Although peroral pancreatoscopy (POPS) has been developed for detailed visualization
of intraductal lesions, the images obtained are often inadequate because of the difficulty
of insertion, the proximity of the pancreatoscope to the lesion, or visualization
challenges due to mucus. Performance can be improved when it is combined with intraductal
ultrasonography (IDUS) [1], narrow-band imaging (NBI) [2], and probe-based confocal laser endomicroscopy (pCLE) [3]; however, POPS alone has not achieved high quality intraductal imaging and is still
under development.
Here, we report for the first time the use of an ultrathin endoscope with a transparent
hood at the tip (Nichendo; Fujifilm Co., Tokyo, Japan) in POPS. This technique has
been used in endoscopic submucosal dissection [4]; however, its use in the pancreaticobiliary region has not been reported.
A man in his 80s underwent follow-up magnetic resonance cholangiopancreatography (MRCP)
for a branch duct intraductal papillary mucinous neoplasm (BD-IPMN); a fistula between
the pancreatic duct branch and the stomach was suspected, with gastric perforation
of the BD-IPMN ([Fig. 1]). To obtain a definitive diagnosis, we initially attempted visualization with a
conventional endoscope (GIF-H290Z; Olympus, Tokyo, Japan); however, insertion was
difficult ([Fig. 2]). Therefore, an ultrathin endoscope (GIF-XP260N; Olympus) with a transparent hood
was used ([Fig. 3], [Video 1]).
Fig. 1 Images from magnetic resonance cholangiopancreatography of an elderly man with branch
duct intraductal papillary mucinous neoplasm (BD-IPMN) performed: a 2 years previously; b during this presentation, with a fistula between the pancreatic duct branch and the
stomach suspected.
Fig. 2 Images of the views obtained with a conventional endoscope (GIF-H290Z; Olympus, Tokyo,
Japan).
Fig. 3 Photograph of the transparent hood (Nichendo; Fujifilm Co., Tokyo, Japan), which has
an outer diameter of 6.9 mm and a length of 9 mm and creates a clear and direct perspective.
An ultrathin endoscope with a transparent hood attached to the tip was used to perform
peroral pancreatoscopy via a fistulous tract, yielding high quality intraductal pancreatic
images, improved insertion, and a stable field of view. Source for the underwater
photographs: ACworks Co. Ltd. Maho Ishikawa.Video 1
This method enabled visualization of the pancreatic duct and its branches. White-light
endoscopy (WLE) and NBI allowed visualization of the mucosa with high quality images
and suggested a relationship between the mucosal appearance and atypical tissue ([Fig. 4]). Characteristic findings including a “bleached coral-like appearance”, indicating
rough mucosa, “jellyfish-like appearance” at the entrance of the pancreatic branch
duct, and “anemone-like appearance” near the gastrostomy were seen ([Fig. 5]).
Fig. 4 Characteristic mucosal appearances seen on: a–c white-light endoscopy; d–f narrow-band imaging for areas with: a, d low grade mucosal changes; b, e high grade changes; c, f invasive carcinoma.
Fig. 5 Mucosal images on peroral pancreatoscopy, along with their underwater likenesses,
showing: a, d the bleached coral-like appearance of low, rough mucosa inside the pancreatic duct;
b, e the jellyfish-like appearance of fragile mucosa floating at the entrance of the pancreatic
duct; c, f the sea anemone-like appearance of a tall, highly atypical mucosa near the gastrostomy.
Source for Figure 5 a and c: ACworks Co. Ltd. Maho Ishikawa.
This is the first report of an ultrathin endoscope with a transparent hood being used
for POPS, providing high quality intraductal pancreatic images, improved insertion,
and a stable field of view.
Endoscopy_UCTN_Code_CCL_1AZ_2AB
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