Endoscopic Ultrasound-guided Ablation Research Articles

Endoscopic Ultrasound-Guided Ablation of Premalignant Pancreatic Cysts and Pancreatic Cancer.

Pancreatic cancer is on the rise and expected to become the second leading cause of cancer-related death by 2030. Up to a one-fifth of pancreatic cancers may arise from mucinous pancreatic cysts, which are frequently present in the general population. Currently, surgical resection is the only curative approach for pancreatic cancer and its cystic precursors. However, only a dismal proportion of patients are eligible for surgery. Therefore, novel treatment approaches to treat pancreatic cancer and precancerous pancreatic cysts are needed. Endoscopic ultrasound (EUS)-guided ablation is an emerging minimally invasive method to treat pancreatic cancer and premalignant pancreatic cysts. Different ablative modalities have been used including alcohol, chemotherapy agents, and radiofrequency ablation. Cumulative data over the past two decades have shown that endoscopic ablation of mucinous pancreatic cysts can lead to cyst resolution in a significant proportion of the treated cysts. Furthermore, novel data are emerging about the ability to endoscopically ablate early and locally advanced pancreatic cancer. In this review, we aim to summarize the available data on the efficacy and safety of the different EUS-ablation modalities for the management of premalignant pancreatic cysts and pancreatic cancer.

Endoscopic ultrasound-guided ablation of pancreatic cystic lesions

Endoscopic ultrasound-guided ablation of pancreatic cystic lesions

Endoscopic ultrasound-guided ablation of solid pancreatic lesions: A systematic review of early outcomes with pooled analysis

BACKGROUNDEndoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) is emerging as a complementary therapeutic approach for pancreatic solid masses. However, results of published data are difficult to interpret because of a retrospective design and small sample size. AIMTo systematically review data on EUS-RFA for solid lesions and to pool the results of the different experiences in order to provide more consistent evidence in terms of safety and efficacy.METHODSA comprehensive systematic literature search on the main databases was performed to identify articles in which patients with pancreatic solid lesions underwent EUS-RFA. The primary outcomes were procedure-related adverse events (AEs) and mortality. Secondary outcomes were the technical success rate and the effects on primary tumor growth. Statistical analyses were performed using Stata version 14.0.RESULTSIn total, 14 studies were included, with 120 patients undergoing 153 ablations of 129 solid pancreatic lesions. The STARmed technology was used in seven studies, the Habib system in six studies, and the HybridTherm probe in one study. The pooled technical success rate was 99.0% (I2: 25.82%). The pooled overall AE rate was 8.0% (I2: 11.46%). Excluding mild AEs, the pooled rates of serious AEs was 1.0% (I2: 0%). No mortality related to the procedure was reported. CONCLUSIONThe present pooled analysis confirms the safety and feasibility of EUS-RFA.

Efficacy of Endoscopic Ultrasound-Guided Ablation with the HybridTherm Probe in Locally Advanced or Borderline Resectable Pancreatic Cancer: A Phase II Randomized Controlled Trial.

