SPYGLASS PANCREATOSCOPY FOR DIAGNOSIS, EVALUATION AND STAGING OF MAIN DUCT INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM

An 84 year-old man, with priors of arterial hypertension and aortic stenosis underwent an abdominal computed tomography due to occasional symptoms of abdominal pain. This exam revealed a hypodense non-enhanced lesion in the head and neck of the pancreas, with 65 × 37 × 46 mm. This lesion was in continuity with the ampulla of Vater and conditioned a diffuse main pancreatic duct (MPD) dilation (12 mm in the body), in probable relation with a main duct intraductal papillary mucinous neoplasm (MD-IPMN). An endoscopic ultrasonography was performed and confirmed the presence of a multiseptated predominantly cystic mass in the head/neck of the pancreas, with hyperechoic material in the center compatible with mucin. After multidisciplinary the patient was proposed for surgery with prior pancreatoscopy to evaluate directly the MPD to help guide the type of surgery. Pancreatoscopy was performed using a peroral digital single-operator pancreatoscopy system (SpyGlass DS; Boston Scientific, Marlborough, Massachusetts, USA). On inspection a “fish mouth” ampulla was observed. After MPD cannulation with sphincterotome, contrast instillation revealed marked MPD dilation. Pancreatoscopy revealed a scarring appearance with friability in the pancreatic tail and body. In the neck and head we observed presence of mucin, papillary fronds and protusions with “fish-egg” appearance. Biopsies were performed in all MPD segments and revealed in the head and neck lesion with papillary architecture and intestinal phenotype, compatible with intraductal papillary mucinous neoplasm with low-grade dysplasia. No lesions were observed in the biopsies performed in the body and tail. The patient was submitted to a subtotal duodenopancreatectomy. Histopathological specimen examination confirmed the findings previously reported and the associated presence of ductal adenocarcinoma (pT1bN0R0).

This case demonstrates the role of pancreatoscopy to help delineate the extent of MD-IPMN and detect skip lesions in the presence of a diffusely dilated main PD, guiding the choice of surgical procedure.