Post written by Shuhei Shintani, MD, from the Division of Gastroenterology, Shiga University of Medical Science, Seta Tsukinowacho, Otsu Shiga, Japan.

This report is the first video case report of the peroral pancreatoscopy (POPS) via the minor duodenum papilla for diagnosis of main duct intraductal papillary mucinous neoplasm (MD-IPMN). This case was novel in 2 points. First, POPS via the minor papilla made diagnosis of the lesion range possible, which contributed to the surgical resection. Second, POPS was safely inserted through a combination of endoscopic minor papilla sphincterotomy (EMPS) and endoscopic minor papilla balloon dilation (EMPBD).

The case was a 65-year-old man with type 2 diabetes mellitus who presented with recurrent acute pancreatitis. Imaging findings showed cystic dilation of the main duct in the pancreatic tail, but no definitive diagnosis was made. ERCP approach via the major papilla was unsuccessful because of the Z-type anatomy of the main duct in the pancreatic head. Therefore, we challenged the approach via the minor duodenum papilla.

Cannulation via the minor duodenum papilla was possible using the wire-guided cannulation method. The insertion of the SpyScope (Boston Scientific, USA) was successful by performing EMPBD next to EMPS. The SpyScope examination clearly detected a mucus-filled duct and a salmon-roe pattern of the epithelium localized to the pancreatic tail. POPS via the minor papilla was performed safely, with no ERCP-related adverse events. This case had a history of diabetes mellitus and needed to preserve as much pancreatic volume as possible. Horizontal progression diagnosis by the SpyScope was very useful for this case.

Regarding ERCP procedure via the minor papilla, the number of cases is small and the evidence is limited. This case report demonstrates that POPS via the minor papilla is a useful and safe tool for diagnosis of MD-IPMN. It is necessary to accumulate more cases and improve the device in the future.

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