EUS-guided Ethanol Ablation Research Articles

S4013 Sugar Shortage: A Case of Insulinoma Managed by EUS-Guided Ethanol Ablation

S4013 Sugar Shortage: A Case of Insulinoma Managed by EUS-Guided Ethanol Ablation

A novel treatment:EUS-guided ethanol ablation for primary hyperparathyroidism ineligible by percutaneous access(with video)

A novel treatment:EUS-guided ethanol ablation for primary hyperparathyroidism ineligible by percutaneous access(with video)

Are Non-Ethanol Based Ablation Therapies Better Than Ethanol Ablation for Pancreatic Cysts?: A Systematic Review and Meta-Analysis

Background: Endoscopic Ultrasound (EUS) guided Ethanol Ablation of the pancreatic cyst has been used as an alternative for surgery in recent years. In this meta-analysis, we compare the outcomes of pancreatic cyst ablation with ethanol-based ablation therapy versus non-ethanol-based ablation therapies. Methods: Selection Criteria included pancreatic cyst ablations with EUS-guided ethanol and non-ethanol ablation. Data was collected and extracted from Medline, Pubmed, and Ovid journals. Statistical analysis used Fixed and random effects models to calculate the pooled proportions.

Comparison of outcomes of EUS-guided ablation and surveillance only for pancreatic cystic lesions: a propensity score–matching study (with videos)

EUS-guided ethanol ablation (EUS-EA) is a recently introduced treatment approach for pancreatic cystic lesions (PCLs), including branch-duct-type intraductal papillary mucinous neoplasms (BD-IPMNs). However, the utility of this procedure is limited owing to its relatively low efficacy in treating PCLs. We retrospectively reviewed patients with PCLs, including those with enlarging suspected BD-IPMNs, or those with PCLs measuring >3cm who were suboptimal candidates for surgery and had been managed using EUS-guided rapid ethanol lavage (EUS-REL; four times of immediate ethanol lavage, 2015-2022) or surveillance-only (SO, 2007- 2022). Propensity score matching (PSM) was performed to minimize bias. The primary outcome was the cumulative incidence rate of BD-IPMN progression. Secondary outcomes were the efficacy and safety of EUS-REL, surgical resection rate (SR), overall survival (OS), and disease-specific survival (DSS) in both groups. Overall, 169 and 610 patients were included in the EUS and SO groups, respectively. PSM created 159 matched pairs. The radiologic complete resolution rate following EUS-REL was 74%. Procedure-related pancreatitis in the EUS group was 13.0% (n=22; 19 mild, and 3 moderate grade); no severe complication was reported. The 10-year cumulative incidence rate of BD-IPMN progression was significantly lower in the EUS group than in the SO group (1.6% vs 21.2%, hazard ratio 12.35, P = .003). EUS-REL showed a lower tendency of SR compared to that associated with SO. The 10-year OS and 10-year DSS were comparable in both groups. EUS-REL was associated with a significantly lower 10-year cumulative incidence rate of BD-IPMN progression and a lower tendency of SR, while its 10-year OS and DSS were similar to those of SO for PCLs. EUS-REL may be a viable alternative to SO for managing patients with enlarging suspected BD-IPMNs or those with PCLs >3cm who are suboptimal candidates for surgery.

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.

Comparison of EUS-guided ablation and surgical resection for nonfunctioning small pancreatic neuroendocrine tumors: a propensity score–matching study

