CC BY-NC-ND 4.0 · Endosc Int Open 2019; 07(09): E1064-E1077
DOI: 10.1055/a-0959-5870
Review
Owner and Copyright © Georg Thieme Verlag KG 2019

Position statement on EUS-guided ablation of pancreatic cystic neoplasms from an international expert panel

Anthony Yuen-Bun Teoh
1   Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
,
Dong Wan Seo
2   Department of Gastroenterology, Asan Medical Centre, Seoul, Korea
,
William Brugge
3   Pancreas Biliary Center, Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, United States
,
John Dewitt
4   Division of Gastroenterology, Department of Medicine, Indiana University Hospital, Indianapolis, Indiana, United States
,
Pradermchai Kongkam
5   Pancreas Research Unit and Gastrointestinal Endoscopy Excellent Center, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
,
Enqiang Linghu
6   Department of Gastroenterology, Chinese PLA General Hospital, Beijing, China
,
Matthew T. Moyer
7   Division of GI-Hepatology and Penn State University Cancer Institute, Penn State Hershey Medical Center, Hershey, Pennsylvania, United States
,
Ji Kon Ryu
8   Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
,
Khek Yu Ho
9   Department of Medicine, National University of Singapore, Singapore
› Author Affiliations
Further Information

Publication History

submitted 30 January 2019

accepted after revision 11 April 2019

Publication Date:
29 August 2019 (online)

Abstract

Background and aim Recently, several guidelines with divergent recommendations on management of pancreatic cystic neoplasm have been published but the role of endoscopic ultrasound (EUS)-guided pancreatic cyst ablation has not been thoroughly addressed. The aim of the current paper is to explore the issues surrounding EUS-guided pancreatic cyst ablation by generating a list of clinical questions and providing answers based on best scientific evidence available.

Methods An expert panel in EUS-guided pancreatic cyst ablation was recruited from members of the Asian EUS group and an international expert panel. A list of clinical questions was created and each question allocated to one member to generate a statement in response. The statements were then discussed in three Internet conference meetings between October 2016 and October 2017. The statements were changed until consensus was obtained. Afterwards, the complete set of statements was sent to all the panelist to vote on strength of the statements, classification of the statement sand grading of the evidence.

Results Twenty-three statements on EUS-guided drainage of pancreatic cyst ablation were formulated. The statements addressed indications for the procedures, technical aspects, pre-procedure and post-procedure management, management of complications, and competency and training in the procedures.

Conclusion The current set of statements on EUS-guided pancreatic cyst ablation are the first to be published by any endoscopic society. Clinicians interested in developing the technique should reference these statements and future studies should address the key issues raised in the document.

