Continuous Intrabiliary Acetylcysteine Infusion Allowed Perioperative Chemotherapy in a Jaundiced Patient with Malignantly Transformed IPMN and Pancreatobiliary Fistula

We report the case of a patient with a malignantly transformed IPMN (intraductal papillary mucinous neoplasm) of the pancreatic head with involvement of the common bile duct (CBD) and borderline resectability. Due to jaundice, immediate cytostatic treatment was not possible. The patient underwent several ERCPs (endoscopic retrograde cholangiopancreatography) with implantation of plastic and metal stents. However, resolution of jaundice could not be achieved. Therefore, a therapy with acetylcysteine was initiated, first orally, then with intermittent and finally continuous biliary flushing, which led to normalization of bilirubin levels. Intraductal biliary treatment with acetylcysteine has previously been described, but only in a palliative setting. This case shows that continuous percutaneous infusion of acetylcysteine into the biliary tree can contribute to the therapy of cholestasisin selected patients with IPMN and borderline resectability by resolving mucus occlusions and thereby allowing a curative approach with perioperative cytostatic treatment.