Pancreatobiliary fistula associated with an intraductal papillary-mucinous pancreatic neoplasm manifesting as obstructive jaundice: report of a case

Intraductal Papillary Mucinous Neoplasm of the Pancreas: A Challenging Diagnosis

Intraductal papillary mucinous neoplasm of the pancreas (IPMN) was classified as a distinct entity from mucinous cystic neoplasm by the WHO in 1995. It represents a mucin-producing tumor that originates from the ductal epithelium and can evolve from slight dysplasia to invasive carcinoma. In addition, different aspects of tumor progression may be seen in the same lesion. Three types are recognized, the branch duct variant, the main duct variant, which shows a much higher prevalence for malignancy, and the mixed-type variant, which combines branch and main duct characteristics. Advances in cross-sectional imaging have led to an increased rate of IPMN detection. The main imaging characteristic of IPMN is the dilatation of the pancreatic duct without the presence of an obstructing lesion. The diagnosis of a branch duct IPMN is based on the proof of its communication with the main pancreatic duct on MRI-MRCP examination. Early identification by imaging of the so-called worrisome features or predictors for malignancy is an important and challenging task. In this review, we will present recent imaging advances in the diagnosis and characterization of different types of IPMNs, as well as imaging tools available for early recognition of worrisome features for malignancy. A critical appraisal of current IPMN management guidelines from both a radiologist's and surgeon's perspective will be made. Special mention is made of complications that might arise during the course of IPMNs as well as concomitant pancreatic neoplasms including pancreatic adenocarcinoma and pancreatic endocrine neoplasms. Finally, recent research on prognostic and predictive biomarkers including radiomics will be discussed.

A rare case of gastric fistulization of a main-duct intraductal papillary mucinous neoplasm

We report a rare case of gastric fistulization in a patient with main-duct (MD) intraductal papillary mucinous neoplasm (IPMN). Fistulization to adjacent organs is a rare complication of this disease, mainly affecting the duodenum; the fact that the stomach was the only organ involved makes this case even more peculiar. The diagnosis of the fistula was made after examination with endoscopic ultrasound, since a previous computed tomography scan could not detect it.

Pancreatic Fistula Extending into the Thigh Caused by the Rupture of an Intraductal Papillary Mucinous Adenoma of the Pancreas

We herein report the first case of a pancreatic fistula extending into the thigh caused by the rupture of an intraductal papillary mucinous neoplasm (IPMN) of the pancreas. An 80-year-old man was suspected to have necrotizing fasciitis because of right femoral pain. Computed tomography showed fluid retention from the pancreatic head to the right iliopsoas muscle and an IPMN at the pancreatic head. The findings of endoscopic retrograde pancreatography led to the suspicion of a minor leak and a pancreatic stent was placed. The patient died due to an uncontrollable infection. A pathological autopsy showed a pancreatic fistula extending into the thigh that had been caused by the rupture of the IPMN.

Refractory Jaundice From Intraductal Papillary Mucinous Neoplasm Treated With Cholangioscopy-Guided Radiofrequency Ablation

Intraductal papillary mucinous neoplasms (IPMNs) are epithelial neoplasms treated with surgical resection when appropriate. We present a 79-year-old man with jandice refractory to endoscopic stenting. Biliary radiofrequency ablation (RFA) with cholangioscopy was used as palliation of obstructive jaundice due to a mucin-producing pancreatic IPMN with fistulous biliary communication. Clinical improvement permitted surgery, and he returned to pre-illness status at 17 months. The use of cholangioscopy in the setting of mucinous filling defects can guide over-the-wire RFA for palliation and may be a bridge to surgery.