Simple SummaryRecently, tumour local thermal ablation has been investigated in pancreatic ductal adenocarcinoma (PDAC), hypothesizing that it may add local efficacy to the chemotherapy systemic activity inducing changes of tumour microenvironment and increased intra-tumour drug efficacy. In this phase II randomized controlled trial we investigated the efficacy of thermal ablation with the HybridTherm probe under endoscopic ultrasound-guidance (EUS) as complement to chemotherapy (HTP-CT arm) versus standard chemotherapy alone (CT arm), in locally advanced and borderline resectable PDAC. A sample size of 33 patients per arm was calculated to verify a 20% improved 6-months progression-free survival (6-PFS) rate with HTP-CT. We randomized 17 and 20 patients to HTP-CT and CT arms, respectively. Although not significantly, we found an improved 6-PFS rate in the HTP-CT arm. However, the overall survival was similar between the two arms. Thus, as the study is underpowered, further investigation of EUS-guided thermal ablation in selected patients is suggested.Endoscopic ultrasound-ablation with HybridTherm-Probe (EUS-HTP) significantly reduces tumour volume (TV) in locally-advanced pancreatic ductal adenocarcinoma (LA-PDAC). We aimed at investigating the clinical efficacy of EUS-HTP plus chemotherapy versus chemotherapy (HTP-CT and CT arms) in LA- and borderline-resectable (BR) PDAC, with 6-months progression-free survival (6-PFS) rate as primary endpoint. In a phase-II randomized-controlled-trial, 33 LA/BR-PDAC patients per-arm were planned to verify 20% improved 6-PFS rate. Radiological response (Choi criteria), TV and serum CA19.9 were assessed up to 6-months. Seventeen and 20 LA/BR-PDAC patients were randomized to HTP-CT or CT. Baseline and CT-related features were balanced. At 6-months, 6-PFS rate was 41.2% and 30% in HTP-CT and CT arms (p = 0.48), respectively. A decrease ≥50% of serum CA19.9 was achieved in 75% and 64.3% of HTP-CT and CT patients (p = 0.53), respectively. TV reduced up to 6-months in 64.3% and 47.1% of HTP-CT and CT patients (p = 0.35), respectively. Resection rate, PFS-time and overall survival (OS-time) were similar. HTP-CT achieves a non-significant 11.2%, 10.7% and 17.2% improved 6-PFS, CA19.9 decrease ≥50% and TV reduction rates over CT, without any impact on resection rate, PFS-time and OS-time. As the study was underpowered, these results suggest further investigation of EUS-local ablation in selected patients with localized disease after induction CT.

Pancreatic Cysts after Endoscopic Ultrasonography-Guided Ethanol and/or Paclitaxel Ablation Therapy: Another Mimic of Pancreatic Pseudocysts

Background: Endoscopic ultrasound-guided ablation (EUS-A) therapy is a minimally invasive procedure for pancreatic-cystic tumors in patients with preoperative comorbidities or in patients who are not indicated for surgical resection. However, histopathologic characteristics of pancreatic cysts after ablation have not been well-elucidated. Methods: Here, we analyzed pathological findings of 12 surgically resected pancreatic cysts after EUS-A with ethanol and/or paclitaxel injection. Results: Mean patient age was 49.8 ± 13.6 years with a 0.3 male/female ratio. Clinical impression before EUS-A was predominantly mucinous cystic neoplasms. Mean cyst size before and after ablation therapy was similar (3.7 ± 1.0 cm vs. 3.4 ± 1.6 cm; p = 0.139). Median duration from EUS-A to surgical resection was 18 (range, 1–59) months. Mean percentage of the residual neoplastic lining epithelial cells were 23.1 ± 37.0%. Of the resected cysts, 8 cases (67%) showed no/minimal (<5%) residual lining epithelia, while the remaining 4 cases (33%) showed a wide range of residual mucinous epithelia (20–90%). Ovarian-type stroma was noted in 5 cases (42%). Other histologic features included histiocytic aggregation (67%), stromal hyalinization (67%), diffuse egg shell-like calcification along the cystic wall (58%), and fat necrosis (8%). Conclusion: Above all, diffuse egg shell-like calcification along the pancreatic cystic walls with residual lining epithelia and/or ovarian-type stroma were characteristics of pancreatic cysts after EUS-A. Therefore, understanding these histologic features will be helpful for precise pathological diagnosis of pancreatic cystic tumor after EUS-A, even without knowing the patient’s history of EUS-A.

Clinical outcomes and efficacy of endoscopic ultrasound guided ablation of pancreatic cancer a systematic review and a meta-analysis.

