Post written by Soma Fukuda, MD, from the Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan.

This case features the use of balloon-assisted enteroscopy and serial pancreatic juice aspiration cytologic examination (SPACE) via an endoscopic nasopancreatic drainage (ENPD) tube to diagnose high-grade pancreatic intraepithelial neoplasia (HG-PanIN) in a patient with altered anatomy after Billroth II surgery.

A double-balloon enteroscope (EI-580BT; Fujifilm, Tokyo, Japan) was advanced to the papilla, and an ENPD tube (Geenen; Cook Medical, Bloomington, Ind, USA) was successfully placed. Over 3 days, 12 pancreatic juice samples were collected; cytology from 1 sample revealed suspicious cells (class IV), leading to preoperative diagnosis. Distal pancreatectomy confirmed HG-PanIN without invasive carcinoma.

Diagnosing early pancreatic neoplasia in patients with surgically altered anatomy is extremely challenging. EUS-guided FNA is often infeasible in such settings. This video highlights how SPACE via ENPD can serve as a viable alternative diagnostic pathway, even in technically demanding cases.

This case illustrates the diagnostic potential of SPACE in anatomically complex scenarios. It reinforces that pancreatic juice cytology, although underused, can be a powerful tool for early detection of pancreatic ductal adenocarcinoma precursors when EUS is not an option. The approach is safe, minimally invasive, and repeatable, making it a valuable consideration for high-risk patients.

To our knowledge, this is the first reported case of preoperative HG-PanIN diagnosis in altered anatomy using SPACE that led to surgical resection. This case supports expanding the role of SPACE in early detection strategies for pancreatic cancer.

Endoscopic and fluoroscopic images of double-balloon enteroscopy-assisted endoscopic retrograde pancreatography. A, Endoscopic image of the major papilla. B, Bile duct cannulation using a papillotome. C, Pancreatic duct cannulation achieved with biliary guidewire assistance. D, Pancreatography showing the MPD stricture and distal MPD dilatation in the pancreatic tail. E, Fluoroscopic image after placement of a 5F ENPD tube. CBD, Common bile duct; ENPD, endoscopic nasopancreatic drainage; MPD, main pancreatic duct.

Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.