Difficulty in management of intraductal papillary mucinous neoplasm-associated pancreatobiliary fistulas and the role of "pig-nose" appearance and intraductal ultrasonography in diagnosis

Pancreatobiliary fistulas associated with intraductal papillary mucinous neoplasms (IPMN) often develop obstructive jaundice and cholangitis; thus, early diagnosis is important. However, computed tomography and cholangiography, the current methods for detecting pancreatobiliary fistulas, are not always effective. We previously reported a case of IPMN-associated pancreatobiliary fistula and proposed a potential new diagnostic marker: the "pig-nose" appearance of the duodenal papilla, which results from dilated pancreatic and bile ducts and can be visualized via endoscopy. In this study, we report another three cases of IPMN-associated pancreatobiliary fistulas detected by a different technology, intraductal ultrasonography (IDUS). As with our previously reported case, we confirmed the utility of the "pig-nose" appearance and IDUS in the diagnosis of IPMN-associated pancreatobiliary fistulas. In addition, we found it difficult to manage biliary obstruction that resulted from the flow of mucinous material through pancreatobiliary fistulas. The obstruction was treated with endoscopic nasal biliary drainage (ENBD), but this was not always successful. In two of our cases, additional treatment with a large diameter fully covered metal stent failed to improve jaundice. Therefore, we conclude that standard endoscopic stenting may not be effective, and that alternative endoscopic methods or surgery may be necessary.

CT and MR imaging features of fistulas from intraductal papillary mucinous neoplasms of the pancreas to adjacent organs: A retrospective study of 423 patients

PURPOSE

The objectives of this study were to determine the frequency with which intraductal papillary mucinous pancreatic neoplasms (IPMNs) show fistulization to adjacent organs and to describe the multidetector row computed tomography (MDCT) and magnetic resonance imaging (MRI) findings for this specific complication.

METHODS

A retrospective analysis of the clinical and imaging files of all patients with IPMNs who were followed over 8 years by our department was performed to identify those with fistula formation. Two radiologists determined the type of IPMN, the number and size of visible fistulas, the involved adjacent organs, the pancreatic location and the presence of imaging findings suggestive of malignant transformation of the IPMN. Histological correlation was also performed.

RESULTS

A total of 423 patients were included. Fistula formation was present in 8 patients (1.9%). The corresponding IPMNs were of the main duct type (n=4; 50%), the branch duct type (n=1; 13%) or the mixed type (n=3; 38%). In half of the cases, these tumors were discovered incidentally. A total of 26 fistulas (1-7 per patient) were identified. These fistulas involved the duodenum (65.4%), stomach (19.2%), common bile duct (11.5%) and colon (3.8%). All patients had fistulas to the duodenum. All fistulas appeared to develop from a malignant IPMN based on the imaging studies, but two of the five available samples did not exhibit atypia (a quarter of all fistulas). In 50% of cases, the IPMN was of the intestinal form.

CONCLUSIONS

Fistulas are uncommon complications of IPMNs, regardless of malignant transformation of the IPMNs. Fistulas appear to predominate among malignant main-duct IPMNs, are generally multiple and affect several organs, and their preferential target is the duodenum. However, fistulas do not adhere to a strict criterion of malignancy.

Pancreatic choledochal fistula complicating acute pancreatitis

Background:

Biliary tract involvement in acute necrotizing pancreatitis is rare.

Case Report:

We report a case of a 53-year-old man who had a pancreatic choledochal fistula complicating acute necrotizing pancreatitis. The fistula was suspected at computed tomography and confirmed at surgery. The patient underwent necrosectomy, cholecystectomy and proximal biliary diversion. He is well at 1-year follow-up.

Conclusions:

Simultaneous presence of air in the biliary tree and pancreatic collection is highly suggestive of a pancreaticobiliary fistula. Pancreatic necrosectomy and proximal biliary diversion resulted in closure of the fistula.