e16261 Background: Endoscopic ultrasound-guided ablation therapy (EUS-A) is a minimally invasive technique increasingly used for the management of surgically unresectable pancreatic cancer. The data on the efficacy and clinical outcome of EUS-A for unresectable pancreatic cancer is lacking. We conducted this systematic review and meta-analysis to evaluate the safety, technical and clinical success of EUS-A therapies specifically for unresectable pancreatic cancer. Methods: Studies were identified with a comprehensive search for EUS-A and pancreatic cancer on PubMed, Google Scholar, Web of Science and Embase data search as of October 2020. The technical and clinical success rates of EUS-A were primary outcomes while adverse events (AEs) rate was secondary outcome. We defined technical success as successful placement of probe within tumor and able to perform ablation regardless of tumor outcome. Clinical success was defined as symptomatic improvement and/or any reduction in tumor size or evidence of necrosis on radiological imaging after EUS-A. A compute pooled analysis was performed using the ‘meta’ package by Schwarzer et al. in the R programming language (version 4.0.2) using random effect model. Results: Nineteen studies including 192 patients (54% females) were included. Common pancreatic tumors were nonfunctional neuroendocrine tumor (NNET) 43.5% (97), followed by locally advanced pancreatic ductal adenocarcinoma (LAPDAC) 27.3% (61), insulinoma 17.9% (40), cystic neoplastic lesions 8.5% (19). The pancreatic head was the most common site of tumor 49.8% (111), followed by body, neck and tail 44.8% (100). EUS-RFA was the most commonly used ablative therapy 63% (12/19 studies), followed by EUS-EA (ethanol ablation) 26% (5/19 studies) while EUS-A using laser and lauromacrogol injection was used in one study each. The mean number of ablation sessions per patient was 1.4 based on the total 243 sessions in 176 patients. The pooled technical success rate of EUS-A was 99.5% [95% CI = 0.90-0.97, I2 = 0%]. The pooled clinical success rate calculated out of total number of pancreatic lesions was 91.1% [95% CI = 0.79-0.92, I2 = 16%]. Clinical improvement in symptoms was reported in 11 studies and a complete resolution or decrease in tumor size was reported in 16 studies. The pooled AEs rate was 22.9% [95% CI = 0.17-0.37, I2 = 43%]. Common AEs were abdominal pain 7.8% (15), pancreatitis 5.2% (10) and pancreatic pseudocyst 2.1% (4). The median follow-up was 9.5 months. Conclusions: EUS-A is a safe and promising modality in the management of unresectable pancreatic cancer with a high technical and clinical success rate. Large prospective studies and clinical trials are required for comparison of clinical outcome of different EUS-A therapies and its widespread application for unresectable pancreatic cancer.

Recent developments in endoscopic ultrasound-guided ablation treatment

Recent developments in endoscopic ultrasound-guided ablation treatment

Response to: ‘The efficacy and safety of endoscopic ultrasound-guided ablation of pancreatic cysts with alcohol and paclitaxel: a systematic review’

aDepartment of Internal Medicine, Division of Gastroenterology and Hepatology, Koc University School of Medicine bDepartment of Internal Medicine, Division of Gastroenterology and Hepatology, American Hospital cDepartment of Pathology, Koc University School of Medicine, Istanbul, Turkey dDepartment of Internal Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA Received 11 February 2019 Accepted 13 February 2019 Correspondence to Tan Attila, MD, Amerikan Hastanesi, Guzelbahce Sokak, No 20, Nisantasi, Istanbul, 34365 Turkey, Tel: + 90 (533) 354 30 90; fax: +90 (212) 311 23 45; e-mail: [email protected]

Clinical outcomes of endoscopic ultrasound-guided ablation of pancreatic cysts with alcohol and paclitaxel.

Clinical outcomes of endoscopic ultrasound-guided ablation of pancreatic cysts with alcohol and paclitaxel.

Endoscopic ultrasound-guided ablation of pancreatic neuroendocrine tumors: with or without alcohol?

Endoscopic ultrasound-guided ablation of pancreatic neuroendocrine tumors: with or without alcohol?

An experimental study on endoscopic ultrasound-guided microwave ablation for porcine liver and pancreas

