A 77-year-old man was admitted with severe abdominal pain. His laboratory tests and
abdominal ultrasound revealed an acute-on-chronic pancreatitis, with a dilated main
pancreatic duct (MPD) up to 10 mm and multiple stones causing the symptoms ([Video 1]).
Video 1 Video showing the investigations and procedures performed in a 77-year-old man with
acute-on-chronic pancreatitis, including abdominal ultrasound, endoscopic retrograde
cholangiopancreatography, single-operator pancreatoscopy, and stone retrieval.
The patient was therefore scheduled to undergo endoscopic retrograde cholangiopancreatography
(ERCP) of the MPD, and this confirmed the ultrasound findings. In addition, a high
grade stenosis of the MPD was observed in the corpus and a 0.018-inch guidewire could
not be passed beyond this under fluoroscopy guidance. On the basis of these findings,
a digital single-operator pancreatoscopy (SOP; SpyGlass DS, Boston Scientific, USA)
was performed. The pancreatoscope was negotiated into the MPD verifying the presence
of the intraductal stones and that the stenosis of the MPD was caused by a membranous
inflammatory scar ([Video 1]).
As an incidental finding, a villous polypoid lesion of 3 mm was seen within the MPD
in the pancreatic head. Under direct visualization, several biopsies were taken using
forceps (SpyBite; Boston Scientific). Subsequently, electrohydraulic lithotripsy of
the stones was performed and the fragments were retrieved. Under pancreatoscopic guidance,
the stenosis was intubated with a guidewire and dilated to 6 mm, following which a
pancreatic plastic stent (10 Fr × 10 cm) was inserted. The patient was free of symptoms
by 2 days after the intervention.
Histology of the lesion revealed a pancreatic intraepithelial neoplasia with severe
nuclear atypia (PanIN-3; a premalignant condition). Therefore, the patient underwent
a pylorus-preserving Whipple’s procedure without complications. The final histology
was confirmed as PanIN-3.
In conclusion, despite the use of high resolution magnetic resonance imaging, computed
tomography scanning, and endoscopic ultrasound [1]
[2], the detection of neoplasia remains a diagnostic challenge in chronic pancreatitis.
SOP offers a unique extension of the available techniques, through which even very
small potentially malignant lesions of the MPD can be visualized and sampled. In this
case, the PanIN-3 lesion was an incidental finding that led to resection of the premalignant
polyp, thereby potentially preventing the development of pancreatic carcinoma [3]
[4].
Endoscopy_UCTN_Code_TTT_1AR_2AI
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