 
  • References

  • 1 Tanaka M, Fernandez-del Castillo C, Adsay V. et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology 2012; 12: 183-197
  • 2 European Study Group on Cystic Tumours of the Pancreas. European evidence-based guidelines on pancreatic cystic neoplasms. Gut 2018; 67: 789-804
  • 3 Scheiman JM, Hwang JH, Moayyedi P. American Gastroenterological Association technical review on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology 2015; 148: 824-848 e822
  • 4 Guyatt GH, Oxman AD, Vist GE. et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008; 336: 924-926
  • 5 Guyatt GH, Oxman AD, Schunemann HJ. et al. GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology. J Clin Epidemiol 2011; 64: 380-382
  • 6 Oh HC, Brugge WR. EUS-guided pancreatic cyst ablation: a critical review (with video). Gastrointest Endosc 2013; 77: 526-533
  • 7 Moyer MT, Sharzehi S, Mathew A. et al. The safety and efficacy of an alcohol-free pancreatic cyst ablation protocol. Gastroenterology 2017; 153: 1295-1303
  • 8 Oh HC, Seo DW, Song TJ. et al. Endoscopic ultrasonography-guided ethanol lavage with paclitaxel injection treats patients with pancreatic cysts. Gastroenterology 2011; 140: 172-179
  • 9 Dewitt J, McGreevy K, Schmidt CM. et al. EUS-guided ethanol versus saline solution lavage for pancreatic cysts: a randomized, double-blind study. Gastrointest Endosc 2009; 70: 710-723
  • 10 Dewitt JM, Al-Haddad M, Sherman S. et al. Alterations in cyst fluid genetics following endoscopic ultrasound-guided pancreatic cyst ablation with ethanol and paclitaxel. Endoscopy 2014; 46: 457-464
  • 11 Moyer MT, Dye CE, Sharzehi S. et al. Is alcohol required for effective pancreatic cyst ablation? The prospective randomized CHARM trial pilot study. Endosc Int Ppen 2016; 4: E603-E607
  • 12 Choi JH, Seo DW, Song TJ. et al. Long-term outcomes after endoscopic ultrasound-guided ablation of pancreatic cysts. Endoscopy 2017; 49: 866-873
  • 13 Gan SI, Thompson CC, Lauwers GY. et al. Ethanol lavage of pancreatic cystic lesions: initial pilot study. Gastrointest Endosc 2005; 61: 746-752
  • 14 Oh HC, Seo DW, Lee TY. et al. New treatment for cystic tumors of the pancreas: EUS-guided ethanol lavage with paclitaxel injection. Gastrointest Endosc 2008; 67: 636-642
  • 15 Oh HC, Seo DW, Kim SC. et al. Septated cystic tumors of the pancreas: is it possible to treat them by endoscopic ultrasonography-guided intervention?. Scand J Gastroenterol 2009; 44: 242-247
  • 16 Dimaio CJ, dewitt JM, Brugge WR. Ablation of pancreatic cystic lesions: the use of multiple endoscopic ultrasound-guided ethanol lavage sessions. Pancreas 2011; 40: 664-668
  • 17 Park JK, Song BJ, Ryu JK. et al. Clinical outcomes of endoscopic ultrasonography-guided pancreatic cyst ablation. Pancreas 2016; 45: 889-894
  • 18 Sainani NI, Saokar A, Deshpande V. et al. Comparative performance of MDCT and MRI with MR cholangiopancreatography in characterizing small pancreatic cysts. AJR Am J Roentgenol 2009; 193: 722-731
  • 19 Sahani DV, Kambadakone A, Macari M. et al. Diagnosis and management of cystic pancreatic lesions. AJR Am J Roentgenol 2013; 200: 343-354
  • 20 Waters JA, Schmidt CM, Pinchot JW. et al. CT vs MRCP: optimal classification of IPMN type and extent. J Gastrointest Surg 2008; 12: 101-109
  • 21 Pilleul F, Rochette A, Partensky C. et al. Preoperative evaluation of intraductal papillary mucinous tumors performed by pancreatic magnetic resonance imaging and correlated with surgical and histopathologic findings. J Magn Reson Imaging 2005; 21: 237-244
  • 22 de Jong K, van Hooft JE, Nio CY. et al. Accuracy of preoperative workup in a prospective series of surgically resected cystic pancreatic lesions. Scand J Gastroenterol 2012; 47: 1056-1063
