Endoscopic Ablation Research Articles

Pulmonary vein isolation-induced vagal nerve injury and gastric motility disorders detected by electrogastrography: The side effects of pulmonary vein isolation in atrial fibrillation (SEPIA) study.

Safety of pulmonary vein isolation (PVI) has been established in clinical studies. However, despite prevention efforts the incidence of damage to (peri)-esophageal tissue has not decreased, and the pathophysiology is incompletely understood. Damage to vagal nerve branches may be involved in lesion progression to atrio-esophageal fistula. Using electrogastrography, we assessed the incidence of periesophageal vagal nerve injury (VNI) following atrial fibrillation ablation and its association with procedural parameters and endoscopic results. Patients were studied using electrogastrography, endoscopy, and endoscopic ultrasound before and after cryoballoon (CB) or radiofrequency (RF) PVI. The incidence of ablation-induced neuropathic pattern (indicating VNI) in pre- and postprocedural electrogastrography was assessed and correlated with endoscopic results and ablation data. Between February 2021 und January 2022, 85 patients (67 ± 10 years, 53% male) were included, 33 were treated with CB and 52 with RF (38 with moderate power moderate duration [25-30 W] and 14 with high power short duration [50 W]). Ablation-induced VNI was detected in 27/85 patients independent of the energy form. Patients with VNI more frequently had postprocedural endoscopically detected pathology (8% mucosal esophageal lesions, 36% periesophageal edema, 33% food retention) but there was incomplete overlap. Pre-existing esophagitis increased the likelihood of VNI. Ablation data and esophageal temperature data did not predict VNI. PVI-induced VNI is quite common and independent of ablation energy source. VNI is part of (peri)-esophageal damage and only partially overlaps with endoscopic findings. VNI-associated acidic reflux may be involved in the complex pathophysiology of esophageal lesion progression to fistula.

Water-immersion and cap-assisted endoscopic ablation of hemorrhagic radiation proctopathy with a novel 1.9/1.5-μm dual-emission endoscopic laser treatment.

Water-immersion and cap-assisted endoscopic ablation of hemorrhagic radiation proctopathy with a novel 1.9/1.5-μm dual-emission endoscopic laser treatment.

Biportal Endoscopic Radiofrequency Ablation of the Sacroiliac Joint Complex in the Treatment of Chronic Low Back Pain: A Technical Note with 1-Year Follow-Up.

Sacroiliac joint (SIJ) pain is a common source of low back pain. Previously reported management strategies for this pain include conservative treatment, SIJ injection, radiofrequency denervation ablation, and SIJ fusion. Herein, we describe the use of biportal endoscopic radiofrequency ablation (BERA) to treat patients with low back pain. We included 16 patients who underwent BERA from April 2018 to June 2020. We marked the S1, S2, and S3 foramina and the SIJ line under fluoroscopy. Skin entry points were positioned at 0.5 cm medial to the SIJ line and at the level of the S1 and S2 foramina. Under local anesthesia, we introduced a 30° arthroscope with a 4 mm diameter through the viewing portal; surgical instruments were inserted through another caudal working portal. We ablated the lateral branches of the S1-S3 foramina and L5 dorsal ramus, which were the sources of SIJ pain. Clinically relevant improvements in both visual analog scale and Oswestry Disability Index scores were noted at 1-, 6-, and 12-month follow-up time points after surgery. The overall patient satisfaction score was 89.1%. BERA for SIJ pain treatment has the advantage of directly identifying and ablating the innervating nerve to the joint. Through this technique, an expanded working angle can be obtained compared with traditional single-port endoscopy. Our study demonstrated promising preliminary results.

Urodynamic changes before and after endoscopic valve ablation in boys diagnosed with the posterior urethral valve without chronic renal failure

