Application and advancements of endoscopy in the management of pancreatic intraductal papillary mucinous neoplasm

doi:10.16139/j.1007-9610.2025.05.01

Abstract

Abstract:

Pancreatic intraductal papillary mucinous neoplasm (IPMN) is a pancreatic cystic lesion with malignant potential, the management of which relies on accurate diagnosis, risk stratification, and surveillance. Endoscopic techniques, particularly endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP), play crucial roles in the diagnosis, risk assessment, and therapeutic decision-making for IPMN. However, their application still faces challenges including technical limitations, operator dependence, cost-effectiveness considerations, and controversies regarding long-term surveillance strategies.This article comprehensively reviewed the current applications and recent advancements in gastrointestinal endoscopy for managing IPMN, and discussed future directions for refining personalized, precision-based treatment approaches.

Key words: Pancreatic intraductal papillary mucinous neoplasm(IPMN), Endoscopic ultrasound(EUS), Endoscopic retrograde cholangiopancreatography (ERCP)

CLC Number:

R735.9

XU Wanqian, ZHOU Chunhua, ZOU Duowu. Application and advancements of endoscopy in the management of pancreatic intraductal papillary mucinous neoplasm[J]. Journal of Surgery Concepts & Practice, 2025, 30(05): 369-377.

References 56

[1]	YASRAB M, KWAK S J, KHOSHPOURI P, et al. Mis-diagnosis of pancreatic intraductal papillary mucinous neoplasms and the challenge of mimicking lesions: imaging diagnosis and differentiation strategies[J]. Abdom Radiol (NY), 2025, 50(5):2241-2257.
[2]	VISSER B C, YEH B M, QAYYUM A, et al. Characteri-zation of cystic pancreatic masses: relative accuracy of CT and MRI[J]. Am J Roentgenol, 2007, 189(3):648-656. doi: 10.2214/AJR.07.2365 URL
[3]	UDARE A, AGARWAL M, ALABOUSI M, et al. Diagnostic accuracy of MRI for differentiation of benign and malignant pancreatic cystic lesions compared to CT and endoscopic ultrasound: systematic review and meta-analysis[J]. J Magn Reson Imaging, 2021, 54(4):1126-1137. doi: 10.1002/jmri.27606 pmid: 33847435
[4]	LIM L G, ITOI T, LIM W C, et al. Current status on the diagnosis and management of pancreatic cysts in the Asia-Pacific region: role of endoscopic ultrasound[J]. J Gastroenterol Hepatol, 2011, 26(12):1702-1708. doi: 10.1111/jgh.2011.26.issue-12 URL
[5]	OHNO E, ISHIKAWA T, MIZUTANI Y, et al. Factors associated with misdiagnosis of preoperative endoscopic ultrasound in patients with pancreatic cystic neoplasms undergoing surgical resection[J]. J Med Ultrason (2001), 2022, 49(3):433-441.
[6]	HAMADA T, OYAMA H, TANGE S, et al. The revised Kyoto criteria and risk of malignancy among patients with intraductal papillary mucinous neoplasms[J]. Clin Gastroenterol Hepatol, 2024, 22(12):2413-2423.e18. doi: 10.1016/j.cgh.2024.05.043 URL
[7]	KOBAYASHI M, KATSUDA H, MAEKAWA A, et al. Development of an intraductal papillary mucinous neoplasm malignancy prediction scoring system[J]. PLoS One, 2024, 19(10):e0312234. doi: 10.1371/journal.pone.0312234 URL
