Endoscopic Ultrasound-guided Ethanol Ablation Research Articles

Endoscopic ultrasound-guided ethanol ablation versus surgical resection of insulinomas.

Insulinoma is a rare tumor of the pancreas that can lead to hypoglycemia. To date, the standard therapy is surgical resection. After the first case report of successful endoscopic ultrasound-guided (EUS) ethanol injection 16 years ago, the need for establishing an alternative treatment method remains unchanged given the high morbidity rates of surgery and its unsuitability in some patients. Here, we provide retrospective data from 33 insulinoma patients that were treated at our center between 2010 and 2021. Of these, 9 patients were treated with EUS-guided ethanol injection and 24 underwent pancreatic surgery. The ethanol group was older (ethanol: mean ± SE 67.8±11.2 years vs. surgery: 52.3±15.7, p=0.014) with a higher Charlson Comorbidity Index (3.0 (1.0;4.0) vs. 1.0 (0.0;2.0), p=0.008). The lowest glucose values were similar between groups before (ethanol: 2.09±0.17 mmol/l vs. surgery: 1.81±0.08, p=0.158) and after (4.95±0.74 vs. 5.41±0.28, p=0.581) the respective treatments. Complications occurred more frequently in the surgery group (11 % vs. 54 %, p=0.026). One patient after prior partial pancreatectomy died postoperatively. The hospitalization time was significantly shorter in the ethanol group (4.78±0.78 days vs. 19.88±4.07, p<0.001). EUS-guided ethanol injection can be similarly effective for the treatment of hyperinsulinemic hypoglycemia compared with pancreatic surgery but seems to be associated with less severe complications. This implies the need for prospective randomized trials in insulinoma patients with a low risk for malignancy.

Efficacy and predictive factors of endoscopic ultrasound-guided ethanol ablation in benign solid pancreatic tumors

Backgrounds and ObjectivesEndoscopic ultrasound-guided ethanol ablation (EUS-EA) has recently been introduced for the management of solid pancreatic tumors, including pancreatic neuroendocrine tumors (PNETs) and solid pseudopapillary tumors (SPTs). The study aims to evaluate the efficacy and predictive factors for response of EUS-EA in solid pancreatic tumors.MethodsBetween October 2015 and July 2021, 72 patients who underwent EUS-EA for solid pancreatic tumors were included. The study outcomes were to evaluate the efficacy of EUS-EA with complete remission (CR) and objective response, and their predictive factors.ResultsDuring follow-up, 47 patients were diagnosed with PNETs and 25 with SPTs. Eight cases reached CR and 48 reached objective response. When compared with SPTs, PNETs showed similar duration to reach CR (median not reached; p = 0.319), but shorter duration to reach objective response (PNETs: median 20.6 months, 95%CI 10.26–30.88; SPTs: median 47.7 months, 95%CI 18.14–77.20; p = 0.018). Ethanol dosage > 0.35 ml/cm3 shortened the duration to reach CR (median not reached; p = 0.026) and objective response (median 42.5 months, 95%CI 25.34–59.66 vs. 19.6 months, 95%CI 10.17–29.09; p = 0.006). CR had no significant predictive factors, but PNETs showed significant predictive factors for objective response (HR 3.34, 95%CI 1.07–10.43; p = 0.038). Twenty-seven patients experienced adverse events, and there were two severe cases.ConclusionEUS-EA for pancreatic solid lesions seems feasible as a local treatment for patients who refuse or are unfit for surgery. Additionally, PNETs seem to be the better candidate for EUS-EA.

Endoscopic ultrasound-guided ethanol and radiofrequency ablation of pancreatic insulinomas: a systematic literature review.

