Complicated intraductal papillary mucinous neoplasia requiring a two-stage operation

Abstract

Introduction: Intraductal papillary mucinous neoplasia (IPMN) is a benign cystic neoplasm that has the potential to transform into pancreatic cancer over time. These lesions are usually asymptomatic. A main pancreatic duct IPMN is usually symptomatic and may present as an emergency when occlusion of the common bile duct with thick mucinous secretion and jaundice develop. This complication is hard to manage pharmacotherapeutically or by endoscopic procedure and may require surgical treatment. Purpose: This is a case report of a complicated main pancreatic duct IPMN that required an urgent, two-stage operation. A review of the literature on the topic was carried out. Case description: A 67-year-old male patient with symptoms of jaundice was diagnosed with acute cholangitis, cholecystitis, and pancreatitis as complications of the mucinous obstruction of the main pancreatic duct and of the common bile duct (CBD) caused by IPMN. The condition was confirmed by cholangio-pancreatoscopy and biopsy. Stenting of CBD was attempted, but the procedure turned out unsuccessful, and we proceeded to an emergency two-stage operation. The first operation consisted of the clearance of the bile ducts from infected mucinous secretion, cholecystectomy, and hepatico-jejunostomy. A Whipple procedure was performed as a second-stage operation. Discussion: Cases of emergency are not common in patients with IPMN. However, obstructive jaundice by mucinous secretion due to the disease is hard to treat only by endoscopy because of the high risk of obstruction of the endoprosthesis. On the other hand, emergency pancreatic resections are associated with a high risk of perioperative complications. Conclusion: Sometimes, the complicated main pancreatic duct IPMNs can pose a challenge for the interdisciplinary team of invasive gastroenterologists and surgeons, and the key to a successful outcome is surgical interventions in two- or three stages that include complications management as the first stage, followed by surgical resection as a second stage operation. Biliary drainage improvement is usually only temporarily successful with the insertion of biliary stents because of the rapid mucinous occlusion and the remaining risk of cholangitis and cholecystitis.