[8]	FUJII Y, MATSUMOTO K, KATO H, et al. Endoscopic ultrasonography findings of pancreatic parenchyma for predicting subtypes of intraductal papillary mucinous neoplasms[J]. Pancreatology, 2021, 21(3):622-629. doi: 10.1016/j.pan.2021.01.026 URL
[9]	YAMAMOTO N, KATO H, TOMODA T, et al. Contrast-enhanced harmonic endoscopic ultrasonography with time-intensity curve analysis for intraductal papillary mucinous neoplasms of the pancreas[J]. Endoscopy, 2016, 48(1):26-34. doi: 10.1055/s-0034-1393563 pmid: 26561919
[10]	KAMATA K, KITANO M, OMOTO S, et al. Contrast-enhanced harmonic endoscopic ultrasonography for differential diagnosis of pancreatic cysts[J]. Endoscopy, 2016, 48(1):35-41. doi: 10.1055/s-0034-1393564 pmid: 26605974
[11]	LISOTTI A, NAPOLEON B, FACCIORUSSO A, et al. Contrast-enhanced EUS for the characterization of mural nodules within pancreatic cystic neoplasms: systematic review and meta-analysis[J]. Gastrointest Endosc, 2021, 94(5):881-889.e5. doi: 10.1016/j.gie.2021.06.028 pmid: 34217751
[12]	YAMASHITA Y, KAWAJI Y, SHIMOKAWA T, et al. Usefulness of contrast-enhanced harmonic endoscopic ultrasonography for diagnosis of malignancy in intraductal papillary mucinous neoplasm[J]. Diagnostics (Basel), 2022, 12(9):2141.
[13]	HAMADA T, OYAMA H, NAKAI Y, et al. Clinical outcomes of intraductal papillary mucinous neoplasms with dilatation of the main pancreatic duct[J]. Clin Gastroenterol Hepatol, 2023, 21(7):1792-1801.e3. doi: 10.1016/j.cgh.2023.01.032 URL
[14]	OHNO E, KAWASHIMA H, ISHIKAWA T, et al. Can contrast-enhanced harmonic endoscopic ultrasonography accurately diagnose main pancreatic duct involvement in intraductal papillary mucinous neoplasms?[J]. Pancreatology, 2020, 20(5):887-894. doi: S1424-3903(20)30197-6 pmid: 32651080
[15]	KAMATA K, TAKENAKA M, MINAGA K, et al. Value of additional endoscopic ultrasonography for surveillance after surgical removal of intraductal papillary mucinous neoplasms[J]. Dig Endosc, 2018, 30(5):659-666. doi: 10.1111/den.13176 pmid: 29675938
[16]	PFLÜGER M J, JAMOUSS K T, AFGHANI E, et al. Predictive ability of pancreatic cyst fluid biomarkers: a systematic review and meta-analysis[J]. Pancreatology, 2023, 23(7):868-877. doi: 10.1016/j.pan.2023.05.005 pmid: 37230894
[17]	BARUTCUOGLU B, ORUC N, AK G, et al. Co-analysis of pancreatic cyst fluid carcinoembryonic antigen and glucose with novel cut-off levels better distinguishes between mucinous and non-mucinous neoplastic pancreatic cystic lesions[J]. Ann Clin Biochem, 2022, 59(2):125-133. doi: 10.1177/00045632211053998 URL
[18]	DU C, HE Z, GAO F, et al. Factors affecting the diagnostic value of liquid-based cytology by EUS-FNA in the diagnosis of pancreatic cystic neoplasms[J]. Endosc Ultrasound, 2024, 13(2):94-99. doi: 10.1097/eus.0000000000000041 pmid: 38947751
[19]	PANICCIA A, POLANCO P M, BOONE B A, et al. Prospective, multi-institutional, real-time next-generation sequencing of pancreatic cyst fluid reveals diverse genomic alterations that improve the clinical management of pancreatic cysts[J]. Gastroenterology, 2023, 164(1):117-133.e7. doi: 10.1053/j.gastro.2022.09.028 pmid: 36209796