IntroductionCurrent research on the posterior urethral valve (PUV) mainly focuses on the follow-up of bladder function after valve ablation. However, few studies exist on the changes in bladder function before and after valve ablation.ObjectivesTo investigate the urodynamic changes before and after PUV ablation and determine the effect of operation on bladder function, in patients.Materials and methodsThe clinical records of 38 boys diagnosed with PUV and undergone urodynamic exams before and after valve ablation were retrospectively reviewed. In addition, differences in patients’ radiographic studies and urodynamic characteristics between pre- and post-operation were evaluated. Moreover, the urodynamic data was compared using the paired t-test and all the data was expressed as means ± SEM. Additionally, p values less than 0.05 were considered to be statistically significant.ResultsAll the patients were diagnosed with PUV and the follow-up period after operation ranged between 9 and 114 months. The urodynamic exams were performed about 6 months after operation. The results revealed that bladder compliance improved from 8.49 ± 4.73 to 13.31 ± 6.78 ml/cmH2O while the maximum detrusor pressure decreased from 95.18 ± 37.59 to 50.71 ± 21.71 cmH2O, after valve ablation. Additionally, there were significant differences in the pre- and post-operation values of bladder compliance and maximum detrusor pressure (p < 0.05). However, there were no significant differences in the pre- and post-operation values with regard to the residual urine volume, maximum bladder volume and maximum urinary flow rate (p > 0.05).ConclusionsThe adequacy of the COPUM incision is necessary. But the study showed that endoscopic valve ablation couldn’t by itself completely improve the bladder function of patients diagnosed with PUV. However, it was able to improve bladder compliance and decrease maximum detrusor pressure to a certain extent. However, bladder compliance still couldn’t reach the normal level.

Foley's Catheter Balloon Avulsion of Posterior Urethral Valve in Children: How Effective?

Background: Endoscopic ablation under direct vision is the gold standard for treatment of posterior urethral valve. However, when the facilities are not available, Foley’s catheter balloon avulsion of the valve suffices. The aim of this study was to evaluate the initial outcome of management of children with posterior urethral valve treated by Foley’s catheter balloon avulsion. Materials and Methods: This was a retrospective study of children, aged 15 years and younger, who were treated for posterior urethral valves at the pediatric surgery unit of a teaching hospital in Enugu, Nigeria. The parameters evaluated included the age of the patient at presentation, duration of symptoms before presentation, time interval between presentation and intervention, presenting symptoms, procedure performed, post-intervention complications, duration of hospital stay and outcome of treatment. Results: A total of 24 children underwent catheter balloon avulsion during the study period. The mean age of the patients at presentation was 18 months and the mean duration of hospital stay was 18 days. Poor urinary stream and overflow incontinence were the most common presentations of the patients. Twenty-three out of 24 (96%) patients achieved full recovery with marked improvements in urinary stream and resolution of urinary symptoms. Patients who had hydronephrosis and vesicoureteric reflux before treatment, had resolutions of their pathologies during the period of follow up. However, one tenth of the patients each, experienced urethral injury and temporary urinary incontinence. Conclusion: In resource poor settings where the necessary facilities are not available, Foley catheter balloon avulsion of posterior urethral valve is a simple and effective modality of treatment.

The first Russian experience of radiofrequency ablation in the treatment of adenoma of the major duodenal papilla with intraductal growth in the common bile duct

Adenoma of the major duodenal papilla can cause bile flow blockade and obstructive jaundice. We present successful endoscopic radiofrequency ablation for adenoma of the major duodenal papilla with intraductal growth in the common bile duct.

Endoscopic resection and ablation of neoplastic lesions of the esophagus: clinical application and techniques

Endoscopic resection and ablation of neoplastic lesions of the esophagus: clinical application and techniques

Anastomotic urethroplasty as management for iatrogenic posterior urethral injuries in an infant

Introduction: Boys born with high imperforate anus have a rectourethral fistula, which usually occurs at the prostatomembranous junction. A recent trend has been to perform a single-stage posterior sagittal posterior anorectoplasty (PSARP) with pull-through and closure of the rectourethral fistula. Inadvertent posterior urethral injury during repair may result in traumatic obliteration of the posterior urethra. Posterior urethral injury is also possible after other procedures such as ablation of posterior urethral valves (PUVs). We evaluated our outcomes of posterior anastomotic urethroplasty in such infants. Materials and Methods: We managed four infants with posterior urethral injury after PSARP and one after endoscopic ablation of PUVs during 2012–2018 at our institution. Iatrogenic injury was noticed post-PSARP on the removal of the urinary catheter. Suprapubic catheter (SPC) was subsequently inserted. Retrograde urethrogram, voiding cystourethrogram, and endoscopy through the SPC tract and urethra were performed before undertaking an anastomotic urethroplasty. Results: Three infants required crural separation and inferior pubectomy. Four infants had an uneventful recovery. One infant had an annular narrowing at the anastomotic site and required endoscopic urethrotomy twice. We waited till the child was older (age 4) and performed urodynamics. This revealed obstructive uropathy. The patient subsequently underwent redo anastomotic urethroplasty with crural separation and inferior pubectomy. He had an uneventful recovery. Our follow-up ranged from 1 to 7 years. Conclusions: Iatrogenic urethral injuries are rare in infants. Anastomotic urethroplasty achieves physiological voiding and prevents complications of prolonged SPC. Even though surgery is challenging, our series suggests that it is feasible with good outcomes.

