Herniation of Pancreatic Intraductal Papillary Mucinous Neoplasm Into Hiatal Hernia

A 97-year-old woman with an upside-down stomach detected three years prior was brought to our hospital because of the sudden onset of recurrent vomiting. The patient had been receiving medical therapy for congestive heart failure and chronic obstructive pulmonary disease. CT findings revealed multiple cystic tumors on the pancreatic tail, with one sized 6 × 4 cm and located on the upper side showing intrusion into the thoracic cavity (Figure 1A). The tumor had compressed the gastric fundus and protruded inward for entry. Magnetic resonance imaging findings revealed multilocular tumors in communication with the main pancreatic duct, thus confirming a diagnosis of branch duct-intraductal papillary mucinous neoplasms (BD-IPMNs) (Figure 1B). The patient was super-old and judged to be unfit for a laparotomy. Endoscopic ultrasound (EUS) imaging showed no solid components in the tumors, while puncture fluid cytology findings indicated no dysplastic cells (Figure 1C, Video S1). Transgastric EUS-guided drainage of the intruding tumor was performed, after which the size was reduced and symptoms were completely resolved (Figure 1D). (A) CT image. CT findings revealed multiple pancreatic cystic tumors on the pancreatic tail and an upper tumor that had entered the thoracic cavity along with an upside-down stomach. The tumor was compressing the gastric fundus from outside the wall (yellow arrow: tumor, green arrow: diaphragm). (B) Magnetic resonance cholangiopancreatography image. Multilocular cystic tumors of the pancreatic tail were revealed. (C) Endoscopic ultrasound imaging showed multiple cystic tumors of the pancreatic tail. (D) CT image obtained following cystic tumor drainage showing reduction in size of the upper cystic tumor on the pancreatic tail (arrow). With an upside-down stomach condition, abdominal organs rarely enter along with the stomach into the thoracic cavity [1] and no reports of herniation of a pancreatic tumor including IPMNs have been presented. For BD-IPMNs, surgery or surveillance is chosen depending on tumor size, presence of solid components, fluid cytology results, and symptoms [2]. Patient age and comorbidities should also be taken into consideration. In the present case, there were no findings indicating malignancy; thus, priority was given to improving symptoms due to advanced age. Transgastric EUS-guided drainage was found to be safe and resolved symptoms in a patient considered unfit for surgery. No long-term follow-up findings are available. Written consent for publication was obtained from the family of the patient. The author declares no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.