Background:Insulinoma is the most common neuroendocrine neoplasm of the pancreas, characterised by hypoglycaemic symptoms. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) and ethanol ablation (EUS-EA) are novel methods for treating insulinoma.We aimed to perform a systematic review to assess the efficacy and safety of EUS-guided ablation techniques for pancreatic insulinomas.Methods:We systematically searched for articles detailing EUS-guided ablations of insulinomas. We performed a qualitative analysis and summarised data on the efficacy and safety of EUS-RFA and EUS-EA techniques.Results:In total, we identified 35 case reports and case series describing 75 patients with insulinomas treatment with EUS-guided ablation. Twenty-seven patients were treated with EUS-RFA, 47 patients with EUS-EA, and 1 patient received EUS-EA and EUS-RFA in the same session. In total, 84 insulinomas were ablated (EUS-RFA: 31, EUS-EA: 53). Most insulinomas were in the head of the pancreas (40%). The clinical success rate for EUS-guided ablation techniques was 98.5%. The median glucose level was 1.95 (Q1-Q3: 1.69–2.13) mmol/L before ablation compared to 6.20 (Q1-Q3: 5.30–7.05) mmol/L after treatment. The median insulin and C-peptide levels before and after RFA/EA were 230 (Q1–Q2: 120–257) pmol/L and 41 (Q1–Q2 35–42) pmol/L; 2077 (Q1–Q2 1644–2459) pmol/L and 819 (Q1–Q2 696–1072) pmol/L, respectively. There were eleven adverse events: seven abdominal pain, two mild acute pancreatitis, one necrotising acute pancreatitis and one local hematoma. All patients recovered, and there were no periprocedural deaths.Conclusions:EUS-guided ablation of insulinoma seems to be a safe and effective treatment and is an alternative to surgical resection in selected cases.

Follow-up case report of an endoscopic ultrasound-guided ethanol ablation: An alternative option for the treatment of pancreatic insulinoma

Follow-up case report of an endoscopic ultrasound-guided ethanol ablation: An alternative option for the treatment of pancreatic insulinoma

Endoscopic ultrasound-guided ethanol ablation for the management of a symptomatic pancreatic insulinoma.

pancreatic insulinoma is a sporadic, usually benign, frequently solitary tumor that is smaller than 20 mm. When it is functioning, patients present with symptoms of hypoglycemia secondary to insulin hypersecretion. The diagnosis is clinical, with biochemical and radiological confirmation. Surgery is the management of choice, although endoscopic ultrasound-guided ablation is currently being developed. we present a prospective case series of pancreatic insulinoma patients with symptoms of severe hypoglycemia, who were treated with endoscopic ultrasound-guided ethanol ablation as an alternative to surgical management. technical and clinical success was achieved in all cases and there were no complications associated with the procedure. the treatment of symptomatic insulinoma by endoscopic ultrasound-guided ethanol ablation could be a safe and effective alternative to surgical management in non-surgical patients or those who refuse surgery.

Safety of endoscopic ultrasound-guided ethanol ablation for pancreatic cystic lesions: A single-center experience of 214 patients

Endoscopic ultrasound-guided ethanol ablation (EUS-EA) for pancreatic cystic lesions (PCLs) has been used in recent years as a feasible treatment modality for low malignant probability PCLs or patients considered high-risk for surgery. The present study aimed to confirm the safety of EUS-EA and to find predictive factors for adverse event (AE). A retrospective review was performed from the prospectively maintained database of patients who underwent EUS-EA for PCLs from June 2006 to April 2018 at Seoul National University Hospital. The primary outcomes of the study were the rates of AEs and severe AEs by EUS-EA. The secondary outcome was the predictive factors of AEs including acute pancreatitis and abdominal pain. A total of 214 patients were evaluated and the diagnoses of PCLs according to cystic fluid analysis and clinical features were as follows: serous cystic neoplasm (32.2%), mucinous cystic neoplasm (26.6%), branch duct type intraductal papillary mucinous neoplasm (BD-IPMN) (29.4%), and pseudocyst (11.7%). Three patients (1.4%) experienced severe AEs. Overall, AEs occurred in 71 (33.2%) patients. BD-IPMN (OR: 2.87; 95% CI: 1.05-7.84; P = 0.040), multilocular cysts (OR: 3.59; 95% CI: 1.09-11.85; P = 0.036), suspected ethanol leakage during procedure (OR: 10.68; 95% CI: 1.98-57.53; P = 0.006), and sticky cystic fluid (OR: 3.83; 95% CI: 1.20-12.24; P = 0.024) were predictive factors for post-procedural acute pancreatitis. PCLs of uncinate process (OR: 2.99; 95% CI: 1.22-7.35; P = 0.017) and PCLs with exophytic portion (OR: 3.70; 95% CI: 1.96-7.01; P<0.001) were predictive factors for post-procedural abdominal pain. EUS-EA is a safe procedure with a very low rate of severe AEs. It seems possible to predict the AEs according to the features of the procedure and PCLs.

Malignant conversion and peritoneal dissemination after endoscopic ultrasound-guided ethanol ablation in intraductal papillary mucinous neoplasm of the pancreas.

