chahine, MD2, Sagar Shah, MD3, Neil R. Jariwalla, MD4, Jason Samarasena, MD5, Jennifer Kolb, MD, MS6, John G. Lee, MD7 1MetroHealth Medical Center, Cleveland, OH; 2H. H. Chao Comprehensive Digestive Disease Center, University of California Irvine, Orange, CA; 3University of California Los Angeles, Los Angeles, CA; 4University of California Irvine Medical Center, Orange, CA; 5University of California - Irvine, Orange, CA; 6University of California Irvine, Orange, CA; 7Digestive Health Institute, UC Irvine, Orange, CA
Introduction: Multiple modalities are available for the investigation of pancreatic duct neoplasms. Available data suggests that in selected patients, pancreatoscopy may play an important role in evaluating the main pancreatic duct for intraductal papillary mucinous neoplasms (IPMNs) following endoscopic ultrasound prior to surgical treatment. Fine needle aspiration (FNA) is the conventional method for tissue acquisition. We present the case of a patient who underwent a pancreatoscopy of a main duct IPMN.
Case Description/Methods: A 66-year-old male patient with worsening back pain presented for evaluation of a cystic mass in the head of the pancreas found on abdominal imaging. Esophagogastroduodenoscopy (EGD) was performed and showed no abnormalities except for mucus extruding through the ampulla of Vater. Endoscopic ultrasound was carried out and demonstrated a large dilated pancreatic duct in the head of the pancreas consistent with a main duct IPMN with possible solid component. The patient then underwent an endoscopic retrograde cholangiopancreatography (ERCP) procedure. Cannulation was successfully attempted and the pancreatoscope was advanced over the guidewire under fluoroscopy. Pancreatoscopy enabled excellent direct visualization revealing abundant thick mucin and abnormal tissue with “fish egg protrusions” characteristic of IPMN. No complications were reported post-procedure.
Discussion: EUS guided FNA of the main pancreatic duct can place the patient with a suspected Main duct IPMN at increased risk for a pancreatic duct leak. Digital Pancreatoscopy specifically has the advantage of directly observing the main pancreatic duct and permitting tissue acquisition. It is a useful tool for the study of IPMNs in order to guide the surgery resection margins as it often allows mapping the extent of the tumor prior to surgical resection. Furthermore, in this case, pancreatoscopy confirmed the diagnosis by identifying characteristic intraductal findings.
Figure: Figure 1: fish egg protrusions seen on pancreatoscopy
Nabil El Hage Chehade indicated no relevant financial relationships.
Anastasia Chahine indicated no relevant financial relationships.
Sagar Shah indicated no relevant financial relationships.
Neil Jariwalla indicated no relevant financial relationships.
Jason Samarasena: Cook Medical – Grant/Research Support. Olympus – Consultant.
Jennifer Kolb indicated no relevant financial relationships.
John Lee indicated no relevant financial relationships.
Nabil El Hage Chehade, MD1, Anastasia Chahine, MD2, Sagar Shah, MD3, Neil R. Jariwalla, MD4, Jason Samarasena, MD5, Jennifer Kolb, MD, MS6, John G. Lee, MD7. P2757 - Say Cheese! Pancreatoscopy of Main-Duct Intraductal Papillary Mucinous Neoplasm, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.