  • 23 Ardengh JC, Lopes CV, de Lima-Filho ER. et al. Impact of endoscopic ultrasound-guided fine-needle aspiration on incidental pancreatic cysts. A prospective study. Scand J Gastroenterol 2014; 49: 114-120
  • 24 Brugge WR, Lewandrowski K, Lee-Lewandrowski E. et al. Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology 2004; 126: 1330-1336
  • 25 Cizginer S, Turner BG, Bilge AR. et al. Cyst fluid carcinoembryonic antigen is an accurate diagnostic marker of pancreatic mucinous cysts. Pancreas 2011; 40: 1024-1028
  • 26 Koito K, Namieno T, Nagakawa T. et al. Solitary cystic tumor of the pancreas: EUS-pathologic correlation. Gastrointest Endosc 1997; 45: 268-276
  • 27 Morris-Stiff G, Lentz G, Chalikonda S. et al. Pancreatic cyst aspiration analysis for cystic neoplasms: mucin or carcinoembryonic antigen--which is better?. Surgery 2010; 148: 638-644 ; discussion 644-635
  • 28 Al-Haddad M, dewitt J, Sherman S. et al. Performance characteristics of molecular (DNA) analysis for the diagnosis of mucinous pancreatic cysts. Gastrointest Endosc 2014; 79: 79-87
  • 29 Gaddam S, Ge PS, Keach JW. et al. Suboptimal accuracy of carcinoembryonic antigen in differentiation of mucinous and nonmucinous pancreatic cysts: results of a large multicenter study. Gastrointest Endosc 2015; 82: 1060-1069
  • 30 Kadayifci A, Al-Haddad M, Atar M. et al. The value of KRAS mutation testing with CEA for the diagnosis of pancreatic mucinous cysts. Endosc Int Open 2016; 4: E391-396
  • 31 Khalid A, Zahid M, Finkelstein SD. et al. Pancreatic cyst fluid DNA analysis in evaluating pancreatic cysts: a report of the PANDA study. Gastrointest Endosc 2009; 69: 1095-1102
  • 32 Winner M, Sethi A, Poneros JM. et al. The role of molecular analysis in the diagnosis and surveillance of pancreatic cystic neoplasms. J Pancreas 2015; 16: 143-149
  • 33 Konda VJ, Meining A, Jamil LH. et al. A pilot study of in vivo identification of pancreatic cystic neoplasms with needle-based confocal laser endomicroscopy under endosonographic guidance. Endoscopy 2013; 45: 1006-1013
  • 34 Napoleon B, Lemaistre AI, Pujol B. et al. In vivo characterization of pancreatic cystic lesions by needle-based confocal laser endomicroscopy (ncle): proposition of a comprehensive ncle classification confirmed by an external retrospective evaluation. Surg Endosc 2016; 30: 2603-2612
  • 35 Napoleon B, Lemaistre AI, Pujol B. et al. A novel approach to the diagnosis of pancreatic serous cystadenoma: needle-based confocal laser endomicroscopy. Endoscopy 2015; 47: 26-32
  • 36 Nakai Y, Iwashita T, Park DH. et al. Diagnosis of pancreatic cysts: EUS-guided, through-the-needle confocal laser-induced endomicroscopy and cystoscopy trial: DETECT study. Gastrointest Endosc 2015; 81: 1204-1214
  • 37 Krishna SG, Swanson B, Hart PA. et al. Validation of diagnostic characteristics of needle based confocal laser endomicroscopy in differentiation of pancreatic cystic lesions. Endosc Int Open 2016; 4: E1124-E1135
  • 38 Kadayifci A, Atar M, Basar O. et al. Needle-Based confocal laser endomicroscopy for evaluation of cystic neoplasms of the pancreas. Dig Dis Sci 2017; 62: 1346-1353
  • 39 Nakai Y, Isayama H, Chang KJ. et al. A pilot study of EUS-guided through-the-needle forceps biopsy (with video). Gastrointest Endosc 2016; 84: 158-162
  • 40 Mittal C, Obuch JC, Hammad H. et al. Technical feasibility, diagnostic yield, and safety of microforceps biopsies during EUS evaluation of pancreatic cystic lesions (with video). Gastrointest Endosc 2018; 87: 1263-1269
  • 41 Chai N, Feng J, Guo Y. et al. Preliminary study of single-operator cholangioscopy for diagnosing pancreatic cystic lesions. Gastrointest Endosc 2017; 86: 208-218