With the increasing detection of pancreatic cysts, many centers have applied endoscopic ultrasound-guided pancreatic cyst ablation (EUS-PCA), even in intraductal papillary mucinous neoplasms (IPMNs) of the pancreas based on early promising outcomes. However, long-term effects of ethanol ablation have been rarely reported, especially regarding oncologic outcomes. We report eight cases of malignancy conversion after EUS-PCA in patients with IPMNs who had worrisome features. Moreover, two patients showed tumor spillage or peritoneal seeding (carcinomatosis) after EUS-PCA. Endoscopic ultrasound-guided pancreatic cyst ablation must not be performed as a treatment for IPMNs, considering adverse results such as tumor spillage and the lack of oncological therapeutic effect.

SUN-312 Insulinoma in Extreme Obese Women Treated with Minimally Invasive Procedure

Introduction: Insulinoma is the most common functioning neuroendocrine tumor of the pancreas. Although rare, is the main cause of endogenous hyperinsulinemic hypoglycemia.The most common clinical manifestations are neurovegetative and neuroglycopenic symptoms secondary to hypoglycemia. Progressive weight gain is also an important clinical feature, due to the anabolic action of insulin and the need to feed periodically in an attempt to reduce hypoglycemia. The presence of neuroglycopenic symptoms, which sometimes may be confounded with psychiatric symptoms, may lead to delay or misdiagnosis. In our country, there are few publications about the early diagnosis and treatment of this neoplasm. Surgery still seems to be the best treatment option but, in selected case in which there are high surgical risk, the minimally invasive procedures, such as endoscopic ultrasound (EUS) guided ethanol ablation can be a good choice of treatment. We report a case of an insulinoma in a patient with extreme obesity,that was submitted to a less invasive treatment due to surgical risks. Case report: A 22-years old woman, presented progressive weight gain of 65 kg in 1 year (163kg, BMI: 59.6kg/m2). After using intragastric balloon for 6 months, she developed hypoglycemic symptoms. Prolonged fasting test (PFT), was performed and showed after 40 minutes plasma glucose: 44mg / dl (< or = 55mg/dl); C peptide: 3.2 ng / ml ( > or = 0,6ng/ml) , insulin: 47 mU / ml (> or = 3mU/ ml), anti-insulin antibody negative. EUS showed a homogeneous hypoechoic lesion in the cephalicregion of uncinate pancreas process and fine needle puncture showed cells with atypia of indeterminate significance. Magnetic Resonance Image of the abdomen showed a 1.9 cm hypervascular nodule in the cephalic portion of the pancreas, very close to cava vein. The main hypothesis was an insulinoma. Due to the patient's severe obesity and the tumor localization, a multidisciplinary team decided to do a minimally invasive procedure. EUS guided ethanol ablation with absolute ethanol and a fine needle aspiration were performed with general anesthesia without complications. On the following days of the procedure, surveillance for pancreatitis was performed. Anatomopathological showed immunohistochemistry positive for insulin and ki67% <1%. Laboratory exams of the 30th postoperative day: fasting glycemia: 89mg / dl, peptide C: 5.18ng / dl, insulin: 45.51 Uui / ml. After 6 months of the procedure, the patient remains without hypoglycemia and lost 10 kg. Conclusion: Insulinoma as described above is a rare condition, but should always be part of the differential diagnosis of obesity and hypoglycemia. Careful analysis and multidisciplinary decision-making for best behavior are key. Minimally invasive treatment is promising, with reduced surgical risks, shorter hospital stay and increased quality of life after the procedure. As seen in our case.

Endoscopic ultrasound-guided ethanol ablation for pancreatic cystic neoplasm(with video)

Objective To evaluate technical feasibility, safety and efficacy of endoscopic ultrasound-guided ethanol ablation (EUS-EA) for pancreatic cystic neoplasms (PCNs). Methods Clinical data of 10 patients with PCNs in Changhai Hospital from July 2013 to April 2017, including demographic information, EUS features, adverse events and follow-up data, were retrospectively studied. Efficacy was assessed according to imaging data. Results The mean largest diameter of the cyst was 2.95±1.56 cm. Cyst fluid analysis showed that there were 6 serous cystic neoplasms, 3 mucinous cystic neoplasms, and 1 indeterminate cyst. Totally 12 operations were performed successfully. No infection, pancreatitis, bleeding, pancreatic fistula or other severe complications with clinical significance occurred. The median follow-up time was 4.0 months (3.0-12.0 months). Three patients achieved complete resolution, 6 achieved partial resolution, 1 was stable disease, and no patient showed progressive tumor. Conclusion EUS-EA for PCNs has high operation success rate, less complication and satisfactory overall efficacy. Key words: Pancreatic neoplasms; Endoscopic ultrasonography; Ethanol; Ablation

Clinical outcomes of endoscopic ultrasound-guided ethanol ablation for pancreatic cystic lesions compared with the natural course: a propensity score matching analysis.

