PMC8286367_01
(A) Duodenoscopy indicating repeat adenoma recurrence after two conventional "hot" en bloc papillectomies. (B) Successful cold snare papillectomy (compare Suppl. Video) with histopathology confirming low-grade adenoma with unclear margins. (C) Discrete initial bleeding tendency that rapidly ceased spontaneously. (D) Putative bleeding point or recurrence insertion point at and putatively from within the pancreatic duct opening. (E) Insertion of prophylactic 4-Fr pancreatic duct pigtail stent after gently flushing blood from the distal pancreatic duct (not shown). (F) Targeted biopsies from the area without pathological proof of residual adenoma
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F1
Unexpectedly, the recent duodenoscopy indicated repeat recurrence (Fig. 1A). Given these uncommon findings and with a view to the most likely recurrence insertion point between the ductal openings, cold snare resection was chosen to limit delayed complications such as hemorrhage as well as transmural and/or pancreatic duct injury (Fig. 1B). After specimen retrieval, minor bleeding was noted (Fig. 1C), ceasing rapidly with a putative bleeding point or resection line at or just from within the pancreatic duct orifice (Fig. 1D). The procedure was terminated by gently flushing some more blood from the distal pancreatic duct and insertion of a 4-Fr prophylactic pancreatic stent (Fig. 1E) and biopsy taken from the suspicious area (Fig. 1F).