[20]	ASGE standards of practice committee, MACHICADO J D, SHETH S G, et al. American society for gastrointestinal endoscopy guideline on the role of endoscopy in the diagnosis and management of solid pancreatic masses: summary and recommendations[J]. Gastrointest Endosc, 2024, 100(5):786-796. doi: 10.1016/j.gie.2024.06.002 URL
[21]	MISHRA A, HUNOLD T M, PEDDU D K, et al. Histologic diagnosis of pancreatic cystic lesions with endoscopic ultrasound fine needle biopsy and impact on management decisions[J]. Dig Dis Sci, 2025, 70(8):2873-2881. doi: 10.1007/s10620-025-09056-1
[22]	KRISHNA S, ABDELBAKI A, HART P A, et al. Endoscopic ultrasound-guided needle-based confocal endomicroscopy as a diagnostic imaging biomarker for intraductal papillary mucinous neoplasms[J]. Cancers (Basel), 2024, 16(6):1238. doi: 10.3390/cancers16061238 URL
[23]	NAKAI Y, ISAYAMA H, SHINOURA S, et al. Confocal laser endomicroscopy in gastrointestinal and pancreatobiliary diseases[J]. Dig Endosc, 2014, 26(Suppl 1):86-94. doi: 10.1111/den.2014.26.issue-s1 URL
[24]	KRISHNA S G, HART P A, MALLI A, et al. Endoscopic ultrasound-guided confocal laser endomicroscopy increases accuracy of differentiation of pancreatic cystic lesions[J]. Clin Gastroenterol Hepatol, 2020, 18(2):432-440.e6. doi: 10.1016/j.cgh.2019.06.010 URL
[25]	KONDA V J, MEINING A, JAMIL L H, et al. A pilot study of in vivo identification of pancreatic cystic neoplasms with needle-based confocal laser endomicroscopy under endosonographic guidance[J]. Endoscopy, 2013, 45(12):1006-1013. doi: 10.1055/s-00000012 URL
[26]	NAKAI Y, IWASHITA T, PARK D H, et al. Diagnosis of pancreatic cysts: EUS-guided, through-the-needle confocal laser-induced endomicroscopy and cystoscopy trial: DETECT study[J]. Gastrointest Endosc, 2015, 81(5):1204-1214. doi: 10.1016/j.gie.2014.10.025 pmid: 25634486
[27]	NAPOLEON B, LEMAISTRE A I, PUJOL B, et al. In vivo characterization of pancreatic cystic lesions by needle-based confocal laser endomicroscopy (nCLE): proposition of a comprehensive nCLE classification confirmed by an external retrospective evaluation[J]. Surg Endosc, 2016, 30(6):2603-2612. doi: 10.1007/s00464-015-4510-5 URL
[28]	NAPOLEON B, PALAZZO M, LEMAISTRE A I, et al. Needle-based confocal laser endomicroscopy of pancreatic cystic lesions: a prospective multicenter validation study in patients with definite diagnosis[J]. Endoscopy, 2019, 51(9):825-835. doi: 10.1055/a-0732-5356 pmid: 30347425
[29]	WU C C H, LIM S J M, TAN D M Y. Endoscopic ultrasound-guided needle-based confocal laser endomicroscopy for pancreatic cystic lesions: current status and future prospects[J]. Clin Endosc, 2024, 57(4):434-445. doi: 10.5946/ce.2023.157 pmid: 38978396
[30]	BALABAN V D, CAZACU I M, PINTE L, et al. EUS-through-the-needle microbiopsy forceps in pancreatic cystic lesions: a systematic review[J]. Endosc Ultrasound, 2021, 10(1):19-24. doi: 10.4103/eus.eus_23_20 URL
[31]	FACCIORUSSO A, KOVACEVIC B, YANG D, et al. Predictors of adverse events after endoscopic ultrasound-guided through-the-needle biopsy of pancreatic cysts: a recursive partitioning analysis[J]. Endoscopy, 2022, 54(12):1158-1168. doi: 10.1055/a-1831-5385 URL
[32]	SCHULZ D, HEILMAIER M, PHILLIP V, et al. Accurate prediction of histological grading of intraductal papillary mucinous neoplasia using deep learning[J]. Endoscopy, 2023, 55(5):415-422. doi: 10.1055/a-1971-1274 URL
