Abstract
Background
A 68-year-old asymptomatic patient was incidentally diagnosed with an intraductal papillary mucinous neoplasia (IPMN) of the pancreas with a pancreaticogastric fistula. He had a history of a right sided nephrectomy due to a renal cell carcinoma 9 years before. The patient underwent an uneventful total pancreatectomy and wedge resection of the stomach.
Methods
The patient’s medical history was studied and compared to recent literature via PubMed.
Results
Pathohistological evaluation confirmed a mixed type IPMN of an intestinal subtype with pancreaticogastric fistula.
Conclusion
Pancreaticogastric fistula due to benign IPMN is extremely rare. Surgical resection including wedge resection of the stomach is the treatment of choice.
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A 68-year-old male Caucasian patient was referred to our clinic with a massive cystic lesion of the pancreas. A computed tomography of the abdomen was performed in a radiologic practice as a follow-up investigation after a right-sided nephrectomy due to a renal cell carcinoma 9 years before.
The patient was asymptomatic and free of any complaints. Magnet resonance imaging revealed a massively dilated main pancreatic duct with a cystic lesion in the pancreatic body infiltrating the greater curvature of the stomach highly suspicious for a pancreaticogastric fistula (Fig. 1). Upper GI endoscopy confirmed infiltration of the stomach without evidence for a malignancy in the biopsies. Laboratory parameters including tumor markers carcinoembryonic antigen and carbohydrate antigen 19–9 were unremarkable.
An uneventful total pancreatectomy and an en-block-wedge resection of the stomach were performed subsequently. Figure 2 demonstrates a view from the stomach with focus on the pancreaticogastric fistula. Pathologic examination revealed a mixed type main duct and side branch IPMN of an intestinal subtype. Carcinoma cells were not identified. The postoperative course was uneventful.
Discussion
IPMN are mucin-producing tumors developed from the epithelium of the main pancreatic duct and its sidebranches.1 They can be classified in intestinal- and in pancreaticobiliary subtypes.2 IPMN are usually asymptomatic and commonly diagnosed incidentally. Most are benign but have the potential for a malignant transformation.2,3 Computed tomography of the abdomen and especially magnet resonance imaging with magnet resonance cholangiopancreatography (MRCP) are suitable for the diagnosis of an IPMN.3 Endoscopic brush biopsy might be helpful but is not essential prior to surgery. Pancreaticogastric fistulas in benign IPMN occur extremely rare. Surgical resection is the treatment of choice.
References
Sahani DV, Kadavigere R, Blake M, Fernandez-Del Castillo C, Lauwers GY, Hahn PF: Intraductal papillary mucinous neoplasm of pancreas: multi-detector row CT with 2D curved reformations—correlation with MRCP. Radiology 2006;238:560–569.
Hall TC, Garcea G, Rajesh A, Dennison AR: Pancreaticogastric fistula secondary to intraductal papillary mucinous neoplasia: a case report and review of the literature. Ann R Coll Surg Engl 2011;93:e32–34.
Jausset F, Delvaux M, Dumitriu D, Bressenot A, Bruot O, Mathias J, Regent D, Laurent V: Benign intraductal papillary-mucinous neoplasm of the pancreas associated with spontaneous pancreaticogastric and pancreaticoduodenal fistulas. Digestion 2010;82:42–46.
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Luu, A.M., Lutz, T., Uhl, W. et al. Pancreaticogastric Fistula Due to Infiltration of a Mixed Type Intrapapillary Mucinous Neoplasia of the Pancreas. J Gastrointest Surg 23, 379–380 (2019). https://doi.org/10.1007/s11605-018-3823-9
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DOI: https://doi.org/10.1007/s11605-018-3823-9