An 82-year-old man was referred for exploration and treatment of a stenosis of the
main pancreatic duct that was found incidentally during a computed tomography (CT)
scan. He reported no symptoms.
Endoscopic ultrasonography (EUS) showed an 8-mm intraductal nodule in the pancreatic
isthmus ([Fig. 1]), with upstream dilatation of the main pancreatic duct, a pancreas divisum, and
a gaping minor papilla. Endoscopic retrograde cholangiopancreatography (ERCP)-guided
brush cytology and EUS-guided biopsy found an intraductal papillary mucinous neoplasia
(IPMN) with dysplasia ([Fig. 2]). Sphincterotomy was performed and a 7-Fr plastic stent was inserted through the
minor papilla.
Fig. 1 Endoscopic ultrasonography view of a tissue nodule protruding into the main pancreatic
duct.
Fig. 2 Endoscopic retrograde cholangiopancreatography view of a small pancreatic duct stricture
with upstream pancreatic duct dilatation.
Pancreatic resection was deemed inadvisable given the patient’s age and comorbid conditions.
After multidisciplinary team discussion, intraductal radiofrequency ablation (RFA)
was offered 2 months later ([Video 1]).
Video 1 Intraductal radiofrequency ablation (RFA) of an intraductal papillary mucinous neoplasia
of the main pancreatic duct: endoscopic ultrasonography (EUS) and endoscopic retrograde
cholangiopancreatography (ERCP) appearances before RFA; the RFA procedure using the
EndoHPB intraductal probe; follow-up ERCP and EUS 3 months later.
A Habib endo-HPB RFA probe (EMcision Ltd, London, UK) was inserted into the dorsal
pancreatic duct over a guidewire ([Fig. 3]) with the two electrodes straddling the mural nodule. RFA was applied for 60 seconds
(power 10 W, effect 8) using a VIO 300 D surgical unit (Erbe Medizin, Tübingen, Germany).
A new 7-Fr stent was placed to prevent secondary stenosis ([Fig. 4]). No adverse events occurred.
Fig. 3 Endoscopic view showing insertion of the EndoHPB radiofrequency ablation probe through
the minor papilla.
Fig. 4 Endoscopic view showing temporary placement of a 7-Fr pancreatic stent after radiofrequency
ablation had been performed.
Follow-up ERCP and EUS 3 months after the RFA showed no evidence of a residual nodule.
Brush cytology found normal pancreatic ductal epithelium and ERCP demonstrated free
pancreatic drainage ([Fig. 5]).
Fig. 5 Image during follow-up endoscopic retrograde cholangiopancreatography 3 months later
showing no residual stricture after stent removal.
RFA removes neoplastic tissue via coagulative necrosis [1]. Experience of pancreatic RFA is scarce owing to the fear of serious adverse events
and the fact that endoscopic biliopancreatic RFA devices have only recently become
available [1]. Only a few animal studies and small clinical series [1]
[2]
[3]
[4]
[5], which included one case of IPMN ablation [2], have been reported, and all of these used EUS guidance. The present case is the
first to report the use of an intraductal RFA catheter that was initially developed
for biliary ablation [1]. The effective outcome and uneventful recovery suggest this technique could be offered
with a curative intent in selected patients.
Endoscopy_UCTN_Code_TTT_1AR_2AF
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
