2020年 · 第58卷第07期

With the advancement and popularization of modern imaging techniques, the detection rate of intraductal papillary mucinous neoplasm (IPMN) is increasingly high. IPMN is considered to be a precancerous lesion, among which main duct type (MD) IPMN has the highest malignant potential, and surgical resection is recommended for MD-IPMN that meets the surgical indications^[1]。 The recurrence rate after IPMN can reach 20%^[2]This may be related to the fact that it may be multifocal or jumping growth, resulting in incomplete resection by surgery. In order to completely remove IPMN, traditional imaging examinations including CT, MRI and endoscopic ultrasound are commonly used to evaluate the involvement range of IPMN before operation. However, the extent of some IPMN lesions is small, which makes the above examinations have a certain false negative rate^[3]。 Pancreatoscopy can explore the main pancreatic duct in real time under direct vision. Previous reports of pancreatoscopy are mostly preoperative oral pancreatoscopy, and less reports of intraoperative application. We summarized the experience of using intraoperative ductoscopy in our center to explore the application value of intraoperative ductoscopy in accurate resection of MD-IPMN.

PatientA 48-year-old male was admitted to the emergency department on March 5, 2018 due to "intermittent dull pain in the upper abdomen for 1 month and vomiting blood once". One month ago, the patient developed dull upper abdominal pain, fatigue and discomfort, intermittent melena, which was tarry-like, about 50 ml/time. After taking the drug, the upper abdominal pain was relieved, but there was still intermittent upper abdominal pain accompanied by back distension and pain. On the day of admission, nausea and vomiting occurred. The vomit was a coffee-colored liquid, about 100 ml, containing a small amount of food residue, accompanied by palpitations, fatigue and dizziness. Weight loss of about 5 kg in the past 1 month. No history of hypertension, diabetes, trauma and surgery; Smoking index: 20 years ×15 cigarettes =300 years, occasional drinking; There is no tumor family genetic history. Physical examination: There was no yellowing stain in the skin and sclera, deep tenderness in the upper abdomen, no obvious mass was palpable, no ascites sign, and normal intestinal sounds. Auxiliary examination: There were no obvious abnormalities in blood routine and liver and kidney function. Tumor markers: carcinoembryonic antigen 0.45 μ g/L, CA50 7.63 U/ml, CA19-9 8.84 U/ml, alpha-fetoprotein 1.34 μ g/L, CA72-4 0.87 U/ml. Blood and urine amylase were normal. Abdominal ultrasonography: solid space-occupying lesions in the tail of the pancreas; Chronic cholecystitis, calculi in the neck of the gallbladder; There were no obvious abnormalities in the structure and blood flow of portal vein, superior mesenteric vein and splenic vein. Abdominal CT examination: neoplastic lesions in the body and tail of the pancreas, involving the stomach, colon and spleen vessels (FIG. 1A）。 Gastroscopy: irregular bulging lesions near the small curve below the gastric fundus and cardia, with unclear boundaries, irregular ulcer formation on the surface of the lesion, covered with dirty moss, nodular unevenness of the mucosa, contact bleeding, disappearance of mucosal structure by methylene blue staining, biopsy of 4 tissues, brittle texture, easy to bleed. Results of gastroscopic biopsy: moderately differentiated adenocarcinoma of the subcardia. After discussion by the multidisciplinary team in our hospital before operation, it was concluded that the source of the patient's primary tumor was undetermined, accompanied by gastrointestinal incomplete obstruction, bleeding, malnutrition and other characteristics, so surgical treatment was performed first.