Intraoperative SpyGlass to determine extension of pancreatic resection in main duct intraductal papillary mucinous neoplasm associated with pancreas divisum
The International Association of Pancreatology recommends that main duct intraductal papillary mucinous neoplasm (IPMN) be treated with partial pancreatectomy  if surgical margins are negative for high-grade dysplasia (HGD) and invasive carcinoma, avoiding total pancreatectomy . However, it is difficult to determine the exact margins of resection during duodenopancreatectomy for main duct IPMN. The latest guidelines recommend SpyGlass to obtain precise measures of margin extension before surgery .
The patient was an asymptomatic 63-year-old man. Routine ultrasound showed main duct dilatation (6 mm), and magnetic resonance imaging (MRI) showed pancreas divisum with signs of chronic pancreatitis. The patient’s main duct dilatation evolved from 6 mm to 32 mm at 2 years of follow-up ([Fig. 1]). Imaging exams confirmed the diagnosis of IPMN, and duodenopancreatectomy was proposed. The MRI left doubt about the resection margin, and SpyGlass was indicated. A bulging papilla with mucoid secretion was observed ([Fig. 2]), and pancreatic sphincterotomy was performed to improve SpyGlass access ([Fig. 3]). Tissue fragments were obtained and revealed HGD at the pancreatic tail ([Fig. 4]). Total pancreatectomy was uneventful and the patient was discharged after 7 days with blood glucose levels stabilized by insulin ([Video 1]).
Video 1 SpyGlass was used intraoperatively to determine extension of pancreatic resection in main duct intraductal papillary mucinous neoplasm associated with pancreas divisum. Total pancreatectomy was ultimately performed and patient course was uneventful.
The biopsies revealed the presence of HGD, and it was not necessary to perform the section of the margins to be frozen during surgery. However, one limitation of SpyGlass is the diameter of the main duct, which needs to be dilated (> 5 mm) once the diameter of the Spyscope is 3.46 mm . In this case, because the main duct measured 5 mm, a direct view of the pancreatic tail was possible while biopsies were performed. Recent studies have shown SpyGlass to be a useful diagnostic and therapeutic tool in biliary diseases , but to the best of our knowledge, it is the first time it has been used in main duct IPMN with full pancreas examination to obtain direct visual images, perform biopsies, and safely change from a duodenopancreatectomy to a total pancreatectomy.
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02 September 2020 (online)
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