ENDOSCOPIC DRAINAGE OF A GIANT NON-RESECTABLE IPMN AFTER PANCREATOSCOPY-GUIDED DIAGNOSTIC

A 73 years-old male presented with a giant cystic lesion developed in the pancreatic lodge. The MRI confirmed a 180/70 mm collection, with T2 enhancement, developed from the main pancreatic duct. Patient had always been asymptomatic and we suspected a giant mucinous tumour or a large walled off necrosis after a misdiagnosed acute pancreatitis.

Intraductal papillary mucinous neoplasms of the pancreas (IPMN) are precancerous cystic lesions of the pancreas involving the main duct or its secondary branches [1]. This cystic tumour had a high risk of malignant transformation because of size and the communication with the main pancreatic duct [2 – 4] so we decided that surgical resection was the best strategy. However, the tumour was in close contact with the gastric wall and surrounded the retroperitoneal vessels so complete surgical resection was impossible.

Then, we performed trans-papillary drainage using a 40/10 mm metallic stent and then endoscopic biopsies by passing a transnasal endoscope through the stent (Video). The biopsies showed non characteristic fibrotic tissue. However, due to the thick walls of the cyst we decided to attempt a second pancreatoscopy using the dedicated usable scope SpyGlass (Boston scientific, Boston, USA). Endoscopic aspect was typical with large papillas (Video) and biopsies with dedicated forceps confirmed a IPMN with low grade dysplasia.

Six months later the patient was still asymptomatic, the tumour dramatically decreased in size, and MRI showed a 60/40 mm cyst. After multidisciplinary team discussion, second attempt of surgery was proposed to resect this IPMN.