Laryngotracheal Stenosis: Our Experience in a Tertiary Care Hospital.

Laryngotracheal stenosis is a recalcitrant disease with high morbidity. Laryngotracheal stenosis can be defined as a partial or circumferential narrowing of the airway and may be congenital or acquired. Sites involved are supraglottis, glottis, or sub glottis. The goal of treating the patient with laryngotracheal stenosis is to reconstruct an adequate airway while preserving phonation and airway protection. Furthermore, there is no fixed treatment for laryngotracheal stenosis, the choice of surgical procedure is determined by the individual anatomy, involved site, length and luminal narrowing of stenotic segment and function of the larynx and trachea, together with patient factors and available facilities. To determine the most common aetiology of laryngotracheal stenosis and to study outcome of various treatment modalities and their efficacies according to the site of stenosis and time of presentation. We have prospectively studied 25 cases of laryngotracheal stenosis who presented in Department of ENT, Civil Hospital, Ahmedabad from May 2019 to December 2021. All patients with clinical suspicion of laryngotracheal stenosis underwent CECT Neck and Thorax with virtual bronchoscopy, flexible bronchoscopy and graded according to myer cotton classification and then included in study. In our study of 25 patients 19 patients had history of intubation. Out of 25 patients, 5 Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation patients had supraglottic stenosis, 14 had subglottic stenosis and 6 patients had tracheal stenosis. 20 patients were tracheostomised. Bilateral vocal cord mobility is pre requisite for any surgical intervention and for decannulation of tracheostomy tube. Laser ablation is best modality for supra glottis stenosis patients. Treatment options of subglottic and tracheal stenosis patients depends on vocal cord mobility, % of luminal narrowing and type of stenosis on flexible bronchoscopy and CT scan. Patients of subglottic or tracheal stenosis having Myer cotton grading 1 or 2 were successfully treated by Laser + Balloon dilatation while grade 3 or 4 by resection and end to end anastomosis. Endoscopic CO2 laser ablation with/without balloon dilatation gives promising results in cases of supra glottic stenosis and in soft, mucosal, short segment (< 1.5cm), grade 1 or 2 stenosis patients with subglottic or tracheal stenosis. In patients with subglottic or tracheal stenosis having hard, cartilage framework involvement, > 1.5cm stenotic segment, Grade 3 or 4 needed external open approach like tracheal resection and end to end anastomosis.

Kidney-sparing surgery for distal high-risk ureteral carcinoma: Clinical efficacy and preliminary experiences in 22 patients.

Several groups proved kidney-sparing surgery (KSS) had equivalent oncological outcomes compared with radical nephroureterectomy (RNU) for the low-risk upper urinary tract urothelial carcinoma (UTUC) patients. Whereas, the clinical efficacy of KSS for high-risk UTUC, especially for distal high-risk ureteral carcinoma, remains unclear. To evaluate the feasibility of KSS for patients with distal high-risk ureter cancer. Our study included 22 patients who diagnose the distal high-risk ureter cancer and underwent KSS between May 2012 and July 2021 in the First Affiliated Hospital of Chongqing Medical University. Overall survival (OS), confirmed as the primary endpoint of present study, was assessed by a blinded independent review committee (BIRC). The secondary endpoints included the postoperative SF-36 (the short form 36 health survey questionnaire) score, progression-free survival (PFS), postoperative complications, and so on. Overall, 17 (77.3%) and 5 (22.7%) patients underwent segmental ureterectomy (SU) and endoscopic ablation (EA), respectively. By the cut-off date, the mean OS was 76.3months (95% Cl: 51.3-101.1months) and the mean PFS was 47.0months (95% Cl: 31.1-62.8months), respectively. And the SF-36 score in a majority of patients was >300 (90.9%). This is a daring endeavor to explore the clinical efficacy of KSS in distal high-risk ureter cancer based on the high-risk UTUC criteria, which shows satisfactory results in the long-term prognosis and operation-associated outcomes. However, future randomized or prospective multicenter studies are necessary to validate our conclusions.

