Peroral pancreatoscopy without a guidewire for intraductal papillary mucinous neoplasm

Peroral pancreatoscopy (POPS) for intraductal papillary mucinous neoplasm (IPMN) facilitates the detection of the mural nodules [1] [2]. However, guidewire seeking prior to POPS causes erythema inside the pancreatic duct, which may lead to misdiagnosis. A novel slim cholangioscope (9-Fr eyeMAX; Micro-Tech, Nanjin, China) has the advantages of easy insertion and high mobility in the bending section [3] [4]. Here, we report a case of POPS without a guidewire for IPMN ([Video 1]).

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Peroral pancreatoscopy without a guidewire in a case of intraductal papillary mucinous neoplasm facilitated an accurate preoperative diagnosis.Video 1

A 76-year-old-man was referred to our hospital because of dilation of the main pancreatic duct. As magnetic resonance cholangiopancreatography or endoscopic ultrasound could not detect mural nodules ([Fig. 1]), we planned to perform POPS without a guidewire.

Fig. 1 A 76-year-old man was referred with intraductal papillary mucinous neoplasm. a Magnetic resonance cholangiopancreatography revealed a pancreatic cyst with main pancreatic duct dilation. b Endoscopic ultrasound showed no mural nodules in the main pancreatic duct.

The orifice of the pancreatic duct was sufficiently dilated, and mucus flowed out. First, the catheter was inserted just over the papilla and the contrast agent was injected up to the pancreatic neck. Subsequently, a 9-Fr eyeMAX was inserted without a guidewire into the dilated main pancreatic duct ([Fig. 2] a). Papillary mural nodules were observed in the main pancreatic duct of the pancreatic head ([Fig. 3] a, b). Given the acute angle of the pancreatic duct between the pancreatic head and body, the eyeMAX was carefully inserted by the assistant with an angle maneuver. The tip of the eyeMAX was easily advanced to the pancreatic tail end without a guidewire ([Fig. 2] b). No focal erythema or mural nodules were observed within the pancreatic duct in the body and tail ([Fig. 3] c, d).

Fig. 2 Fluoroscopic images of peroral pancreatoscopy with 9-Fr eyeMAX (Micro-Tech, Nanjin, China). a The main pancreatic duct in the pancreatic head was dilated, and eyeMAX was inserted without a guidewire. b EyeMax was advanced to the tail end.

Fig. 3 Images of peroral pancreatoscopy. a, b Mural nodules in the pancreatic head. c Focal erythema was not observed in the pancreatic body. d EyeMax reached the pancreatic tail end.

The pancreatic duct in the head was filled with mucus, and various forms of mural nodules were observed. EyeMAX was easily inserted into the branched duct, and mural nodules were detected. Negative biopsies were performed in several areas of the body and tail. Finally, targeted biopsies were performed in the pancreatic head.

The patient was discharged 2 days later without any complications.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Arnelo U, Siiki A, Swahn F. et al. Single-operator pancreatoscopy is helpful in the evaluation of suspected intraductal papillary mucinous neoplasms (IPMN). Pancreatology 2014; 14: 510-514
• 2 de Jong DM, Stassen PMC, Groot Koerkamp B. et al. The role of pancreatoscopy in the diagnostic work-up of intraductal papillary mucinous neoplasms: a systematic review and meta-analysis. Endoscopy 2023; 55: 25-35
• 3 Ogura T, Bessho K, Hattori N. et al. Technical aspects of transpapillary biopsy for gallbladder cancer using a novel cholangioscope. Endoscopy 2023; 55: E1085-E1086
• 4 Miwa H, Sugimori K, Endo K. et al. Pancreatic pseudocyst with biliary fistula diagnosed using a novel slim peroral cholangioscope. Endoscopy 2024; 56: E164-E165

Publication History

Article published online:
19 September 2024