Objective To evaluate the feasibility and safety of endoscopic ultrasound-guided microwave ablation (EUS-MWA) for porcine liver and pancreas by assessing physiological state and pathological changes. Methods EUS-MWA was performed on liver and pancreas of 8 healthy pigs after general anesthesia. The needle size was 1.9 mm in diameter, and the power of ablation was 65 W, 10 min on liver and 60 W, 5 min on pancreas. The levels of blood amylase and hepatic transaminase were examined before and after the operation. All pigs underwent CT scan on the right postoperative day to assess the extent of ablation and complications. Two pigs were killed 6 hours after operation and 2 others were killed 24 hours after operation to assess structural damage around the puncture path. The remaining 4 pigs were raised to 2 weeks after operation to observe diet, activities and mental state. The ablated areas of liver and pancreas underwent pathological analysis after dissection, and non-ablation regions were treated as the control. Results All 8 pigs underwent EUS-MWA and their vital signs were stable during the operation. Except for the difficulty in locating the pancreas in one case, other surgical procedures were smooth and 18 ablations were performed totally (10 in liver and 8 in pancreas). CT scans showed quasi-circular low density lesions in the liver and pancreas, and the maximum diameter of the ablation area in liver and pancreas was 2.8±0.3 cm, 1.8±0.2 cm respectively. There was no free intraperitoneal gas, ascites or pleural effusion. The level of blood amylase increased at 6 hours after operation and the peak value occurred within 12-24 hours. The level of hepatic transaminase had a mild elevation. The rearing group showed transient food refusal and activity reduction after the operation, but all returned to normal within 1-2 days. No fever, vomiting or other abnormalities occurred. Puncture path burn, adjacent organ damage and bleeding was not observed except for one case of gastric wall burns during pancreas ablation. Pathology showed massive coagulative necrosis and peripheral bleeding area in the liver ablation center, and diffuse focal necrosis in the tissue of the pancreatic ablation area. Conclusion EUS-MWA is safe and feasible for porcine liver and pancreas, which can be used for the treatment of human liver and pancreatic diseases in the future. Key words: Ultrasonography; Microwaves; Endoscopes; Animal experimentation

The efficacy and safety of endoscopic ultrasound-guided ablation of pancreatic cysts with alcohol and paclitaxel: a systematic review.

Endoscopic ultrasound (EUS)-guided pancreatic cyst ablation with alcohol lavage or paclitaxel-based regimens are investigative modalities. To evaluate the safety and efficacy of EUS-guided pancreatic cyst ablation with alcohol lavage or paclitaxel-based regimens. A systematic review of computerized bibliographic databases was carried out for studies of EUS-guided pancreatic cyst ablation with alcohol lavage or paclitaxel-based regimens from January 1980 to February 2018. EUS-guided cyst ablation-related outcomes (cyst resolution) and complications. Data were extracted from six studies (N=207 patients) for EUS-guided cyst ablation with alcohol lavage and eight studies (N=347 patients) for EUS-guided cyst ablation with paclitaxel-based regimens. The pooled proportion of patients with complete cyst resolution was 68/207 (32.8%) for EUS-guided cyst ablation with alcohol lavage and 221/347 (63.6%) for EUS-guided cyst ablation with paclitaxel. Postablation adverse events with EUS-guided ablation with alcohol lavage were 44/207 (21.7%), and those with EUS-guided ablation with paclitaxel-based regimens were 52/347 (15%). Limitations of this study are because of the variability in study design and regimens tested, paucity of randomized trials, and differences in pancreatic cyst types receiving treatment. EUS-guided cyst ablation appears to be effective and safe. The effect on pancreatic cancer incidence is unknown; EUS-guided pancreatic cyst ablation modalities require further improvement and validation to determine their role in the treatment of patients with pancreatic cystic lesions.

Endoscopic Ultrasound-Guided Ablation of Pancreatic Cystic Neoplasms: A Systematic Review and Meta-Aanalysis: Presidential Poster Award

Endoscopic Ultrasound-Guided Ablation of Pancreatic Cystic Neoplasms: A Systematic Review and Meta-Aanalysis: Presidential Poster Award

Endoscopic ultrasound-guided ablation of pancreatic cystic neoplasms: ready for prime time?

With the increase in the use of cross-sectional diagnostic imaging, there has been a concomitant rise in the rate of detected pancreatic cystic lesions. Recent years have seen the rise of newly developed therapeutic modalities to treat pancreatic lesions via ablation. Specifically, through the use of endoscopic ultrasound-guided therapy, endoscopists can potentially ablate these lesions safely and with minimally invasive techniques. In this manuscript we review 4 major endoscopic ultrasound-guided ablative therapies: radiofrequency ablation, ethanol injection, chemo ablation, and cryoablation. We also review the efficacy and safety of these techniques and future directions in the management of cystic pancreatic lesions.