Treatment strategies for small pancreatic neuroendocrine tumors (PNETs)<2 cm in size are still under debate. The feasibility and safety of EUS-guided ethanol ablation (EUS-EA) have been demonstrated. However, sample sizes in previous studies were small with no comparative studies on surgery. Therefore, we aimed to compare the safety and long-term outcomes of EUS-EA with those of surgery for the management of nonfunctioning small PNETs. We retrospectively reviewed patients with PNETs who were managed by EUS-EA (from 2011 to 2018) and surgery (from 2000 to 2018) at Asan Medical Center. Propensity score matching (PSM) was performed to increase comparability. The primary outcome was early and late major adverse events (Clavien-Dindo grade≥III) after treatment. Secondary outcomes were 10-year overall (OS) and disease-specific survival (DSS) rates, length of hospital stay, and development of endocrine pancreatic insufficiency. Of all patients, 97 and 188 patients were included in the EUS-EA and surgery groups, respectively. PSM created 89 matched pairs. EUS-EA was associated with a significantly lower rate of early major adverse events (0% vs 11.2%, P= .003). Late major adverse events occurred more frequently after surgery, with no significant difference between groups (3.4% vs 10.1%, P= .07). Both treatment modalities showed comparable 10-year OS and DSS rates. The length of hospital stay was significantly shorter in the EUS-EA group (4 days vs 14.1 days, P< .001), and endocrine pancreatic insufficiency was less common after EUS-EA than after surgery (33.3% vs 48.6%, P= .121). EUS-EA had fewer adverse events and a shorter hospital stay with similar OS and DSS rates compared with surgery, suggesting that EUS-EA may be a preferred alternative to surgical resection in selected patients with nonfunctioning small PNETs.

Safety and efficacy of EUS-guided ablation of pancreatic lesions with ethanol versus ethanol with paclitaxel: A systematic review and meta-analysis.

EUS-guided ethanol ablation has emerged as an alternative method for pancreatic lesions. Recently, paclitaxel was added to ethanol to assess ablative effects in pancreatic lesions. We performed a systematic review and meta-analysis on EUS-guided ethanol ablation (EUS E) versus EUS-guided ethanol with paclitaxel (EUS EP) ablation for the management of pancreatic lesions. Comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, Google Scholar, and Web of Science databases (from inception to May 2020). The primary outcome evaluated complete ablation of the lesions radiologically and the secondary outcome evaluated adverse events (AEs). Fifteen studies on 524 patients were included in our analysis. The pooled complete ablation rate was 58.89% (95% confidence interval (CI) = 38.72-77.80, I2 = 91.76%) and 55.99% (95% CI = 44.66-67.05, I2 = 0) in the EUS E and EUS EP groups (P = 0.796), respectively. The pooled AE rates were 13.92% (95% CI = 4.71-26.01, I2 = 83.43%) and 31.62% (95% CI = 3.36-68.95, I2 = 87.9%) in the EUS E and EUS EP groups (P = 0.299), respectively. The most common AE was abdominal pain at 7.27% (95% CI = 1.97-14.6, I2 = 68.2%) and 12.44% (95% CI = 0.00-39.24, I2 = 81.1%) in the EUS E and EUS EP groups (P = 0.583), respectively. Correlation coefficient (r) was ‒0.719 (P = 0.008) between complete ablation and lesion size. Complete ablation rates were comparable among both groups. AE rates were higher in the EUS EP group. Further randomized controlled trials are needed to validate our findings.

EUS-guided ethanol ablation for pancreatic cysts: Is it really better than natural course?

EUS-guided ethanol ablation for pancreatic cysts: Is it really better than natural course?

