Direct Pancreatoscopy with Narrow Band Imaging in Patient with Pancreas Divisum and Intraductal Papillary Mucinous Neoplasm
Comments: Intraductal Papillary Mucinous Neoplasia are recently recognized pancreatic tumors that present as 3 main subtypes. The first type involves the main pancreatic duct only. The second type only affects the side-branches. And the third is a mixed type involving both the main duct and the side-branches. Main duct IPMN is the most commonly recognized type due to accompanying presenting symptoms such as abdominal pain, jaundice or weight loss. It is also associated with the highest malignant potential at approximately 40%. Typically the initial diagnosis is suspected on non-invasive imaging studies, and visualization and tissue sampling which may assist in operative planning by establishing the degree of dysplasia and extent of dysplasia. Narrow Band Imaging, or NBI, is a new technology that enhances mucosal structures and the vasculature and may enhance peroral pancreatoscopy imaging. However, the clinical experience with NBI pancreatoscopy is limited, and this is the first report of direct and dorsal pancreatoscopy. A 65-year old woman with a history of Billroth II for peptic ulcer disease presented with a 3 month history of new onset diabetes. She denied abdominal pain, weight loss, and jaundice and she had no history of pancreatitis. A CT scan demonstrated a diffusely dilated main pancreatic duct with possible intraductal filling defects seen here. The pancreatic duct dilation is seen all the way into the duodenum. She was referred for endoscopic ultrasound which demonstrated a pancreatic duct dilated to 16 mm and intraductal amorphous material consistent with mucin. The head of the pancreas was not examined due to her surgical anatomy. A 11.3 mm high-definition pediatric colonoscope equipped with NBI was advanced to the gastroenteric anastomosis. A patulous major papilla with a small amount of mucin exuding was encountered. The endoscope was then advanced towards the minor papilla where a large amount of mucin completely occupied the entire lumen. Upon closer inspection, papillary fronds are seen emanating from the dorsal pancreatic duct. The colonoscope was advanced gently into the dorsal pancreatic duct. A 10% solution of N-acetylcysteine was used to irrigate the duct, and gentle suction applied to clear the intraductal mucin. This significantly improved visualization and allowed a detailed examination of the pancreatic ductal epithelium. At first, papillary projections were seen, carpeting most of the pancreatic duct. NBI was then switched on and further highlighted the papillary fronds and their vasculature. This nest clip compares white light and NBI imaging of the same location within the pancreatic duct. Note how NBI enhances visualization of the papillary and finger-like fronds. With NBI, the vasculature within each individual frond can be easily seen in fine detail. With NBI, no nodules or masses or tumor vessels were appreciated. This Fluoroscopy image shoes the endoscope positioned within the mind-body of the pancreas. Then, under direct visualization, multiple biopsies were taken from the pancreatic duct. Next attention was turned to the patulous major papilla. An extraction balloon was used to cannulate the ventral pancreatic duct. Contrast injection revealed limited filling of a small ventral duct with no communication to the dorsal duct consistent with pancreas divisum. Next biliary cannulation was attempted using a rotatable sphincterotome which was bowed and rotated counterclockwise to achieve the desired position. Note the gentle “jiggling” maneuver which is some timed helpful to facilitate rotation of the sphincterotome. Using the re-oriented sphincterotome, deep biliary cannulation was attempted and achieved. Note the clear separation of the biliary and pancreatic orifices. A 0.035 inch guidewire was advanced into the bile duct and contrast injected. A markedly dilated extra- and intra-hepatic biliary system and a smooth distal common bile duct stricture that were thought to be due to compression from pancreatic IPMN were seen. Histologic examination revealed papillary ductal mucosa that on higher power consisted of columnar cells with low-grade dysplasia. These findings are consistent with the intestinal subtype of IPMN. The patient met with a surgeon but declined surgery. With plans is to perform surveillance imaging and endoscopy. In summary, this is the first report of direct dorsal pancreatoscopy which confirmed the diagnosis of main duct IPMN and the extent of involvement. It also facilitated tissue sampling under direct visualization. NBI enhanced the visualization of the ductal mucosa, as well as the fine details of the IPMN papillary projections and its associated vasculature.
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Daniel A. Ringold, MD University of Colorado Denver |
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Citation: Ringold, DA (Jun 01 2009). Direct Pancreatoscopy with Narrow Band Imaging in Patient with Pancreas Divisum and Intraductal Papillary Mucinous Neoplasm. The DAVE Project. Retrieved Feb, 9, 2010, from http://daveproject.org/viewfilms.cfm?film_id=861 Times viewed since Feb 2006: 2015 |
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