  • 42 Zhu H, Jiang F, Zhu J. et al. Assessment of morbidity and mortality associated with endoscopic ultrasound-guided fine-needle aspiration for pancreatic cystic lesions: A systematic review and meta-analysis. Dig Endosc 2017; 29: 667-675
  • 43 Guarner-Argente C, Shah P, Buchner A. et al. Use of antimicrobials for EUS-guided FNA of pancreatic cysts: a retrospective, comparative analysis. Gastrointest Endosc 2011; 74: 81-86
  • 44 Klein A, Qi R, Nagubandi S. et al. Single-dose intra-procedural ceftriaxone during endoscopic ultrasound fine-needle aspiration of pancreatic cysts is safe and effective: results from a single tertiary center. Ann Gastroenterol 2017; 30: 237-241
  • 45 Marinos E, Lee S, Jones B. et al. Outcomes of single-dose peri-procedural antibiotic prophylaxis for endoscopic ultrasound-guided fine-needle aspiration of pancreatic cystic lesions. United European Gastroenterol J 2014; 2: 391-396
  • 46 Polkowski M, Jenssen C, Kaye P. et al. Technical aspects of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Guideline – March 2017. Endoscopy 2017; 49: 989-1006
  • 47 Varadarajulu S, Bang JY, Hebert-Magee S. Assessment of the technical performance of the flexible 19-gauge EUS-FNA needle. Gastrointest Endosc 2012; 76: 336-343
  • 48 Cho MK, Choi JH, Seo DW. Endoscopic ultrasound-guided ablation therapy for pancreatic cysts. Endosc Ultrasound 2015; 4: 293-298
  • 49 Gelczer RK, Charboneau JW, Hussain S. et al. Complications of percutaneous ethanol ablation. J Ultrasound Med 1998; 17: 531-533
  • 50 Gomez V, Takahashi N, Levy MJ. et al. EUS-guided ethanol lavage does not reliably ablate pancreatic cystic neoplasms (with video). Gastrointest Endosc 2016; 83: 914-920
  • 51 Linghu E, Du C, Chai N. et al. A prospective study on the safety and effectiveness of using lauromacrogol for ablation of pancreatic cystic neoplasms with the aid of EUS. Gastrointest Endosc 2017; 86: 872-880
  • 52 Ebrahimi SRS, Enamzadeh E, Babaei H. An evidence-based review of off-label uses of polidocanol. Curr Clin Pharmacol 2017; 12: 223-230
  • 53 Kim KH, mcgreevy K, La Fortune K. et al. Sonographic and cyst fluid cytologic changes after EUS-guided pancreatic cyst ablation. Gastrointest Endosc 2017; 85: 1233-1242
  • 54 Dewitt J, dimaio CJ, Brugge WR. Long-term follow-up of pancreatic cysts that resolve radiologically after EUS-guided ethanol ablation. Gastrointest Endosc 2010; 72: 862-866
  • 55 Oh HC, Seo DW, Kim SH. et al. Systemic effect of endoscopic ultrasonography-guided pancreatic cyst ablation with ethanol and paclitaxel. Dig Dis Sci 2014; 59: 1573-1577
  • 56 Committee AT, dimaio CJ, Mishra G. et al. EUS core curriculum. Gastrointest Endosc 2012; 76: 476-481
  • 57 Eisen GM, Dominitz JA, Faigel DO. et al. Guidelines for credentialing and granting privileges for endoscopic ultrasound. Gastrointest Endosc 2001; 54: 811-814
  • 58 Teoh AYB, Dhir V, Kida M. et al. Consensus guidelines on the optimal management in interventional EUS procedures: results from the Asian EUS group RAND/UCLA expert panel. Gut 2018; 67: 1209-1228
  • 59 Yachimski P, Varadarajulu S. Endoscopic ultrasound-guided pancreatic cyst ablation: more peril than promise?. Gastroenterology 2017; 153: 1183-1185
  • 60 Fernandez-Del Castillo C. EUS treatment of pancreatic cysts: let's keep the alcohol (and the chemotherapy) locked in the cupboard. Gastroenterology 2011; 140: 2144-2145
  • 61 Crippa S, Pezzilli R, Bissolati M. et al. Active surveillance beyond 5 years is required for presumed branch-duct intraductal papillary mucinous neoplasms undergoing non-operative management. Am J Gastroenterol 2017; 112: 1153-1161