Endoscopic ultrasound-guided ethanol ablation for functioning insulinoma

Background:Most diagnosed pancreatic neuroendocrine tumors (pNETs) are nonfunctioning tumors (90.8%); the remaining 9% are malignant functioning tumors. While surgical resection is the standard of care, alternative management options may be mandated in symptomatic patients who refuse or are ineligible for surgery. We present a case of endoscopic ultrasound (EUS)-guided ethanol ablation of symptomatic insulinoma in a patient who refused surgery.Case Presentation:A 35-year-old man was referred to our facility with suspected insulinoma for EUS evaluation. During a 48-h supervised fast, a plasma glucose of 30 mg/dl was obtained with a corresponding serum insulin level of 235 μIU/mL (normal: 20–80) and C-peptide level of 19.9 ng/mL (normal: 2.8–9.9). Computed tomography abdomen revealed a normal pancreas with no detected masses. On admission, he was on intravenous glucose 25% at an infusion rate of 250 mL/h and octreotide (150 mcg subcutaneously three times daily). EUS examination revealed a small hypoechoic pancreatic tail mass 2 cm ×1.5 cm with no vascular involvement or detected lymph nodes. EUS-fine needle aspiration was done using a 25G needle. Pathological examination was consistent with NET. The patient's family initially refused surgery; EUS-guided ethanol ablation was therefore considered. The lesion was injected with 3 mL of ethanol using 25G needle resulting in a hyperechoic blush within the center of the tumor. Following the procedure, there was partial clinical success with the patient's glucose infusion rate decreased to 100 mL/h. After 3 days, a second session was considered. The lesion was re-injected with 3 mL of ethanol using 22G needle resulting in a hyperechoic blush of the lesion. Again, there was partial clinical success with the patient's glucose infusion rate decreased to 50 mL/h. There were no postprocedural complications. The patient's family decided to do surgery and distal pancreatectomy was done.Discussion:EUS-guided ethanol ablation of functioning pNETs is a less common therapeutic tool. A recent literature review showed 19 patients who underwent EUS-guided ethanol ablation of functioning pNETs from 2006 to 2015 with technical and clinical success in 100% of cases. This case reports another EUS-guided ethanol ablation of functioning insulinoma added to the documented cases, with partial clinical success. Despite partial clinical success, EUS-guided ethanol ablation is feasible and safe when applied to symptom relief in functioning tumors in patients who refuse or are ineligible for surgery.

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.

Successful Endoscopic Ultrasound-Guided Alcohol Ablation of Sporadic Insulinoma Using Three-Dimensional Targeting (with Video).

Surgical resection is considered the standard of care in the management of symptomatic insulinoma. In this video, we describe the successful management of a symptomatic insulinoma by using linear array endoscopic ultrasound (EUS)-guided ethanol ablation in a poor surgical candidate. EUS-guided ethanol ablation of insulinoma offers a safer, effective, and less invasive alternative to surgery.

Efficacy of EUS-guided ethanol ablation in the treatment of insulinoma

Objective To evaluate the safety and efficacy of endoscopic ultrasonography (EUS) guided ethanol ablation in patients with insulinoma. Methods The data of 10 patients with insulinoma treated at the First Affiliated Hospital of Guangxi Medical University from December 2013 to January 2015 were prospectively analyzed. Results The patients were given EUS-guided ethanol ablation with dose of 0.10 to 2.00 ml (average 0.70 ± 0.62 ml) in pancreatic lesions for 15 times. No complications were observed during and after the procedure. The blood glucose improved after the procedure [4.8(3.9-5.5) mmol/L VS 2.4(1.9-2.5) mmol/L, P<0.05] and the serum insulin level significantly decreased[83.7(40.1-143.5) pmol/L VS 177.3(66.5-200.6) pmol/L, P<0.05]. The average hospital stay was (4.3±1.5) days. The patients were followed up for 6-12 months. EUS indicated that the echo of pancreatic lesions changed from high to low. CE-EUS revealed low enhancement and lack of blood supply. Conclusion EUS-guided ethanol ablation may become a promising minimally invasive treatment for insulinoma because of its safety, efficacy and low price. Trail registration Clinical Trial.gov, NCT02121366 Key words: Insulinoma; EUS; Alcohol injection; Efficacy

Safety and Efficacy of EUS-Guided Ethanol Ablation for Treating Small Solid Pancreatic Neoplasm.

The strategy for treating small borderline malignant pancreatic neoplasms--such as neuroendocrine tumor (NET) and solid pseudopapillary neoplasm (SPN)--is surgical resection. However, pancreatic resection of these lesions still causes significant morbidity. We evaluated the safety and efficacy of EUS-guided ethanol ablation to treat small solid pancreatic neoplasms. A total of 8 patients with small borderline malignant pancreatic neoplasms and co-morbidities who refused surgery were included. We identified 2 cases of nonfunctioning NET, 3 cases of insulinomas, 1 case of gastrinoma, and 2 cases of SPN. EUS-guided ethanol ablation was performed, and treatment outcomes were assessed with clinical symptom, hormone assay, and imaging study. The mean tumor diameter was 15 mm (range, 7-29 mm), and the median volume of injected ethanol was 2.8 mL (range, 1.2-10.5 mL). There was 1 severe acute pancreatitis after EUS-guided ethanol ablation with 20-gauge CPN needle. During follow-up (median 16.5 months), 6 patients achieved treatment success; however, 2 patients (1 nonfunctioning NET and 1 SPN) still had persistent tumors. The patient with persistent SPN underwent surgical resection and the histopathological results showed peripancreatic infiltration with perineural invasion. Among 6 patients who achieved initial treatment success, 1 patient experienced tumor recurrence within 15 months and underwent repeated EUS-guided ethanol ablation. In conclusion, EUS-guided ethanol ablation therapy is a promising option for patients with small solid pancreatic neoplasm. Multiple sessions or surgical interventions may be required if there is a recurrent or persistent mass, and procedure-related adverse events must be carefully monitored.

