CASE REPORT Intraductal papillary mucinous neoplasm (IPMN), characterized by excessive mucin 2secretion, can obstruct biliary drainage (BD) and cause obstructive jaundice (OJ), often necessitating endoscopic BD. The viscous mucin frequently results in recurrent stent-related complications, necessitating innovative treatment approaches. 1, 2 An 82-year-old man had undergone endoscopic BD for OJ caused by IPMN with placement of a double-pigtail plastic stent (DPPS). OJ recurred on day 23 after DPPS placement, prompting referral to our institution. Despite correct DPPS positioning, abdominal imaging revealed a dilated pancreatic duct with IPMN and a dilated biliary tract. Stent replacement for the OJ was performed. During the endoscopic procedure, the major papilla was dilated owing to mucin discharge from the IPMN. Mucin and food debris also adhered to the DPPS at the stent drainage holes and the distal end (Figure 1). Figure 1.: Obstructive jaundice recurred on day 23 after DPPS placement, and the patient was subsequently referred to our institution. Abdominal computed tomography showing a dilated biliary tract (A: asterisk indicates dilated biliary tract; arrow indicates the plastic stent), clear dilation of the main pancreatic duct, and a low-absorption area within the main pancreatic duct, suggesting mucus retention with penetration into the stomach (A, B: arrowhead), due to an intraductal papillary mucinous neoplasm, despite accurate placement of the DPPS in the stenosis (C: arrow indicates the plastic stent). DPPS, double-pigtail plastic stent. BD was accomplished using a 2-step approach: a self-made modified single-pigtail plastic stent (mSPPS), originating from an endoscopic nasobiliary drainage tube, was used to reach the duodenal D3 (6Fr, cut to 20 cm in length; Flexima, Boston Scientific, Marlborough, MA), 3 to prevent mucin and food debris adhesion to the stent. Even if bile flow impairment occurs with a fully covered self-expandable metallic stent (FcSEMS) due to a large amount of mucus, bile will flow directly through the mSPPS. FcSEMS has a larger diameter than DPPS, suggesting better prevention of stent occlusion caused by mucin excretion. However, given the highly viscous nature of mucin, FcSEMS may still be susceptible to biliary tract occlusion within the stent lumen or retrograde blockage due to mucin reflux (Figures 2 and 3, Video 1). Figure 2.: Stent replacement for obstructive jaundice in the present case. During the endoscopic procedure, dilation of the major papilla was observed due to mucin discharge from the intraductal papillary mucinous neoplasm. Mucin and food debris were found adhered to the double-pigtail plastic stent at the stent drainage holes and the distal end (A). Biliary drainage was performed using an endoscopic nasobiliary drainage tube (6Fr, cut to a length of 20 cm, Flexima, Boston Scientific) to prevent mucin and food debris adhesion to the stent drainage holes (B) and (C), and a fully covered self-expandable metallic stent (8 × 70 mm, Bonastent, Sewoon Medical, Korea) to relieve bile duct compression (D). Figure 3.: Fluoroscopic image just after stent placement (A) and 4 weeks later (B) in the present case. The metallic and self-made modified single-pigtail plastic stents were confirmed to be appropriately positioned, with good attenuation by biliary drainage, and no evidence of stent occlusion. "href": "Single Video Player", "role": "media-player-id", "content-type": "play-in-place", "position": "float", "orientation": "portrait", "label": "Video 1", "caption": "Effectiveness of a modified single-pigtail plastic stent in treating obstructive jaundice associated with intraductal papillary mucinous neoplasms. ", "object-id": {"pub-id-type": "doi", "id": "", "pub-id-type": "other", "content-type": "media-stream-id", "id": "1ₙz37bd3d", "pub-id-type": "other", "content-type": "media-source", "id": "Kaltura"} FcSEMS and mSPPS are complementary, and thus, this patient was able to undergo surgery without stent trouble. Particularly during critical treatment phases (preoperative management or chemotherapy) where maintaining stent patency is essential, the use of 2 stents may represent a valuable therapeutic option. DISCLOSURES Author contributions: K. Soga: Conceptualization, data curation, formal analysis, investigation, methodology, project administration, resources, supervision, validation, visualization, and writing—original draft. I. Kobori, M. Tamano: Writing—review and editing. K. Soga is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report.
Soga et al. (Sun,) studied this question.