Long-term outcomes after endoscopic ultrasound-guided ablation of pancreatic cysts

Background and study aims The aim of this study was to investigate the long-term outcomes after endoscopic ultrasound (EUS)-guided pancreatic cyst ablation. Patients and methods In a single-center, prospective study, 164 patients with pancreatic cysts underwent EUS-guided cyst ablation using ethanol with paclitaxel. The inclusion criteria were as follows: unilocular or oligolocular cysts; clinically indeterminate cysts that required EUS fine-needle aspiration; and/or cysts that grew during the observation period. Treatment response was classified as complete resolution, partial resolution, or persistent cyst, with < 5 %, 5 % - 25 %, and 25 % of the original cyst volume, respectively. Results The median largest diameter of the cyst was 32 mm and the median volume was 17.1 mL. Based on cyst fluid analysis there were 71 mucinous cystic neoplasms, 16 serous cystic neoplasms, 11 intraductal papillary mucinous neoplasms, 3 pseudocysts, and 63 indeterminate cysts. Sixteen treated patients (9.8 %) had adverse events (1 severe, 4 moderate, and 11 mild). Treatment response was as follows: complete resolution in 114 (72.2 %), partial resolution in 31 (19.6 %), and persistent cysts in 13 (8.2 %). Twelve of the 13 patients with persistent cysts underwent surgery. During clinical and imaging follow-up (median 72 months, interquartile range 50 - 85 months) of the 114 patients with complete resolution, only two patients (1.7 %) showed cyst recurrence. Based on multivariate analysis, the absence of septa (odds ratio [OR] 7.12, 95 % confidence interval [CI] 2.72 - 18.67) and cyst size less than 35 mm (OR 2.39, 95 %CI 1.11 - 5.16) predicted complete resolution. Conclusion Among patients with pancreatic cysts in whom complete resolution was achieved after EUS-guided cyst ablation, 98.3 % remained in remission at 6-year follow-up. Unilocular form and small cyst size were predictive of complete resolution. This treatment approach may be an effective and durable alternative to surgery.Trial registered at ClinicalTrials.gov (NCT 00689715).

Endoscopic ultrasound-guided ablation of branch-duct intraductal papillary mucinous neoplasms: Feasibility and safety tests using porcine gallbladders.

Radiofrequency ablation (RFA) and ethanol ablation are accepted methods of tissue destruction for treating cystic tumors. The aim of the present study was to evaluate the feasibility, efficacy, and safety of endoscopic ultrasound (EUS)-guided ablation using normal porcine gallbladders as a substitute model for branch-duct intraductal papillary mucinous neoplasms (BD-IPMN). Six adult mini pigs were included in this prospective study. EUS-guided RFA with or without ethanol ablation of the gallbladder was carried out using a prototype 18-gauge endoscopic RFA electrode, and RFA and ethanol ablation were done in a single session. Outcomes were assessed in terms of macroscopic and microscopic evaluations of the treated gallbladders. The prototype RFA electrode was used for ablation of the mucosa, aspiration of the internal contents of the gallbladder, and ethanol injection. RFA plus ethanol lavage resulted in a greater mean percentage of denuded gallbladder mucosa (97.5%) than RFA alone (55.8%). Effects of ablation extending to the cystic duct and partially denuded cystic duct mucosae were detected in five of the six pigs. There were no major procedure-related adverse events. EUS-guided ablation of the gallbladder mucosa was feasible and effective in the porcine model. Additional studies will be required to fully assess the risk of procedure-related damage to the main pancreatic duct before using this technique in a clinical setting.

Abstract B95: Is ethanol required for cyst ablation in patients with premalignant type pancreatic cysts?

