Single-Operator Pancreatoscopy for Diagnosis Evaluation and Staging of Mixed-Type Intraductal Papillary Mucinous Neoplasm

摘要

An 84-year-old man with previous history of arterial hypertension and aortic valve stenosis underwent an abdominal computed tomography due to abdominal pain. This exam revealed a hypodense non-enhanced lesion in the head and neck of the pancreas, measuring 65 × 37 × 46 mm. This lesion was in continuity with the ampulla of Vater and resulted in diffuse main pancreatic duct (MPD) dilation (12 mm in the body), suspected to represent an intraductal papillary mucinous neoplasm (IPMN) with main duct involvement. Endoscopic ultrasonography confirmed the presence of a multiseptated predominantly cystic mass in the headeck of the pancreas (Fig. ​(Fig.1).1). After multidisciplinary discussion, the patient was recommended for surgery with prior pancreatoscopy to evaluate the MPD directly to help guide surgical management. The pancreatoscopy was performed using a digital single-operator peroral pancreatoscopy system (SpyGlass DS; Boston Scientific, Marlborough, MA, USA). On inspection with the duodenoscope a “fish mouth” ampulla was observed (Fig. ​(Fig.2).2). After MPD cannulation using a sphincterotome, contrast instillation revealed a diffusely dilated duct (Fig. ​(Fig.3).3). Given the diffuse and important dilation of the duct it was possible to pass the 10-Fr SpyScopeTM through the wire up to the tail and inspect the duct during withdrawal. When it is necessary to advance the SpyScopeTM again we usually reinsert the wire to facilitate scope advancement while maintaining a stable position of the duodenoscope. Pancreatoscopy showed a scarring appearance with friability in the MPD, at the level of the pancreatic tail and body. In the neck and head, we observed the presence of mucin, papillary fronds, and projections with a “fish-egg” like appearance (Hara classification type 2; Fig. ​Fig.4).4). We combined the pancreatoscopy image with the fluoroscopic control, taking the relation of the pancreas with the spine as an anatomical reference for the different pancreatic sections, which allowed us to understand the position of the scope inside the duct. Biopsies using SpyBiteTM forceps were performed in the different MPD segments (at least 3 samples per segment). SpyBiteTM was passed along the accessory channel of the scope after removal of the wire. We usually lubricate the forceps using silicone spray to facilitate the passage. The SpyScopeTM dials were kept in a neutral position to avoid bending that hinders advancement of the forceps. The pathology examination revealed lesions with papillary architecture and intestinal phenotype in the head and neck, consistent with IPMN with low-grade dysplasia. No lesions were observed in the biopsies performed in the body and tail region. The patient was submitted to a subtotal duodenopancreatectomy. Surgical specimen histology confirmed the previously reported findings and associated presence of a focal ductal adenocarcinoma, with 15 mm of extension (pT1bN0R0). The patient remains well 1 year after surgery, with no evidence of disease recurrence in the follow-up.