The features of early intraductal papillary mucinous neoplasms and postoperative sutures under high-definition pancreatoscopy and EUS (with video).

A 65-year-old man underwent distal pancreatectomy for the suspected IPMNs in the pancreas tail 2 years ago. The postoperative pathology result turned out to be IPMN with obvious moderate dysplasia lesion in the main pancreatic duct (PD), and the excision site was lesion-free. This patient was followed up with magnetic resonance cholangiopancreatography once every 6 months, and the remnant PD grew wider gradually [Figure 1]. Moreover, an obvious hyperechoic mass was found in the dilated PD close to the excision site under the latest EUS examination [Figure 2A]. Therefore, we performed endoscopic retrograde cholangiopancreatography and high-definition pancreatoscopy inspection (eyeMAX, 9F; Micro-Tech, Nanjing, China) for the patient. First, typical fish-eye sign was found on the main papilla [Figure 3], and pancreatography confirmed the obviously dilated proximal PD. Subsequently, the pancreatoscopy was inserted into the PD, and some postoperative sutures, which presented a hyperechoic mass under EUS, were found in the excision site of distal PD unexpectedly [Figure 2B]. Moreover, a lot of white translucent papillary lesions were found growing from the wall of PD or floating in the pancreatic liquid [Figure 4]. Finally, biopsy was conducted under pancreatoscopy, and the pathology result turned out to be papillary tissue covered with mucoid epithelium [Figure 5], consistent with IPMN. Previous studies have confirmed that pancreatoscopy was helpful for the diagnosis of suspected IPMN. [1,2] However, the appearance of early IPMN under pancreatoscopy was not known to endoscopists. This study presented the features of early IPMN using a high-definition