Abstract Background: Mucinous pancreatic cystic lesions have the propensity to progress into pancreatic cancer. Currently radiographic surveillance or surgical resection is recommended for this premalignant type of cyst, both of which have significant limitations. Recently, endoscopic ultrasound-guided cyst ablation has emerged as an innovative and promising alternative treatment approach. Previous studies have shown that EUS-guided ethanol lavage of pancreatic cysts is safe and results in complete cyst resolution in 1/3 of patients. Subsequent studies demonstrated marked increases in rates of ablation with infusion of paclitaxel following ethanol lavage, which raises the question of whether alcohol is necessary for effective ablation. This is important, since ethanol extravasation is felt to have caused two complications in previous trials, abdominal pain and pancreatitis. This study hypothesizes that the removal of alcohol lavage prior to chemotherapy infusion will not impair ablation rates and will decrease complication rates. A secondary aim of this study is to assess whether a custom chemoablation cocktail tailored to pancreatic neoplasia (paclitaxel+gemcitabine) will improve ablation rates overall. Gemcitabine was chosen because it dilutes paclitaxel for injection and has been the standard in pancreatic cancer chemotherapy. Recently, the combination of paclitaxel and gemcitabine was shown to improve response rates and progression-free survival when compared with gemcitabine alone. Methods: Patients with mucinous or indeterminate type pancreatic cysts of 1-5cm’s without signs of malignancy were randomized to undergo either EUS-guided lavage with 80% alcohol or normal saline followed by infusion of 3 mg/ml paclitaxel + 19mg/ml gemcitabine (both arms). 9 patients were enrolled in this initial pilot study and evaluated post op, at 72 hours, with two week lab tests and by CT scan at 3, 6, and 12 months to assess response rates and for any complications. Results: The initial 9 patients of this trial (expected to have an N of 78 when complete) were randomized for this pilot study with 8 patients then able to be treated. Pancreatic cysts ranged in maximum diameter from 2.2cm to 3.8 cm (mean 2.9 cm). Location included body (n=4), head (n=2), neck (n=1) and tail (n=1). The overall reduction in cyst surface area was 67% at 3 months and 82% at 6 months. At 6 months size reduction was 81% in the alcohol infusion arm and 83% in the alcohol-free arm. Complications were mild abdominal pain (1) in the alcohol free arm (12.5%), moderate abdominal pain (1), and mild pancreatitis (1) in the alcohol arm (25%). Conclusion: The treatment of mucinous type pancreatic cysts with either alcohol or saline lavage followed by gemicitabine-paclitaxel infusion is feasible and safe in this limited pilot study. Initial results indicate that alcohol-free ablation does not impair ablation efficacy and is associated with fewer complications although the full sample size will be required to prove this hypothesis with any certainty. Citation Format: Matthew T. Moyer, Setareh Sharzehi, Charles E. Dye, Wafik El-Deiry, Thomas J. McGarrity, Abraham Mathew, Niraj Gusani, Raquel E. Davila, Brooke Ancrile. Is ethanol required for cyst ablation in patients with premalignant type pancreatic cysts? [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer: Innovations in Research and Treatment; May 18-21, 2014; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2015;75(13 Suppl):Abstract nr B95.

Endoscopic ultrasound-guided ablation therapy for pancreatic cysts.

Pancreatic cysts are being encountered frequently because of rapid advances in radiologic technology and an increased cross-sectional imaging demand. Management of pancreatic cystic tumors is challenging because most of them are asymptomatic; they are potentially malignant, and surgery has substantial morbidity and mortality. Endoscopic ultrasound (EUS)-guided fine-needle aspiration of pancreatic cystic tumors is accepted as a minimally invasive technique, which also enables injection of ablative agents into cysts under EUS guidance. In this review, the basic procedural steps and technical considerations of cyst ablation and their clinical issues including safety, feasibility, and therapeutic outcome will be summarized.

Role of Computed Tomography Perfusion in the Evaluation of Pancreatic Necrosis and Pancreatitis After Endoscopic Ultrasound-Guided Ablation of the Pancreas in a Porcine Model

To evaluate the role of computed tomography (CT) perfusion in detection of pancreatic necrosis and pancreatitis after endoscopic ultrasound-guided ethanol ablation of porcine pancreas and to correlate the evaluation with histopathology. Under endoscopic ultrasound guidance, 0.9% saline (control) and ethanol at 60%, 80%, and 100% concentrations were injected into the pancreatic tails of 4 pigs. On day 4, dynamic perfusion CT of the pancreas was performed. Perfusion analysis and evaluation of enhancement characteristics were done and correlated with histopathology. Ethanol injections at 80% and 100% concentrations resulted in focal necrosis surrounded by focal pancreatitis, whereas 60% ethanol injection caused severe focal pancreatitis with microscopic necrosis. The necrotic area revealed reduced blood flow, blood volume, permeability-surface area product, and increased mean transit time compared with pancreatitis and normal tissue (P < or = 0.001). In the control pig, no pancreatitis or necrosis was observed on perfusion images and histopathology. Pancreatic necrosis and pancreatitis after ethanol injection reduced the tissue perfusion on CT in comparison to normal tissue, with the changes being more substantial in necrosis than pancreatitis. These findings have possible implications in the accurate detection of pancreatic necrosis in patients with severe pancreatitis.