Diagnosis of a mucinous pancreatic cyst and resection of an intracystic nodule using a novel through-the-needle micro forceps.

Pancreatic cystic lesions (PCLs) are detected in over 2% of patients who undergo computed tomography (CT) and magnetic resonance imaging screening [1,2]. Most PCLs are harmless, but some have the potential for malignant transformation. The management of PCLs is challenging, with high resource use. The standard option for the acquisition of cellular material from PCLs is endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA). Although many types of needles are available [3], it is usually not possible to obtain a reliable biopsy from the cystwall for amore certain histological diagnosis. In four recently reportedcases, a through-the-needle forceps was used to obtain biopsies from PCLs [4–6]. We report the first case in which a novel through-the-needlemicro forceps (Moray, US Endoscopy, Ohio, USA) (●" Fig.1) was used to diagnose a PCL, and to biopsy and resect an intracystic nodule. The patient was an 85-year-old woman with an incidental finding of a 30×20mm solitary PCL in the body of the pancreas on CT scan. The finding was also apparent on EUS. The lesion showed no connection with the pancreatic ducts, but a small nodule could be seen inside the cyst (●" Fig.2a,b). A 19-G FNA needle (EchoTip Ultra; Cook Medical, Limerick, Ireland) was used to access the cyst. After the stylet was removed, a micro forceps was advanced through the FNA needle into the cyst, and four biopsies were taken from the cyst wall. In addition, the cyst fluid, which was serous, was aspirated. The nodular lesion was biopsied and then resected (●" Video 1). The patient was observed for 2 hours after the procedure, and then discharged. No complications were reported at 2 weeks’ follow-up. The cyst fluid revealed few mucinous cells. Carcinoembryonic antigen and amylase levels were in the normal range. The biopsies showedmucinous epithelium consistent with a mucinous cyst, and a nodule made up of connective tissue with a mucinous lining (●" Fig.3).