Digital single-operator cholangioscopy-guided endoluminal radiofrequency of an intraductal papillary mucinous neoplasia of the main pancreatic duct

A 64-year-old woman with a history of recurrent acute pancreatitis was referred for treatment of intraductal papillary mucinous neoplasia (IPMN) that was found during a computed tomography (CT) scan in a local hospital. Magnetic resonance cholangiography (MRCP) presented dilation of the main pancreatic duct and suspicious nodules in the main pancreatic duct ([Fig. 1]). Endoscopic retrograde cholangiopancreatography (ERCP) showed that the pancreatic duct was significantly dilatated and there seemed to be a cystic lesion at the head of the pancreas ([Fig. 2]). Further evaluation of digital single-operator cholangioscopy (DSOC) found that the pancreatic duct was full of thick, mucinous fluid, and a few of papillary neoplasms were located at the junction of the main branch and branches of the pancreatic duct in the head of the pancreas ([Video 1]). Tissues were obtained by biopsy forceps and histopathologically examined.

Fig. 1 Magnetic resonance cholangiography (MRCP) showed dilation of the main pancreatic duct and suspicious nodules in the main pancreatic duct.

Fig. 2 Endoscopic retrograde cholangiopancreatography (ERCP) showed dilation of the main pancreatic duct, which was the same as in the MRCP; however, there were no obvious filling defects.

Video 1 Digital single-operator cholangioscopy (DSOC) was used to examine the pancreatic duct. Neoplastic tissues were biopsied and then destroyed by endoluminal radiofrequency under direct vision.

The patient and her relatives all refused to have her undergo radical surgery, and intraductal radiofrequency ablation (RFA) was offered. A novel radiofrequency operation electrode was inserted into the pancreatic duct over DSOC ([Fig. 3]). DSOC-guided endoluminal radiofrequency was used to destroy the neoplasms under direct vision. After radiofrequency ablation, these neoplasms became necrotic ([Fig. 4]). A 5-Fr stent was placed to prevent secondary stenosis ([Fig. 5]). No adverse events occurred. Finally, pathology examination revealed IPMN with mild dysplasia. To date, the patient has not developed acute pancreatitis again after 3 months of follow-up.

Fig. 3 A digital single-operator cholangioscopy (DSOC)-guided endoluminal radiofrequency catheter was inserted into the pancreatic duct. The working channel diameter of this catheter was 1 mm; the working channel length was 5 mm.

Fig. 4 The papillary neoplasms were found by DSOC. After radiofrequency ablation, these neoplasms became necrotic.

Fig. 5 A 5-Fr stent was placed to prevent secondary stenosis and post-ERCP pancreatitis.

RFA ablates neoplastic tissue via local thermal coagulative necrosis [1]. Previous studies have shown that endoscopic biliopancreatic RFA is a safe and effective therapy [2] [3] [4]. However, these methods are guided by fluoroscopic images. The present case report is the first to report the use of a DSOC-guided endoluminal radiofrequency catheter. The effective outcome and uneventful recovery suggest that this technique could be offered with a curative intent in selected patients. Meanwhile, it could offer a novel, accurate, and microinvasive treatment method for pancreatic duct-related disorders.

Endoscopy_UCTN_Code_TTT_1AR_2AF

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Rustagi T, Chhoda A. Endoscopic radiofrequency ablation of the pancreas. Dig Dis Sci 2017; 62: 843-850
• 2 Lorenzo D, Barret M, Bordacahar B. et al. Intraductal radiofrequency ablation of an intraductal papillary mucinous neoplasia of the main pancreatic duct. Endoscopy 2018; 50: 176-177
• 3 Xia MX, Wang SP, Yuan JG. et al. Effect of endoscopic radiofrequency ablation on the survival of patients with inoperable malignant biliary strictures: A large cohort study. J Hepatobiliary Pancreat Sci 2022; 29: 693-702
• 4 Zheng X, Bo ZY, Wan W. et al. Endoscopic radiofrequency ablation may be preferable in the management of malignant biliary obstruction: A systematic review and meta-analysis. J Dig Dis 2016; 17: 716-724

Publication History

Article published online:
27 September 2023