A single-center experience on endoscopic ultrasonography-guided ethanol ablation of insulinomas

Background/objectivesAs the most frequent functional pancreatic neuroendocrine tumor, insulinomas may cause a plethora of symptoms and severe impairment in the living of patients by endogenous hyperinsulinemia and subsequent hypoglycemia. Surgery has been regarded as the first choice although a high risk of complications. Ethanol ablation is a promising non-surgical option that could achieve tumor shrinking in a short-term period. But the impact of symptom control and the long-term efficacy lack sufficient and good-quality evidence. MethodsA total number of 14 endoscopic ultrasonography-guided ethanol ablations were performed in 9 patients between September 2016 and September 2018 in Peking Union Medical College Hospital. The data were collected and prospectively analyzed. ResultsThe follow-up duration ranged from 21 to 1567 days in 9 patients, with a median of 994 days. 4 patients were free from relapse during a median follow-up of 1108 days (range: 994–1567 days). In 5 patients who suffered relapses, the median duration with symptom relief after the first ablation was 128 days (range: 13–393 days). If only repeated ablation was taken into consideration, the median duration with symptom relief was 26 days (range: 1–516 days). No complications happened during the procedures. The severe complication rate after the first ablation was 0.0% (0/9), compared to 7.14% (1/14) if each procedure was counted separately. The only severe complication documented was acute pancreatitis which was completely relieved after symptomatic treatment. ConclusionsFor patients who are not suitable for surgical resections, endoscopic ultrasonography-guided ethanol ablation of insulinomas could be an effective and safe alternative to relieve symptoms of hypoglycemia.

Endoscopic ablation therapy for the pancreatic neoplasms.

Recently, endoscopic ultrasound (EUS)-guided ablation therapy has been reported as a less invasive therapy for patients with pancreatic neoplasms. Some ablation techniques, including injective ablation (using ethanol or other ablative agents), radiofrequency ablation (RFA), photodynamic therapy, and laser ablation, have been described in the literature. Among these, injective ablation and RFA are more frequently used for treating pancreatic neoplasms. Few studies have evaluated the effectiveness of EUS-guided ethanol ablation (EUS-EA) for potentially malignant solid neoplasms (neuroendocrine neoplasms or solid pseudopapillary neoplasms) and have reported a complete response (CR) rate of 60-80%. In addition, the CR rate after EUS-RFA for these lesions has been reported to be 55-100%, with no additional procedure-related adverse events (AEs). Regarding the amelioration of the symptoms of an insulinoma, the success rates of both the therapies were found to be excellent. Regarding complete tumor ablation, EUS-RFA appeared to be superior to EUS-EA. Although EUS-RFA has been reported as a safe treatment for pancreatic cancers, its effectiveness remains inadequate. Some studies have examined the effectiveness of EUS-guided injection ablation therapy for pancreatic cystic neoplasms (PCNs) and have reported CR rates that range from 35% to 79%. Alcohol-free chemotherapeutic agent ablation appears to be effective, with a low risk of AEs. However, studies on the effectiveness of EUS-RFA for PCNs are limited. In the future, EUS-guided ablation therapy could become a more widely used approach for potentially malignant and malignant pancreatic lesions.

Long-term Outcomes of Endoscopic Intraductal Radiofrequency Ablation for Ampullary Adenoma with Intraductal Extension after Endoscopic Snare Papillectomy.

