Technique Spotlight:
EXALT™ Model D Single-Use Duodenoscope

Dr. Aditya Gutta

Aditya Gutta, Stuart Sherman
MD, MD
Indiana University School of Medicine
Indianapolis, IN

Patient History

Patient is a 75 year old male with a past history of cognitive dysfunction related to Alzheimer's Dementia, CAD, Benign Essential HTN, DLD, DM-2, Prostate Cancer s/p prostatectomy, Chronic Calcific Pancreatitis on PERT with creon (24,000 IU 1 cap with meals) with recurrent abdominal pain related to eating. The patient underwent evaluation via cross-sectional imaging for suspected main pancreatic stones and Intraductal Papillary Mucinus Neoplasm (main PD-IPMN). IV contrast-enhanced CT abdomen pelvis showed the main pancreatic duct was dilated to 18 mm with intraductal pancreatic stones in the upstream body and tail. Parenchymal calcifications noted in the tail of the pancreas. Filling defects noted in the main duct in the head/genu suspicious for mucus. No strictures noted. Relavant labs on the day of procedure: AST 18, ALT 10, ALP 32, T bili 0.5, Lipase 32 (ULN=59), Cr 1.57
Procedure image 1

Major papilla partially within a duodenal diverticulum and with an indwelling endo-biliary stent. Biliary cannulation alongside the stent and subsequent stent removed with some stone extraction.

Procedure image 2

Scout film with biliary stent

Procedure

The patient was intubated and placed in a supine position. An EUS (Olympus, GF-UCT180) was done which showed findings consistent with chronic calcific pancreatitis (Rosemont criteria 9/9). Obstructive stones were noted in the main duct in the pancreatic body. Changes suggestive of mucin and a soft tissue lesion was noted in the genu of the pancreas. ERCP was subsequently performed with the EXALT™ Model D Single-Use Duodenoscope. No clear appearance of a fish-mouth orifice was seen on endoscopic examination of the pancreatic orifice. The main pancreatic duct was cannulated with a sphincterotome and guidewire (0.025 inch x 450 cm angled guidewire). Changes of severe chronic pancreatitis (Cambridge 5) were noted. The main duct in the pancreatic head contained filling defects suggestive of mucin. The pancreatic duct in the body of the pancreas and pancreatic duct in the tail of the pancreas contained multiple stones. 

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The pancreatic duct was explored endoscopically using the SpyScope DS II direct visualization system and was advanced to the pancreatic body with excellent visibility. Diffuse frond/villous-like epithelium was noted in the main pancreatic duct in the head and genu of the pancreas with mucin floating in the duct. Fluid was aspirated through the SpyScope DS II for amylase concentration, cytology and CEA. The abnormal epithelium was biopsied with the SpyScope DS II directed SpyBite™ biopsy forceps. The pancreatic duct in the body of the pancreas contained a few stones. The SpyScope DS II was then withdrawn. The stones in the pancreatic body were then extracted with a stone-extraction balloon and basket.

 

Procedure image 3
 Dilation of the biliary orifice
Procedure image 4
Biliary cannulation with limited cholangiogram showing main bile duct stones and subsequent balloon dilation of the biliary orifice.
Procedure image 5
Biliary cannulation with limited cholangiogram showing main bile duct stones and subsequent balloon dilation of the biliary orifice.
Procedure image 6
Cholangiogram showing clearance of main bile duct stones and residual stones in the gall bladder.

Post Procedure

The patient did well in recovery post-procedure with no immediate post-procedure complications and was discharged as an outpatient. On a follow up phone call 2 weeks later, the patient was doing well with no delayed post-procedure complications. The results of the pancreatic juice analysis (CEA 13,807, Amylase 3,714) and biopsies of the duct epithelium were consistent with an IPMN. There was no high-grade dysplasia/malignancy on pathology. As per the family’s wishes, although there is a high risk of progression to malignancy and the definite treatment being surgery, given the patient’s advanced age and co-morbidities and given the very high risk of surgery compared the expected benefit, we elected not pursue aggressive interventions.

Procedure image 7
 Trans-papillary plastic gall-bladder stent.
Procedure image 8
Numerous gall-bladder stones noted. Wire advanced into the gallbladder and trans-papillary plastic stent placed into the gallbladder.

Discussion

This was a procedure with high complexity due to the following factors: advanced age of the patient; advanced maneuvers perfomed to diagnose a main PD-IPMN and successfully extract most of the main pancreatic duct stones. Pancreatoscopy with a SpyScope DS II, aspiration of pancreatic juice with the SpyScope DS II and SpyScope DS II directed SpyBite™ biopsy forceps of the mucinous epithelium of the main pancreatic duct was done. No immediate or delayed patient-related complications were noted.

 
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