BackgroundEndoscopic ultrasound-guided ethanol ablation (EUS-EA) is a recently introduced treatment for pancreatic cystic lesions (PCLs). However, clinical benefits such as survival gain and maintenance of quality of life (QOL) have not been fully established. The aim of this study was to evaluate the clinical benefits of EUS-EA compared with the natural course (NC) of PCLs.MethodsThis retrospective comparative study of patients with PCLs investigated an EUS-EA group (n = 118) and an NC group (n = 428). Propensity score matching (PSM) analysis was applied to minimize the effects of selection bias. The overall survival as the primary outcome and the surgical resection rate and complete remission (CR) rate as the secondary outcomes were evaluated.ResultsBetween 84 matched pairs of both groups, there were no significant differences in the baseline clinical characteristics and the mean follow-up duration (78.88 ± 38.86, 75.90 ± 57.46 months, p = 0.694). Overall survival did not differ significantly (194.12 ± 5.60, 247.54 ± 12.70 months, p = 0.235). The surgical resection rate (4.8% versus 26.2%, p < 0.001) was significantly lower in the EUS-EA group. CR was observed only in the EUS-EA group and the CR rate was 32.1%.ConclusionsEUS-EA for PCLs with low risk of malignancy might not be able to obtain a survival benefit, but showed maintenance of QOL by avoidance of unnecessary surgery, and a certain level of CR when compared to the NC. EUS-EA could be considered a useful treatment option for these, but careful application is needed because of the limited effects in some types of PCLs.

Endoscopic ultrasound-guided ethanol ablation therapy for pancreatic insulinoma: an unusual strategy.

SummaryInsulinomas are the most frequent cause of hyperinsulinaemic hypoglycaemia. Although surgical enucleation is the standard treatment, a few other options are available to high-risk patients who are elderly or present with co-morbidities. We present a case report of an 89-year-old female patient who was admitted to the emergency department due to recurrent hypoglycaemia, especially during fasting. Laboratory work-up raised the suspicion of hyperinsulinaemic hypoglycaemia, and abdominal CT scan revealed a 12 mm nodular hypervascular lesion of the pancreatic body suggestive of neuroendocrine tumour. The patient was not considered a suitable candidate for surgery, and medical therapy with diazoxide was poorly tolerated. Endoscopic ultrasound-guided ethanol ablation therapy was performed and a total of 0.6 mL of 95% ethanol was injected into the lesion by a transgastric approach; no complications were reported after the procedure. At 5 months of follow-up, no episodes of hypoglycaemia were reported, no diazoxide therapy was necessary, and revaluation abdominal CT scan revealed a pancreatic nodular lesion with a size involution of about half of its original volume. The patient is regularly followed-up at the endocrinology clinic and shows a significant improvement in her wellbeing and quality of life.Learning points:Insulinomas are the most frequent cause of hyperinsulinaemic hypoglycaemia.Surgical enucleation is the standard treatment with a few other options available to high-risk patients.Endoscopic ultrasound-guided ethanol ablation therapy is one feasible option in high-risk patients with satisfactory clinical outcomes, significant positive impact on quality of life and low complication rates related to the procedure.

68Ga-Exendin-4 PET/CT in Evaluation of Endoscopic Ultrasound–Guided Ethanol Ablation of an Insulinoma

A 32-year-old man with endogenous hyperinsulinemic hypoglycemia was clinically diagnosed with an insulinoma. Conventional imaging result was negative, and a previous exploratory laparotomy with distal pancreatectomy failed to detect the tumor. Ga-exendin-4 PET/CT showed a lesion with intense radioactivity in the head of the pancreas suggestive of an insulinoma, and endoscopic ultrasound-guided ethanol ablation was performed. Postablation evaluation with Ga-exendin-4 PET/CT showed markedly decreased radioactivity of the tumor. The symptoms and blood glucose monitoring also suggested partial response of the insulinoma.

Endoscopic Ultrasound–Guided Ethanol Ablation for Control of Local-Regional Metastatic Insulinoma

Endoscopic Ultrasound–Guided Ethanol Ablation for Control of Local-Regional Metastatic Insulinoma

Efficacy and Safety of Endoscopic Ultrasound-guided Ethanol Ablation Therapy for Pancreatic Neuroendocrine Tumors.

