PMC4347963_01
MRCP scan showing multifocal BD-IPMN with three big cystic lesions (BD-IPMNs) with associated dilation of the main pancreatic duct.
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MRCP images (Fig. 1) showed a dilation of MPD (especially at the body, with maximum diameter of 6-7 mm) with three cystic lesions at the uncinate process, body and tail of the pancreas (32 mm, 23 mm and 20 mm maximum diameters respectively), all in connection with main pancreatic duct (Branch-Duct IPMNs - BD-IPMNs).
T2-weighted axial scan demonstrating the worrisome 7-mm diameter mural nodule inside the main BD-IPMN located at the uncinate process.
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On T2-weighted axial sequences among the three BD-IPMNs, the lesion located at the uncinate process showed an enhancing 7-mm diameter suspicious mural nodule inside (Fig. 2).
MRCP scan showing the selective absence of pancreatic parenchyma at the isthmus with preservation of the main pancreatic duct.
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On the contrary, we identified a selective glandular agenesis of the pancreatic isthmus (Fig. 3).
Intraoperative finding: a 2.5 cm long main pancreatic duct not surrounded by pancreatic parenchyma and ready to be cut for frozen section.
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The "supposed" isthmus zone was totally occupied only by the naked main pancreatic duct (Fig. 4) for about 2.5 cm in length, with a diameter of about 6-7 mm.
Duct-to-mucosa pancreaticojejunostomy.
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Hence, a standard pylorus-preserving pancreaticoduodenectomy was performed with duct-to-mucosa pancreaticojejunostomy (Fig. 5), hepaticojejunostomy and duodenojejunostomy.