EUS-Guided Ablation of Pancreatic Cystic Neoplasms: A Large Nationwide Survey Analysis of Practice Patterns

Abstract

Introduction: EUS-guided pancreatic cyst ablation (EUS-PCA) offers a minimally invasive therapeutic alternative to surgery and surveillance in patients with pancreatic cystic neoplasms. Although EUS-PCA was first reported over 10 years ago, data regarding its safety, the extent of its adoption in clinical practice and the barriers to more widespread use remain unclear. The aim of this study is to gather information on endosonographer's awareness, practice pattern and potential concerns/limitations regarding EUS-PCA. Methods: US based endosonographers were surveyed using an anonymous online survey consisting of 12 questions regarding practitioner's experience, type of practice, EUS volume, absence or presence of experience in performing EUS-PCA. Data regarding types of cysts suitable for EUS-PCA, patient selection criteria, indications, ablation techniques, complications, and barriers to performing EUS-PCA were collected. Results: 236 (34%) endosonographers completed the survey. 61% identified themselves as academic/university-based practitioners. 21.6% respondents had performed EUS-PCA - 25% of which had performed >30 EUS-PCA. Factors associated with having performed EUS-PCA included longer (>10 years) EUS experience (OR 1.95, 95% CI: 1.03-3.66; p=0.04) and a higher (>500) annual EUS volume (OR 2.34, 95% CI: 1.13-4.82; p=0.02) (Tables 1 & 2). Presumed BD-IPMN was the most commonly ablated pancreatic cyst (75%) followed by presumed mucinous cystadenoma (61%). 78% of EUS-PCA were performed in high risk surgical patients. 94% respondents have utilized ethanol lavage, 52% ethanol lavage plus paclitaxel, and 21% radiofrequency for EUS-PCA. 65% respondents never experienced any major complications (hospitalization, surgery), whereas 33% reported major complications in < 10% cases. Lack of data/controlled trials, lack of expertise &/or experience, and lack of definition of ideal lesion for ablation were identified as the top 3 barriers to performing more EUS-PCA. 54% of those who have never performed EUS-PCA and 48% current EUS-PCA performers envisage using it more frequently in future.Table 1: Comparison of endosonographers based on presence or absence of experience in performing EUS-PCATable 2: Comparison of endosonographers based on total number of EUS-PCA procedures performedConclusion: Although the technique is known and safe, EUS-PCA is not widely performed in the US. Most EUS-PCA are currently done by experienced, high volume endosonographers for presumed BD-IPMN in high surgical risk patients. Finally, the barriers for widespread adoption of this procedure include limited data on efficacy, ideal lesion, and limited procedural experience.