There are limitations in treating ampullary adenomas with intraductal extension using conventional endoscopic modalities. Endoscopic intraductal radiofrequency ablation (ID-RFA) may be useful for treating intraductal (common bile duct [CBD] and/or pancreatic duct [PD]) extensions of ampullary adenomas, but long-term data are lacking. We thus evaluated the long-term outcomes of endoscopic ID-RFA for managing ampullary adenomas with intraductal extension. Prospectively collected endoscopic ID-RFA database at Asan Medical Center was reviewed to identify consecutive patients with ampullary adenoma who underwent ID-RFA for intraductal extension between January 2018 and August 2021. Technical success, short-term and long-term clinical success, and adverse events were evaluated. A total of 29 patients (14 CBD, 1 PD, and 14 CBD and PD) were analyzed. All patients had undergone endoscopic snare papillectomy prior to ID-RFA. A median of one session of ID-RFA (range, 1 to 3) for residual or relapsed intraductal extension of ampullary adenoma were successfully performed (technical success=100%). Both biliary and pancreatic stenting were routinely performed after ID-RFA to prevent ductal stricture. After a median follow-up of 776 days (interquartile range, 470 to 984 days), the short-term and long-term clinical success rates were 93% and 76%, respectively. Seven patients experienced procedural adverse events and three patients developed ductal strictures. Endoscopic ID-RFA showed good long-term outcomes in treating residual or relapsed ampullary adenomas with intraductal extension. Repeated ID-RFA may be considered as an option for managing recurrence. Further studies are needed to standardize the procedure.

Novel histologic score predicts recurrent intestinal metaplasia after successful endoscopic eradication therapy.

Endoscopic eradication therapy (EET) is an effective treatment for Barrett's esophagus (BE); however, disease recurrence remains problematic requiring surveillance post-treatment. While data regarding predictors of recurrence are limited, uncontrolled reflux may play a significant role. Our aim was to develop a scoring system based on histopathologic reflux in surveillance biopsies following EET to identify patients at high risk for recurrence of BE. Patients were identified from two centers in the treatment with resection and endoscopic ablation techniques for BE consortium. Hematoxylin and eosin-stained slides of surveillance biopsies post-EET were assessed for histologic changes associated with reflux from a cohort of patients who also underwent pH-metry (derivation cohort). We developed a novel scoring system (Recurrent Epithelial Changes from Uncontrolled Reflux [RECUR]) composed of dilated intercellular spaces, epithelial ballooning, basal cell hyperplasia, and parakeratosis, to identify patients with abnormal esophageal acid exposure. This scoring system was then used to grade surveillance biopsies from patients with or without recurrence of BE following EET (validation cohort). Of 41 patients in the derivation cohort, 19.5% had abnormal acid exposure times (AET) while on proton pump inhibitor therapy. The mean (SD) RECUR score for patients with AET <4% was 4.0 (1.6), compared with 5.5 (0.9) for AET ≥4% (P = 0.015). In the validation cohort consisting of 72 patients without recurrence and 64 patients with recurrence following EET, the RECUR score was the only significant predictor of recurrence (odds ratio: 1.36, 95% confidence interval: 1.10-1.69, P = 0.005). Histologic grading of surveillance biopsies using the RECUR scoring system correlates with BE recurrence following EET.

Long-term outcomes of endoscopic ultrasound-guided laser ablation for liver tumors in the caudate lobe: 5 years of experience

Objectives Liver tumor in the caudate lobe is challenging to treat, partly due to its deep location. Endoscopic ultrasound-guided laser ablation (EUS-LA) is a new attractive option for tumors in high-risk or difficult-to-reach locations. This prospective study investigated the long-term efficacy of EUS-LA for tumors in the caudate lobe, and factors that predict outcomes. Methods From June 2016 to July 2021, twenty consecutive patients (aged 56.95 ± 10.06 years) with 25 caudate lobe tumors (15.64 ± 6.37 mm) underwent EUS-LA. Treatment outcomes were assessed and predictive factors were calculated via univariate and multivariate analyses. Results Twenty-five tumors achieved complete ablation after the first or second session of EUS-LA. The treatment effectiveness was 100%. During a median follow up of 27 months (3–60), four tumors (16%) developed local tumor progression and 15 patients (75%) experienced intrahepatic distant recurrence. According to univariate and multivariate analyses, the significant prognostic factor of local tumor progression was tumor size >2 cm (p = 0.047). Significant prognostic factors of intrahepatic distant recurrence were: tumor number, alpha-fetoprotein level, and total bilirubin level (p = 0.020, 0.019, 0.010, respectively). No adverse events related to EUS-LA were observed. Conclusion EUS-LA is a viable, safe, and effective treatment option for patients with liver tumor in the caudate lobe. Tumor size >2 cm increases the risk of post-procedural local tumor progression. Intrahepatic tumor number, and pretreatment alpha-fetoprotein level and total bilirubin level are associated with intrahepatic distant recurrence. Registration Clinicaltrials.gov, ID: NCT02816944(June 29, 2016)

Endoscopic Ultrasound-Guided Pancreatic Interstitial Laser Ablation Using a Cylindrical Laser Diffuser: A Long-Term Follow-Up Study.

