Endoscopic intraductal radiofrequency ablation of remnant intrapapillary mucinous neoplasm with acute hemorrhage after incomplete surgical resection

An 83-year-old woman presented with recurrent hemosuccus pancreaticus. The patient had previously undergone a distal pancreatic resection due to intrapapillary mucinous neoplasm, with main duct involvement of the tail. Upper endoscopy revealed active bleeding through the ampulla of Vater. During a previous episode of pancreatic bleeding, intraductal injection of fibrin glue had been performed.

Endoscopic retrograde pancreatography demonstrated dilated pancreatic ducts of the remnant pancreatic head. Approximately 3 cm above the papilla, the main pancreatic duct showed a 10-mm-long irregular stricture ([Fig. 1]). As the patient refused surgical treatment, radiofrequency ablation (RFA) was performed using a bipolar RFA catheter (EndoHPB; EMcision, Montreal, Canada) designed for biliary RFA. The RFA catheter was advanced over a 0.035-inch guidewire (Jagwire; Boston Scientific Corp., Natick, Massachusetts, USA) ([Fig. 2]). RFA was applied for a total of 90 seconds using 8 W soft coagulation mode, effect 1 (ERBE VIO 300 D; ERBE Elektromedizin GmbH, Tübingen, Germany). The patient developed mild pancreatitis following RFA, with a maximum serum lipase of 9.6 µmol/L after 12 hours, which returned to normal within 24 hours. Computed tomography scan 2 days after ablation showed a 20-mm cystic ablation area in the pancreatic head ([Fig. 3]). The patient developed no further bleeding during 10 weeks of follow-up.

Fig. 1 Pancreatic duct system in the head with visible stenosis caused by the bleeding tumor.

Fig. 2 Radiofrequency ablation probe positioned in the stenosis during ablation.

Fig. 3 Computed tomography scan 2 days after radiofrequency ablation, showing a hypodense lesion in the pancreatic head, corresponding to the ablation area.

Whereas endoscopic ultrasound-guided RFA is under evaluation for the ablation of pancreatic lesions, we are not aware of any previous case of direct intraductal application of RFA [1]. Intraductal RFA has the potential to treat complications of intraductal tumor growth such as bleeding. Bleeding from the pancreatic duct often requires radiological or surgical intervention [2]. In the present case, RFA was used to treat bleeding. However, RFA may also be a treatment option for the treatment of small intraductal neoplasms. At present, intraductal RFA is approved for the treatment of malignant biliary strictures [3] and is an alternative to photodynamic therapy [4].

Endoscopy_UCTN_Code_TTT_1AR_2AK

Competing interests: None

• References

• 1 Kim HJ, Seo DW, Hassanuddin A et al. EUS-guided radiofrequency ablation of the porcine pancreas. Gastrointest Endosc 2012; 76: 1039-1043
• 2 Han B, Song ZF, Sun B. Hemosuccus pancreaticus: a rare cause of gastrointestinal bleeding. Hepatobiliary Pancreat Dis Int 2012; 11: 479-488
• 3 Tal AO, Vermehren J, Friedrich-Rust M et al. Intraductal endoscopic radiofrequency ablation for the treatment of hilar non-resectable malignant bile duct obstruction. World J Gastrointest Endosc 2014; 6: 13-19
• 4 Strand DS, Cosgrove ND, Patrie JT et al. ERCP-directed radiofrequency ablation and photodynamic therapy are associated with comparable survival in the treatment of unresectable cholangiocarcinoma. Gastrointest Endosc In press 2014;