Endoscopic-guided chemoablation of an inoperable main-duct intraductal papillary mucinous neoplasm

Sclerosing mesenteritis (SM) is a rare inflammatory condition causing thickening/foreshortening of the mesentery, challenging the performance of pancreatic surgery. We report a patient with main-duct intraductal papillary mucinous neoplasm (IPMN) who had concomitant SM for whom operative management was not feasible. After discussion with gastroenterology, an alternative treatment approach was employed. The patient is a 58-year-old male who presented with main-duct IPMN of the pancreatic head with main pancreatic duct dilation >10 mm. At operative exploration, he was found to have SM, preventing the ability to perform a tension-free reconstruction as part of a pancreatoduodenectomy. The patient was instead offered interval sessions of endoscopic ultrasound guided (EUS) guided chemoablation with gemcitabine/paclitaxel under compassionate use. Surveillance cytology and molecular testing, initially notable for a guanine nucleotide-binding protein, alpha-stimulating activity polypeptide (GNAS) gene mutation, has been negative for 3 years. The patient remains asymptomatic without adverse events. This case demonstrates the potential application of EUS-guided chemoablation for select inoperable IPMN.