Recently, endoscopic ultrasonography (EUS)-guided ethanol ablation for small pancreatic neuroendocrine tumors (p-NETs) has been reported. However, the efficacy and safety of the technique remain unclear. We have launched a prospective pilot study of EUS-guided ethanol ablation for p-NETs. The major eligibility criteria are the presence of a pathologically diagnosed grade (G) 1 or G2 p-NET, a tumor size of 2cm, and being a poor candidate for surgery. A total of 5 patients will be treated. The primary endpoint will be the complete ablation rate at 1 month after treatment.

Endoscopic ultrasound-guided ethanol ablation therapy for pancreatic insulinoma: an unusual strategy

Endoscopic ultrasound-guided ethanol ablation therapy for pancreatic insulinoma: an unusual strategy

Success of endoscopic ultrasound-guided ethanol ablation of pancreatic cysts: a meta-analysis and systematic review.

Endoscopic ultrasound (EUS)-guided ethanol ablation has emerged as an efficacious and safe alternative management option for pancreatic cysts. We undertook a meta-analysis and systematic review to assess the overall safety and efficacy of EUS-guided ethanol ablation of pancreatic cysts. EUS-guided ethanol ablation of pancreatic cysts. Articles were searched in Medline, Pubmed, and Ovid journals. Fixed and random effects models were used to calculate the pooled proportions. Initial search identified 1,319 reference articles, in which 120 relevant articles were selected and reviewed. Data was extracted from seven studies (n = 152) of EUS-guided ethanol ablation of pancreatic cysts, which met the inclusion criteria. With EUS-guided ethanol ablation, the pooled proportion of patients with complete cyst resolution was 56.20 % (95 % CI = 48.16 to 64.08) and partial cyst resolution was 23.72 % (95 % CI = 17.24 to 30.89). Postprocedural complications after ablation were significant for abdominal pain in 6.51 % (95 % CI = 3.12 to 11.04) and pancreatitis in 3.90 % (95 % CI = 1.39 to 7.60) of the pooled percentage of patients. Publication bias calculated using Harbord-Egger bias indicator gave a value of -1.09 (95 % CI = 10.21 to 8.03, p = 0.77). The Begg-Mazumdar indicator gave a Kendall's tau b value of 0.05 (p ≥ 0.99). EUS-guided ethanol ablation may be a safe alternative treatment modality for pancreatic cysts, with acceptable intraprocedural and postprocedural complications. However, due to the limited data available, prospective randomized controlled trials with a long follow up period are required in this area.

Su1467 Success of Endoscopic Ultrasound-Guided Ethanol Ablation of Pancreatic Cysts: A Meta-Analysis and Systematic Review

Background Endoscopic ultrasound (EUS)-guided ethanol ablation has emerged as an efficacious and safe alternative management option for pancreatic cysts. We undertook a meta-analysis and systematic review to assess the overall safety and efficacy of EUS-guided ethanol ablation of pancreatic cysts.

Endoscopic Ultrasound-Guided Ethanol Ablation of a Large Metastatic Carcinoid Tumor: Success With a Note of Caution

Endoscopic Ultrasound-Guided Ethanol Ablation of a Large Metastatic Carcinoid Tumor: Success With a Note of Caution

Endoscopic ultrasound-guided ethanol ablation of a large metastatic carcinoid tumor: success with a note of caution

Endoscopic ultrasonography with fine needle infusion (EUS-FNI) of alcohol is the most reported method for EUS-guided tumor ablation. Several studies have reported successful EUS-guided ablation of pancreatic neuroendocrine tumors. However, these tumors have been relatively small (< 3 cm). In this report, a 50-year-old man with a metastatic carcinoid tumor with a large porta hepatis mass was referred to our clinic for EUS-guided ethanol ablation. After two separate EUS-FNI ablations, there was a 36 % reduction in tumor size (9.0 × 11.4 cm to 6.7 × 9.8 cm) with associated tumor lysis syndrome. Chromogranin A levels decreased from 460 to 132 ng/mL. The patient reported complete resolution of abdominal pain within 2 weeks, but only mild improvement in flushing and diarrhea. In conclusion, large metastatic neuroendocrine tumors can be successfully treated with EUS-guided ethanol ablation. Evidence-based guidelines are needed with regard to the appropriate volume of ethanol injected in EUS-guided ablation to promote the efficacy and safety of this emerging procedure.

Endoscopic ultrasound-guided ethanol ablation of pancreatic remnant following complicated total pancreatectomy

Endoscopic ultrasound-guided ethanol ablation of pancreatic remnant following complicated total pancreatectomy