Ultraslim Endoscopy for the Diagnosis of Pancreatic Intraductal Papillary Mucinous Neoplasm

Following 3 years of repeated upper abdominal pain, which worsened over 3 days, an 83-year-old female patient was admitted to our hospital. She had previously been hospitalized twice for acute pancreatitis within the same 3-year period. Magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) revealed a clumpy mixed-signal mass measuring 56 × 40 mm in the uncinate process of the pancreas, which communicated with the pancreatic duct ([Fig. 1]). Subsequent endoscopic retrograde cholangiopancreatography (ERCP) identified a dilated main pancreatic duct (MPD) up to 13.5 mm with a filling defect at the pancreatic head ([Fig. 2A]), while the major papilla appeared normal ([Fig. 2B]). Following successful papillary balloon dilatation with a 10-mm-balloon catheter, an ultraslim upper endoscope (GIF-XP290N, Olympus, Tokyo, Japan; 5.8-mm outer diameter, 2.2-mm working channel) was manually inserted through the major papilla and into the pancreatic duct at the pancreatic head utilizing the freehand technique.[1] Within the dilated MPD near the pancreatic head, a papillary tumor exhibiting villous and fish-egg-like protrusions was observed ([Fig. 3A]). A biopsy was performed under direct visual guidance ([Fig. 3B]), revealing a histopathological examination ([Fig. 4A]) and immunohistochemistry ([Fig. 4B, C]) consistent with intraductal papillary mucinous neoplasm (IPMN) with high-grade dysplasia. The main duct IPMN (MD-IPMN) of the pancreatic head was the final diagnosis, based on imaging, clinical, and histopathology results. Unfortunately, the patient passed away at home 1 year after diagnosis.