Endoscopic Retrograde Cholangiopancreatography (ERCP) Assisted Enucleation Of Deep Pancreatic Neuroendocrine Tumors (pNETs): A Novel Technique To Increase Procedure Safety And Decrease Risk Of Post-operative Pancreatic Fistula

Introduction Pancreatic neuroendocrine tumors are slow-growing tumors that account for 1-2% of all pancreatic malignancies. Enucleation of low-grade pancreatic neuroendocrine tumors has the advantage of avoiding short and long-term morbidities related to formal resections; however, it carries a risk of significant post-operative pancreatic fistula, especially if the tumor is close to the main pancreatic duct. We have recently started using intra-operative ERCP to facilitate enucleation of pNETs ≤ 3 mm from MPD. This technique has not previously been described in the literature. Methods Intraoperative ERCP is considered for patients with pNETs ≤ 3 mm from main pancreatic duct who are being considered for enucleation. Intraoperative pancreatography is performed after enucleation, to assess for extravasation of contrast from main pancreatic duct or major side branches at the site of tumor excision. If no extravasation is noted, a pancreatic stent is deployed, and the procedure is terminated. Significant contrast extravasation on pancreatogram is considered an indicator for the development of significant post-operative pancreatic fistula, and the procedure needs to be converted to a formal pancreatic resection. Results We described the steps of the technique, accompanied by images from a patient case. A treatment algorithm is provided detailing a step-by-step approach in patients considered for ERCP assisted enucleation. Conclusion The described technique of ERCP assisted enucleation allows safe resection of pancreatic neuroendocrine tumors ≤ 3 mm from main pancreatic duct through assessment of main pancreatic duct integrity, decreasing the risk of significant post-operative pancreatic fistula, and avoiding the morbidity of major pancreatic resections.