The patient is an 84 year old male who had previously been diagnosed with a main duct IPMN involving the pancreatic head.
The patient had opted for expectant management in lieu of surgical resection, and had been relatively asymptomatic for 2 years, until presenting with jaundice, cholangitis, and gram negative sepsis.
An abdominal CT demonstrated diffuse intrahepatic biliary dilation, prominent dilation of both the common bile and main pancreatic duct, and a septated lesion in the pancreatic head.
The endoscopic appearance of the papilla at ERCP demonstrated a mucinous, bloody lesion arising from the pancreatic duct orifice. The biliary orifice was identified at the apex of the papilla and selective bile duct cannulation was achieved using the sphincterotome and guidewire.
Cholangiogram demonstrated a massively dilated common bile duct with a distal filling defect consistent with biliary invasion by the mucinous pancreatic lesion.
A fully covered metal biliary stent was deployed over the wire under fluoroscopic and endoscopic guidance.
Successful stent deployment was followed by drainage of injected contrast and purulent bile.
Fluoroscopy demonstrated interval drainage of contrast and development of pneumobilia. Note the absence of a waist in the deployed stent, likely due to the soft, mucinous nature of the obstructing lesion.
Main duct IMPN have high rate of malignant transformation, which, once established, may result in invasion of local structures including the duodenum and distal biliary tree. In such cases, endoscopic biliary stent placement may result in effective palliation of jaundice.
The hope is that placement of a fully covered stent will prevent stent occlusion due to mucinous ingrowth. At 2 month follow-up the patient has normal liver biochemical tests.
Patrick Yachimski, MD, Vanderbilt University Medical Center