EUS-guided ethanol ablation

Dennis Yang, MD, from the Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, in New York, New York, USA presents this video case “EUS-guided ethanol ablation of symptomatic pancreatic insulinomas.”

In this video, we describe the technique of EUS-guided ethanol ablation and evaluate its safety and efficacy for the treatment of patients with symptomatic insulinomas considered to be poor operative candidates, those who refused surgery, and those following incomplete surgical resection. Four patients (mean age 59 years; range 47-86 years) underwent EUS-guided fine-needle injection (FNI) of 98% ethanol for therapy of a sporadic (n=3) or multiple endocrine neoplasia 1-associated (n=1) insulinoma. EUS-FNI was performed using a linear echoendoscope with a 22-gauge needle. Small aliquots of 0.1 ml of ethanol were injected repeatedly within the tumor until a hyperechoic blush was seen expanding within the lesion. The mean size of the insulinomas was 1.9 cm (range 1.1-2.6 cm). A total of 2 (n=1) and 1 (n=3) treatment sessions were performed, with a mean ethanol volume of 3.1 ml (range 0.5-7 ml). There were no intraprocedural adverse events. Three out of 4 patients remained completely asymptomatic at follow-up (median 17.3 months; range 5-30 months).

Figure 1. EUS-guided ethanol ablation performed with a 22-gauge needle by injection of 98% alcohol in 0.1-mL aliquots. Repeated injections are performed until a hyperechoic blush is seen expanding in the tumor.

Insulinomas are the most common functioning islet cell tumor of the pancreas. Surgical resection is the standard of care while medical therapy is often reserved for non-surgical candidates. EUS-guided ethanol ablation of insulinomas has emerged as an alternate treatment modality in non-surgical candidates or in those intolerant/non-responsive to medical therapy. In this video session, we describe the technical aspects of EUS-guided ethanol injection and demonstrate its safety and efficacy for the management of symptomatic pancreatic insulinomas.

EUS-guided ethanol ablation appears to be a feasible, safe and effective treatment of symptomatic pancreatic insulinomas. Treatment is primarily focused on symptomatic control rather than oncologic cure. In our experience, the use of a 22-gauge needle attached to a 1 ml tuberculin needle allowed precise injection of ethanol, with the appearance of a hyperechoic blush within the tumor as a marker of treatment effect.

Find more VideoGIE cases online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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