[33]	DONG W, ZHEN D, XIAOYAN W, et al. The effectiveness of endoscopic ultrasonography findings to distinguish benign and malignant intraductal papillary mucinous neoplasm[J]. Surg Endosc, 2023, 37(6):4681-4688. doi: 10.1007/s00464-022-09752-3 pmid: 36881188
[34]	MACHICADO J D, CHAO W L, CARLYN D E, et al. High performance in risk stratification of intraductal pa-pillary mucinous neoplasms by confocal laser endomicroscopy image analysis with convolutional neural networks (with video)[J]. Gastrointest Endosc, 2021, 94(1):78-87.e2. doi: 10.1016/j.gie.2020.12.054 URL
[35]	LEE T C, ANGELINA C L, KONGKAM P, et al. Deep-learning-enabled computer-aided diagnosis in the classification of pancreatic cystic lesions on confocal laser endomicroscopy[J]. Diagnostics (Basel), 2023, 13(7):1289.
[36]	KRISHNA S G, ABDELBAKI A, LI Z, et al. Towards automating risk stratification of intraductal papillary mucinous neoplasms: artificial intelligence advances beyond human expertise with confocal laser endomicroscopy[J]. Pancreatology, 2025, 25(5):658-666. doi: 10.1016/j.pan.2025.05.011 URL
[37]	YOUNIS F, BEN-AMI SHOR D, LUBEZKY N, et al. Endoscopic ultrasound-guided radiofrequency ablation of premalignant pancreatic-cystic neoplasms and neuroendocrine tumors: prospective study[J]. Eur J Gastroenterol Hepatol, 2022, 34(11):1111-1115. doi: 10.1097/MEG.0000000000002422 URL
[38]	BARTHET M, GIOVANNINI M, LESAVRE N, et al. Endoscopic ultrasound-guided radiofrequency ablation for pancreatic neuroendocrine tumors and pancreatic cystic neoplasms: a prospective multicenter study[J]. Endoscopy, 2019, 51(9):836-842. doi: 10.1055/a-0824-7067 pmid: 30669161
[39]	BARTHET M, GIOVANNINI M, GASMI M, et al. Long-term outcome after EUS-guided radiofrequency ablation: prospective results in pancreatic neuroendocrine tumors and pancreatic cystic neoplasms[J]. Endosc Int Open, 2021, 9(8):E1178-E1185.
[40]	CHO S H, SEO D W, OH D, et al. Long-term outcomes of endoscopic ultrasound-guided ablation vs surgery for pancreatic cystic tumors[J]. Clin Gastroenterol Hepatol, 2024, 22(8):1628-1636.e4. doi: 10.1016/j.cgh.2024.03.021 URL
[41]	MOYER M T, HEINLE J W, RHOADES S E, et al. Successful EUS-guided pancreatic cyst chemoablation safely allows reduction in the frequency of radiographic surveillance: long-term follow-up of randomized prospective data[J]. Gastrointest Endosc, 2024, 99(6):962-970. doi: 10.1016/j.gie.2023.12.008 URL
[42]	HAMADA T, OYAMA H, TAKAHARA N, et al. Role of endoscopy in clinical management of intraductal papillary mucinous neoplasms[J]. J Gastroenterol Hepatol, 2025, 40(5):1045-1058. doi: 10.1111/jgh.v40.5 URL
[43]	ASHIDA R, KAWABATA K I, ASAMI R, et al. Novel treatment system using endoscopic ultrasound-guided high-intensity focused ultrasound: a proof-of-concept study[J]. Pancreatology, 2024, 24(1):88-92. doi: 10.1016/j.pan.2023.11.013 pmid: 38036413
[44]	ELTA G H, ENESTVEDT B K, SAUER B G, et al. ACG clinical guideline: diagnosis and management of pancreatic cysts[J]. Am J Gastroenterol, 2018, 113(4):464-479. doi: 10.1038/ajg.2018.14 pmid: 29485131