Local ablative treatment is another option for improving outcomes and has been evaluated for locally advanced pancreatic cancer. We previously suggested endoscopic ultrasound (EUS)-guided interstitial laser ablation using a cylindrical laser diffuser (CILA) might be a feasible therapeutic option based on experiments performed on pancreatic cancer cell lines and porcine model with a short follow-up (3 days). The aim of this study was to investigate the safety of EUS-CILA performed using optimal settings in porcine pancreas with a long-term follow-up (2 weeks). EUS-CILA (laser energy of 450 J; 5 W for 90 s) was applied to normal pancreatic tissue in porcine (n = 5) under EUS guidance. Animals were observed clinically for 2 weeks after EUS-CILA to evaluate complications. Computed tomography and laboratory tests were carried out to evaluate safety. Two weeks after EUS-CILA, all pigs were sacrificed, and histopathological safety and efficacy evaluations were conducted. EUS-CILA was technically successful in all five cases. No major complications occurred during the follow-up period. Body weight of porcine did not change during the study period without any significant change in feed intake. Animals remained in excellent condition throughout the experimental period, and laboratory tests and computed tomography (CT) scans provided no evidence of a major complication. Histopathological evaluation showed complete ablation in the ablated area with clear delineation of surrounding normal pancreatic tissue. Mean ablated volume was 55.5 mm2 × 29.0 mm and mean ablated areas in the pancreatic sections of the five pigs were not significantly different (p = 0.368). In conclusion, our experimental study suggests that EUS-CILA is safe and has the potential to be an effective local treatment modality. No major morbidity or mortality occurred during the study period. Further evaluations are warranted before clinical application.

Radiofrequency ablation remodels the tumor microenvironment and promotes neutrophil-mediated abscopal immunomodulation in pancreatic cancer.

Pancreatic ductal adenocarcinoma (PDAC) presents a 5-year overall survival rate of 11%, despite efforts to improve clinical outcomes in the past two decades. Therapeutic resistance is a hallmark of this disease, due to its dense and suppressive tumor microenvironment (TME). Endoscopic ultrasound guided radiofrequency ablation (EUS-RFA) is a promising local ablative and potential immunomodulatory therapy for PDAC. In this study, we performed RFA in a preclinical tumor-bearing KrasG12D; Trp53R172H/+; Pdx1:Cre (KPC) syngeneic model, analyzed local and abscopal affects after RFA and compared our findings with resected PDAC specimens. We found that RFA reduced PDAC tumor progression in vivo and promoted strong TME remodeling. Additionally, we discovered tumor-infiltrating neutrophils determined abscopal effects. Using imaging mass cytometry, we showed that RFA elevated dendritic cell numbers in RFA-treated tumors and promoted a significant CD4+ and CD8+ T-cell abscopal response. In addition, RFA elevated levels of PD-L1 and checkpoint blockade inhibition targeting PD-L1 sustained tumor growth reduction in the context of RFA. This study indicates RFA treatment, which has been shown to increase tumor antigen shedding, promotes antitumor immunity. This is critical in PDAC where recent clinical immunotherapy trials have not resulted in substantial changes in overall survival.

PMON123 Diagnostically Challenging Case of Cushing's Syndrome from a Pancreatic Neuroendocrine Tumor Treated with Radiofrequency Ablation

