Biliary tract intraductal papillary mucinous neoplasm: single-operator cholangioscopy and clearance of mucin obstruction

Abstract

Biliary tract intraductal papillary mucinous neoplasm: single-operator cholangioscopy and clearance of mucin obstructionBiliary tract intraductal papillary mucinous neoplasm (BT-IPMNs) are the counterparts of pancreatic IPMNs, and are characterized as papillary lesions that produce mucin and spread along the biliary mucosa causing obstructive jaundice [1]. These tumors can develop anywhere along the biliary tree, and are considered to be premalignant lesions [2]. We report a case of a BT-IPMN diagnosed by cholangioscopy-guided biopsy, and a novel technique of clearing the biliary tree with a mucolytic solution.A 49-year-old man presented with obstructive jaundice (serum bilirubin 15 mg/dL) and abdominal pain. Contrast computed tomography showed focal dilatation of bile ducts in segments IV and VIII and dilatation of the common bile duct, with no stones or adenopathy (• " Fig. 1 a, • " Fig. 1 b). Endoscopic retrograde cholangiopancreatography (ERCP) detected amorphous filling defects of the common bile duct with poor opacification of the intrahepatic ducts, especially at the right side (• " Fig. 2 a,• " Fig. 2 b). As a mucin clot was obstructing bile flow, a 5-minute wash with mucolytic agent (n-acetyl cysteine) through an inflated extractor balloon (• " Video 1) was done to improve clearance. Single-operator cholangioscopy (SpyGlass; Boston Scientific, Natick, Massachusetts, USA) was performed to evaluate the extent and involvement of the tumor growth within the bile duct as well as to provide direct-view biopsies (• " Fig. 3). A protruded, friable 8-mm lesion, located in the right intrahepatic duct, was biopsied and histopathological examination revealed a mucinous papillary neoplasm without dysplasia (• " Fig. 4 a, • " Fig. 4 b).The patient recovered without adverse events, his serum bilirubin levels decreased to 2 mg/dL, and a surgical resection was planned. BT-IPMN is a rare variant of bile duct tumor, with malignancy varying on several reports to as high as 64 % -89 % [1,3,4]. Clinical presentations include abdominal pain, jaundice, and acute cholangitis. Peroral cholangioscopy can assess the spread of the tumor and allows histological confirmation, providing better information for surgical planning [5]. We undertook a novel approach of mucin removal by injection of a mucolytic agent, thus improving biliary clearance before surgery. Endoscopy_UCTN_Code_TTT_1AR_2ADCompeting interests: None Video 1Biliary tract intraductal papillary mucinous neoplasm: clearance of mucin clot and SpyGlass cholangioscopy-guided biopsies. Cases and Techniques Library (CTL) E150Franzini

Unconventional treatment of inoperable biliary IPMN with an oesophageal stent in the common bile duct: case report

“… 1 , 2 SpyGlass DS cholangioscopy offers an accurate endoscopic method for diagnostic visual impression, staging of tumour extent and gaining accurate biopsies. 5 , 11 It is also helpful in evaluating the instant effect after endoscopic RF ablation. By standard imaging modalities alone, such as MRI or abdominal CT, BT-IPMN may not be accurately diagnosed and staged because the differentiation, for example, from biliary sludge is not possible, as was the case here.…”

Cholangioscopy and probe‐based confocal laser endomicroscopy for real‐time diagnosis of intraductal papillary mucinous neoplasm of the bile duct

“…Intraductal papillary mucinous neoplasm of the bile duct (IPMN‐B) characterized by similar pathologic features with IPMN of the pancreas, is a rare variant of bile duct tumor, with a malignant potential of 74% . Cholangioscopy is useful for the diagnosis of IPMN‐B . pCLE is a novel technique adopted to obtain real‐time in vivo histological images.…”