PMC10244506_01
Gastroscopy showing a pancreatico-gastric fistula covered with mucus.
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F1
A gastroscopy showed an ulcerative lesion covered with mucus (Figure 1).
(A) CT scan showing the MPD dilated to 1.3 cm with the presence of a fistula between the main pancreatic duct and the stomach. (B) Endoscopic ultrasound showing a non-homogenous pancreas with diffused calcifications with a dilated MPD of 1.3 cm. MPD, main pancreatic duct.
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F2
The main pancreatic duct (MPD) was dilated to 1.3 cm, with the presence of a fistula between the main pancreatic duct and the stomach (Figure 2).
MRI images showing different views and sequences of the fistulation between the MPD and the stomach. Upper row, axial T1 + gadolinium; middle row, axial T2-weighted images; lower row, coronal T2-weighted images. MPD, main pancreatic duct.
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F3
Magnetic resonance cholangiopancreatography (MRCP) images showed no additional findings when compared with the CT scan (Figure 3). MPD with a diameter of approximately 1.3 cm (Figure 3). Multiple biopsies from the edges of the fistula via a gastroscopy yielded main-branch IPMN.
(A) An en bloc total pancreatectomy with wedge resection from the stomach including the fistula and splenectomy. (B) Gross sectional specimen showing a neoplasm involving the head, body, and tail of the pancreas and also showing the fistulation between the stomach and the main pancreatic duct (MPD). (C,D) Microscopic pathological pictures showing (1) ductal adenocarcinoma of the pancreas and intestinal-type morphology and (2) intraductal papillary mucinous neoplasm with an associated invasive carcinoma.
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F4
An en bloc total pancreatectomy with wedge resection of the stomach including the fistula, splenectomy, and Roux-en-Y choledochojejunostomy and gastrojejunostomy were performed (Figure 4A). The neoplasm involved the head, body, and tail of the pancreas with a fistulation between the stomach and the MPD (Figure 4B). All margins were tumor-free, with no lymphovascular invasion (0/30) (pT3 pN0) (Figures 4C,D).