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.

Su1468 Mural Nodule of 10mm or Larger As Predictor of Malignancy for Intraductal Papillary Mucinous Neoplasm of the Pancreas: Pathological and Radiological Validation

and DerSimonian Laird method (random effects model). The heterogeneity among studies was tested using Cochran's Q test based upon inverse variance weights. Results: Initial search identified 1,230 reference articles, in which 120 relevant articles were selected and reviewed. Data was extracted from 6 studies (N = 139) 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 53.19% (95% CI = 44.74 to 61.56) and partial cyst resolution was 27.12% (95% CI = 19.96 to 34.94). Post procedural complications after ablation was significant for abdominal pain in 7.17% (95% CI = 3.43 to 12.12) and pancreatitis in 4.15% (95% CI = 1.45 to 8.17) of the pooled percentage of patients. Conclusions: EUS-guided ethanol ablation may be a safe alternative treatment modality for pancreatic cysts, with acceptable intra-procedural and post procedural 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 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.

Mo1373 EUS-Guided Ethanol Ablation of Small Solid Pancreatic Neoplasm

The treatment strategy of small borderline malignant pancreatic neoplasm such as insulinoma or solid pseudopapillary neoplasm (SPN) has been surgical resection. However, pancreatic resection still carries significant morbidity. We evaluated the efficacy and safety of EUS-guided ethanol ablation in small solid pancreatic neoplasm.

EUS-guided ethanol ablation for management of metastatic hepatocellular carcinoma

EUS-guided ethanol ablation for management of metastatic hepatocellular carcinoma

Sp616 EUS-Guided Ethanol Ablation for Management of Metastatic Hepatocellular Carcinoma

A 77 year old man with a history of hemochromatosis is found to have a new hepatocellular carcinoma approximately 3 years ago. His initial treatment included percutaneous RFA, partial hepatectomy, and retroperitoneal lymph node resection. At 6 months post-op, a metastatic lymph node is discovered in the right retrocrural space. This was successfully treated by external radiation therapy (XRT). At 19 months post-op, a large metastatic lymph node is found in the aorto-caval region. This initially responded to XRT. However, 1 year later the lesion has increased in size and serum AFP is 93.4 ng/ml. Multidisciplinary evaluation pursued. Patient was not a candidate for further XRT. Surgery not an option. And percutaneous ablation was not felt to be feasible. EUS-guided ethanol ablation was thus offered as an a potential alternative. A linear echoendoscope was advanced to the duodenal bulb, where the metastatic lymph node was able to be visualized. A 22-gauge needle was advanced into the periphery of the lesion in a trans-duodenal approach. 98% ethanol was then slowly injected through the needle directly into the mass. A “blush” was seen at the site of ethanol injection. The needle was slowly withdrawn as the ethanol was injected, with care taken to avoid extravasation of the injectate. Ablation was performed at various sites throughout the tumor until an ablation effect was seen throughout the lesion. A total of 21 cc of ethanol was injected. Follow-up at 10 weeks demonstrated near-normalization of serum AFP (13.9 ng/ml) as well as non-enhancing low attenuation on CT, consistent with complete treatment effect. Follow-up at 5 months demonstrates serum AFP of 19.1 ng/ml, suggestive of continued local tumor control. EUS-guided ethanol ablation of metastatic HCC is a potential treatment option in select patients where traditional therapies are not feasible or are considered suboptimal.