[45]	SUZUKI R, THOSANI N, ANNANGI S, et al. Diagnostic yield of endoscopic retrograde cholangiopancreatography-based cytology for distinguishing malignant and benign intraductal papillary mucinous neoplasm: systematic review and meta-analysis[J]. Dig Endosc, 2014, 26(4):586-593. doi: 10.1111/den.12230 pmid: 24450356
[46]	TANAKA M, FERNÁNDEZ-DEL CASTILLO C, ADSAY V, et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas[J]. Pancreatology, 2012, 12(3):183-197. doi: 10.1016/j.pan.2012.04.004 pmid: 22687371
[47]	MORI Y, OHTSUKA T, TAMURA K, et al. Intraoperative irrigation cytology of the remnant pancreas to detect remnant distinct pancreatic ductal adenocarcinoma in patients with intraductal papillary mucinous neoplasm undergoing partial pancreatectomy[J]. Surgery, 2014, 155(1):67-73. doi: 10.1016/j.surg.2013.06.059 URL
[48]	VEHVILÄINEN S, FAGERSTRÖM N, VALENTE R, et al. Single-operator peroral pancreatoscopy in the preoperative diagnostics of suspected main duct intraductal papillary mucinous neoplasms: efficacy and novel insights on complications[J]. Surg Endosc, 2022, 36(10):7431-7443. doi: 10.1007/s00464-022-09156-3 pmid: 35277769
[49]	DE JONG D M, STASSEN P M C, GROOT KOERKAMP B, et al. The role of pancreatoscopy in the diagnostic work-up of intraductal papillary mucinous neoplasms: a systematic review and meta-analysis[J]. Endoscopy, 2023, 55(1):25-35. doi: 10.1055/a-1869-0180 URL
[50]	ARNELO U, VALENTE R, SCANDAVINI C M, et al. Intraoperative pancreatoscopy can improve the detection of skip lesions during surgery for intraductal papillary mucinous neoplasia: a pilot study[J]. Pancreatology, 2023, 23(6):704-711. doi: 10.1016/j.pan.2023.06.006 URL
[51]	HAN S, CHANDRASEKHARA V. Endoscopic retrograde cholangiopancreatography: pancreatic endoscopy[J]. Gastroenterol Clin North Am, 2024, 53(4):643-661. doi: 10.1016/j.gtc.2024.07.002 URL
[52]	HAN S, RAIJMAN I, MACHICADO J D, et al. Per oral pancreatoscopy identification of main-duct intraductal papillary mucinous neoplasms and concomitant pancreatic duct stones: not mutually exclusive[J]. Pancreas, 2019, 48(6):792-794. doi: 10.1097/MPA.0000000000001333 URL
[53]	TANISAKA Y, MIZUIDE M, FUJITA A, et al. Inspection of intraductal papillary mucinous neoplasm via the papilla using a novel slim pancreatoscope under balloon enteroscopy[J]. Endoscopy, 2024, 56(S 01):E80-E82. doi: 10.1055/a-2239-2060 URL
[54]	王维钊, 孙超, 邓登豪, 等. 全覆膜金属支架在无法行外科手术的胰腺导管内乳头状黏液性肿瘤患者中的应用[J]. 中国内镜杂志, 2023, 29(5):84-88.
	WANG W Z, SUN C, DENG D H, et al. Application of fully covered metal stents in patients with intraductal papillary mucinous neoplasms of the pancreatic duct who are unfit for surgical resection[J]. China J Endosc, 2023, 29(5):84-88.
[55]	SCHEPIS T, TRINGALI A, D'AVERSA F, et al. Endoscopic pancreatic sphincterotomy in patients with IPMN-related recurrent pancreatitis: a single center experience[J]. Dig Liver Dis, 2023, 55(1):107-112. doi: 10.1016/j.dld.2022.10.006 URL
[56]	QING Q, DENG X, DENG X, et al. A single-center study examining the safety and effectiveness of ERCP with pancreatoscopy and endoluminal radiofrequency ablation for main-duct IPMN treatment[J]. Sci Rep, 2025, 15(1):5420. doi: 10.1038/s41598-025-89889-y