Preoperative Perioral Pancreatoscopy to choose adequate pancreatic surgery to be performed. This video was made by Mateus Cândido Emmerle, João Guilherme Ribeiro Jordão Sasso, Luisa Bicudo de Oliveira and Marcos Eduardo Leira dos Santos. These are our disclosures. Pancreatic surgery are known for their high morbidity and mortality. It is essential that the procedure has a precise indication so that appropriate surgery is performed and the possibility of complications is reduced. Pancreatoscopy is a tool increasingly used to guide pancreatic resections for IPNM. A 62-year-old female referred for evaluation of an incidental finding in CT scan. Contrast-enhanced CT scan showed us a cystic tumor on head of pancreas with 39 mm communicating with the main pancreatic duct involving the head and body of the pancreas. Surgery team indicated total pancreatectomy. Therapeutic approach. An ERCP with perioral pancreatoscopy was requested. As you can see, the tip of the duodenal scope is positioned in second portion of duodenum and we can see both the major and minor duodenal papilla. We can see a bulging in minor duodenal papilla. Firstly, the sphincter tome was inserted in major duodenal papilla and the ventral portion of the pancreas was cannulated with the guide wire. The pancreas was then injected. Major papilla sphincterotomy was performed. Thereafter, the minor papilla was cannulated. Contrast was injected. In minor papilla, sphincterotomy was performed. Here we could see the dorsal pancreas. In these two radioscopic images, we can see both ventral and dorsal pancreas contrasted. Therapeutic approach, perioral pancreatoscopy. A 10 French cholangioscope was inserted through a guide wire during evaluation in dorsal pancreas. No lesions were identified and the mucosa was normal. During evaluation in ventral pancreatic duct, a protruding lesion was identified. The lesion presented with villous protrusions. Multiple biopsies were taken during evaluation of the lesion in the ventral pancreatic duct. Pathology showed an intrapapillary mucinous neoplasm. Follow-up, the final diagnosis was pancreas division and head restricted IPMN. Pancreatic head resection with segmental duodenectomy was performed. It was performed in ERCP with sphincter tome and guide wire. And after pancreatic evaluation, we performed a pancretoscopy. It was performed with a XEN French device designed for biliary and pancreatic duct evaluation. As the pancreatic tract was dilated, it was possible to perform a pancreatic evaluation using this device. This case demonstrates that there are limitations for evaluation of IPMN with MRI and endoscopic ultrasound. The pancretoscopy allows a more accurate diagnosis of pancreas division and facilitates determination of resection margins. When suitable, pancretoscopy may be an excellent tool to achieve a definitive diagnosis in pancreatic tract and to guide the most precise surgery for each patient.

preoperative perioral pancreatoscopy

pancreatic surgery

complications

cholangioscope

IPMN