Direct peroral cholangioscopy and pancreatoscopy for diagnosis of a pancreatobiliary fistula caused by an intraductal papillary mucinous neoplasm of the pancreas: a case report

Here, we report a case of a pancreatobiliary (PB) fistula caused by an intraductal papillary mucinous neoplasm (IPMN) of the pancreas. The PB fistula was suspected after endoscopic retrograde cholangiopancreatography (ERCP) and diagnosed after direct visualization with a direct peroral cholangioscopy and pancreatoscopy by using an ultra-slim endoscope. No previous reports exist on the precise diagnosis of a PB fistula with direct peroral cholangioscopy and pancreatoscopy. In our case report, a 69-year-old man underwent an ERCP because of a pancreatic head mass and biliary tract obstruction. During ERCP, a fistula between the common bile duct (CBD) and main pancreatic duct (MPD) was suspected. After endoscopic sphincterotomy, we examined both the CBD and MPD with an ultra-slim videoendoscope (GIF-N260; Olympus Optical Co, Tokyo, Japan) under direct visualization and biopsy of the mass. The analysis of the biopsy specimen confirmed this mass to be an IPMN of the pancreas. When we examined the CBD, one fistula with copious mucin secretion was identified at the distal CBD. In conclusion, direct peroral cholangioscopy and pancreatoscopy using the ultra-slim endoscope is an efficient tool for diagnosis of PB fistula and pancreatic IPMN.

Postoperative recurrence of an IPMN of the pancreas with a fistula to the stomach

We report on a case of a 74 year old man who was diagnosed with a recurrence of non-invasive carcinoma of intraductal papillary mucinous neoplasm (non-invasive IPMN) by postoperative gastroscopy (GS). A pylorus preserving pancreatico duodenectomy for IPMN in the pancreatic head was performed. A histopathological study revealed non-invasive adenocarcinoma. At first, the local recurrence of the tumor around the superior mesenteric artery circumference was diagnosed and disappeared with gemcitabine. Later, the GS showed the elevated lesion with mucin hypersecretion in the remnant stomach. The lesion had a central dip and a fistula common to the pancreas was confirmed on fisterography. We diagnosed a recurrence of IPMN and administered chemotherapy again. However, he died of his original illness. There are no reports of postoperative recurrence of IPMN checked by GS. It should be remembered that the elevated lesion of the remnant stomach is considered as one of the recurrent patterns of IPMN.

Metachronous intraductal papillary mucinous neoplasm with carcinoma in situ of the pancreas arising within a short interval: report of a case

A 61-year-old man with an intraductal papillary mucinous neoplasm (IPMN) and carcinoma in situ (CIS) of the pancreatic body initially underwent a distal pancreatectomy. Postoperative follow-up included computed tomography (CT) and ultrasonography (US) every 6 months. Intraductal papillary mucinous neoplasm of the pancreatic head was diagnosed 17 months later using peroral pancreatoscopy (POPS) including a biopsy, revealing IPMN with highly dysplastic changes. A total pancreatectomy was therefore performed. The pathological examination revealed IPMN with CIS. The patient was discharged from the hospital and is doing well as of 1 year postoperatively. Although cautious surveillance seems mandatory, consensus has not yet been reached regarding postoperative surveillance. This report presents an unreported case of metachronously arising IPMN with CIS within a relatively early interval, thus suggesting that surveillance every 6 months is preferable to > or = 1 year. In addition, endoscopic US, endoscopic retrograde cholangiopancreatography, intraductal US, or POPS should be included in pathological examinations to avoid missing opportunities to treat lesions such as noninvasive IPMN with a good prognosis. Surgically indicated patients with noninvasive recurrence should therefore be strongly considered to undergo a total pancreatectomy.

Pancreaticobiliary fistula evident after ESWL treatment of pancreatolithiasis

Here we report a patient with a pancreaticobiliary fistula that was possibly associated with pancreatolithiasis. He was admitted due to mild pancreatitis. Pancreatolithiasis was revealed in the parenchyma of the head region and in the main pancreatic duct of the pancreas body with distal dilatation. Extracorporeal shock wave lithotripsy (ESWL) effectively eliminated the pancreatic stones; however, an apparent internal fistula from the middle portion of the common bile duct (CBD) to the main pancreatic duct was revealed where the parenchymal stones had been located. The patient was considered to be in the same condition as pancreato-biliary malunion without CBD dilatation, and was treated with laparoscopic cholecystectomy.