Direct peroral pancreatoscopy with an ultraslim endoscope for the evaluation of intraductal papillary mucinous neoplasms.

benign and malignant intraductal papillary mucinous neoplasms (IPMNs) of the pancreas and to determine their exact extent. Peroral pancreatoscopy including narrow-band imaging (NBI) is useful for the evaluation of these neoplasms [1,2], but it is technically difficult and requires two skilled endoscopists and endoscopic systems [3]. The ultraslim upper endoscope has been proposed for direct visual examination of the biliopancreatic duct by a single operator [4,5]. However, the usefulness of direct peroral pancreatoscopy (D-POP) is clinically limited by the inconsistent success rates owing to the inability to keep the position of endoscope stable. An intraductal balloon passed through the endoscope may permit ease of access and stable positioning of the endoscope within the pancreatic duct. After anchoring the intraductal balloon within the proximal pancreatic duct, the endoscope can be advanced over the balloon catheter. The feasibility of intraductal balloon-guided D-POP with NBI was evaluated in four patients with IPMNs (●" Fig. 1). An ultraslim upper endoscope (GIF-XP260N; Olympus, Tokyo, Japan) was advanced directly through the major papilla into the pancreatic duct assisted bya 5-Fr intraductal balloon catheter (MTW Endoskopie, Wesel, Germany) (●" Fig. 2, ●" Video 1). NBI and forceps biopsy were carried out duringD-POP, which showed the papillary tumor with villous lesions in the pancreatic duct (●" Fig. 3). NBI showed the surface structure and capillary vessels of the lesion with greater clarity (●" Fig. 4,●" Video 2). All patients successfully underwent intraductal balloon-guided D-POP with NBI without procedure-related complications. Biopsy specimens showed adenocarcinomas in two patients and adenoma with dysplasia in one patient (●" Fig. 5), all of whom were recommended surgery. The fourth patient had chronic inflammation and is being followed up regularly. In conclusion, the high success rate in this case series illustrates the feasibility of using intraductal balloon-guided D-POP with an ultraslim endoscope in patients with IPMNs. Acknowledgment !