Abstract Background The delayed diagnosis of Cushing's syndrome (CS) results in advanced disease, treatment delays and poor outcomes. We present a patient with ectopic ACTH-syndrome (EAS) from a pancreatic neuroendocrine tumor (NET) whose care posed significant diagnostic and therapeutic challenges. Clinical Case 59F with classic Cushing's stigmata (including striae, plethora, supraclavicular and dorsocervical fat pads, muscle wasting), and two-year history of rapid weight gain, hypertension, T2DM, hyperlipidemia, severe osteoporosis complicated by multiple vertebral compression fractures, presented for workup and management of ACTH dependent CS. CS was confirmed (Baseline: ACTH 96 [7.2-63.3 pg/ml], serum cortisol 19.6 [4.8 - 19.5 mcg/dL]; LDSST: cortisol 18.5 [&amp;lt;1.8 mcg/dL], dexamethasone 547 [&amp;gt;200 ng/dL]; 24-hour Urine Free Cortisol: 191.60 [&amp;lt;45 mcg/d], 24-hour Cr 484 mg/day; LNSC: 436, 464 [29-101 ng/dL]; 8 mg ODST cortisol 7.2 mcg/dL). Pituitary MRI showed possible 0.5 cm left anterior pituitary lesion. Inferior petrosal sinus sampling (IPSS) to differentiate between Cushing's disease and EAS was initially planned, however, her course was complicated by an NSTEMI and acute/subacute lacunar infarcts in the left parietal and frontal lobes, and IPSS was deemed contraindicated. Additional workup was pursued including POMC 154 [&amp;lt;40 fmol/ml], Chromogranin A 538 [0-103 ng/ml] (on pantoprazole), pancreatic polypeptide 798 [0 - 435 pg/mL], 24-hour 5HIAA/Creatinine 3 [0 - 15 mg/24hr]. Chest/Abdominal/Pelvis CT showed a 1.5 cm incidental lipid rich adrenal adenoma; workup was negative for pheochromocytoma/ Conn's tumor/ adrenocortical carcinoma. Given elevated POMC and clinical suspicion for EAS, the patient underwent 68Ga-DOTATATE PET-CT scan which revealed an avid 7 mm lesion (SUVmax 14.5) in the pancreatic tail suspicious for a pancreatic NET- the presumed ectopic source of ACTH. Given the patient's poor functional status she was not a candidate for tumoral resection via distal pancreatectomy. Ketoconazole was initiated for treatment of hypercortisolism with good biochemical control, but the patient developed liver toxicity. The decision was made to pursue endoscopic ultrasound guided biopsy and radiofrequency ablation of the lesion. Pathology confirmed ACTH immunoreactive low-grade pancreatic NET. Post-procedure, morning ACTH was 8 pg/ml and cortisol was 9.1 mcg/dL, and the patient required steroids for relative adrenal insufficiency. Further follow up with repeat POMC, cortisol, ACTH levels, 24-hour UFC is required to monitor response. Conclusion IPSS is the gold standard test for differentiating Cushing's disease from EAS but is only available in select centers and for suitable candidates. This case supports the potential utility of POMC peptide measurements in the differential diagnosis of CS and the use of advanced nuclear imaging modalities for tumor localization. For patients with functional pNET who are poor surgical candidates or intolerant of pharmacotherapy, novel endoscopic ablation may offer a lower risk therapeutic option and its use should be further investigated. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Preliminary data from FABULAS: a Feasibility study of RadioFrequency endoscopic ABlation, with ULtrasound guidance, as a non-surgical, Adrenal Sparing treatment for aldosterone producing adenomas

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Utilization trends for endoscopic ablation therapy and esophagectomy in Barrett’s esophagus from 2005 to 2019

Guidelines have shifted to now recommend endoscopic eradication therapy for Barrett’s esophagus (BE) with low and high-grade dysplasia. Previously, esophagectomy was the standard therapy for high-grade dysplasia. However, it is unclear to what degree ablation therapy has affected utilization of esophagectomy. In this retrospective observational cohort study of BE patients without cancer from the Premier Healthcare Database, the prevalence of utilization of endoscopic ablation therapy and of esophagectomy in BE were calculated and temporal trends were evaluated. A total of 938, 333 BE cases were included in the study. There was a significantly increasing trend of ablation over the period 2006 to 2010 (Annual Percentage Change (APC); 95% CI 0.56% [0.51%, 0.61%]), a significantly decreasing trend for the period 2011 to 2015 (APC; 95% CI − 0.15% [− 0.20%, − 0.11%]), and a shallow increasing trend for the period 2016 to 2019 (APC; 95% CI 0.09% [0.06%, 0.11%]). For esophagectomy, there was a significantly decreasing trend for the period 2006 to 2009 (APC; 95% CI − 0.03% [− 0.04%, − 0.02%]; P < 0.001) that corresponded to the uptrend in utilization of endoscopic ablation. There was a stable trend of esophagectomy over the period 2010 to 2019 (APC; 95% CI − 0.0006% [− 0.0002%, 0.0005%]; P = 0.1947). Adoption and increased utilization of endoscopic ablation therapy for BE has coincided with a decrease in esophagectomy, and is the predominate method of therapy for BE with dysplasia.