Toufic Kachaamy, MD and Rahul Pannala, MD present this case from the VideoGIE section “Intraoperative laparoscopic-assisted pancreatoscopy and its role in differentiating main duct intraductal papillary mucinous neoplasm from chronic pancreatitis.”
This case describes the multidisciplinary management of a patient with a severely dilated pancreatic duct suspicious for main duct intraductal papillary mucinous neoplasm (IPMN). IPMN are epithelial neoplasms of the pancreatic duct composed of mucin producing columnar cells. They can progress from low grade to high grade dysplasia to carcinoma. Main duct IPMN have the highest malignant potential. Current guidelines recommend surgical resection for any patient with main duct IPMN and a dilated pancreatic duct of greater than 10mm if they are surgical candidates. Main duct IPMN need to be differentiated from chronic obstructive pancreatitis which can have similar radiologic appearance. Tools to differentiate IPMN from chronic pancreatitis include non invasive imaging with CT and MRCP and more invasive such as EUS and ERCP with pancreatic duct sampling and testing for CEA, cytology, pathology and molecular analysis. Pancreatoscopy involve direct examination of the pancreatic duct, obtaining more specific biopsies and a more certain diagnosis. It is reserved for situations where other less invasive tests were inconclusive. In addition, pancreatoscopy allows determination of the extent of pancreatic involvement in preparation for surgery. It can be performed via the oral route and with surgical assistance when the oral route is not successful. Examination of the entire pancreatic duct as in this case can rule out IPMN and avoid morbid surgery such as total pancreatectomy.
We felt that showcasing this case video was important because it shows the technique of laparoscopy assisted pancreatoscopy. In addition it provides high definition images of the pancreatic duct appearance and a pancreatic duct stone in situ. Images such as the ones shown in the video and article are rarely obtained because they require a large enough pancreatic duct to allow the use of a high definition endoscope.
Lessons to learn from this case include the importance of multidisciplinary management of patients with complex pancreatic diseases, the technique of pancreatoscopy, and the appearance of the normal pancreatic duct mucosa. Laparascopic assisted pancreatoscoy risk include abdominal surgery related adverse events in addition to pancreatic surgery specific adverse events such as pancreatitis and pancreatic duct leaks. While not performed in this case, pancreatic duct stenting can be considered to decrease the risk of a leak. Careful attention should be made to avoid leakage of pancreatic fluid during pancreatic duct access.
Find more VideoGIE cases online.
The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.