Endoscopic ultrasound-guided ethanol ablation versus surgical resection of insulinomas

Abstract

Purpose 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.

Materials and Methods 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.

Results 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).

Conclusion 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.

Zusammenfassung

Ziel Insulinome sind seltene Tumore des Pankreas, die zu Hypoglykämien führen können. Die chirurgische Resektion ist die aktuelle Standardtherapie. Nach der ersten Fallbeschreibung einer erfolgreichen EUS-gesteuerten Alkoholinjektion vor 16 Jahren besteht unverändert der Bedarf einer Behandlungsalternative – angesichts der hohen operativen Morbidität und der fehlenden Anwendbarkeit bei einigen Patienten.

Material und Methode Wir zeigen die retrospektiven Daten von 33 Insulinom-Patienten, die in unserem Zentrum zwischen 2010 und 2021 behandelt wurden. Von diesen wurden 9 Patienten durch eine EUS-geführte Alkohol-Injektion und 24 durch eine Pankreas-Chirurgie behandelt.

Ergebnisse Die Alkohol-Therapie-Gruppe war älter (Alkohol: median ± SE 67,8 ± 11,2 Jahre vs. Chirurgie: 52,3 ± 15,7, p=0,014) mit einem höheren Charlson-Comorbidity-Index (3,0 [1,0; 4,0] vs. 1,0 [0,0; 2,0], p=0,008). Die niedrigsten Blutzucker waren in beiden Gruppen gleich vor den jeweiligen Behandlungen (Alkohol: 2,09 ± 0,17mmol/l vs. Chirurgie: 1,81 ± 0,08, p=0,158) und danach (4,95 ± 0,74 vs. 5,41 ± 0,28, p=0,581). Komplikationen traten häufiger in der Chirurgie-Gruppe auf (11% vs. 54%, p=0,026). Ein Patient starb nach partieller Pankreatektomie postoperativ. Die Krankenhaus-Verweildauer war signifikant kürzer in der Alkohol-Gruppe (4,78 ± 0,78 Tage vs. 19,88 ± 4,07, p<0,001).

Schlussfolgerungen Die EUS-gesteuerte Alkoholinjektion kann genauso effektiv sein wie die chirurgische Behandlung der hyperinsulinämen Hypoglykämie, scheint aber mit weniger schweren Komplikationen assoziiert zu sein. Hieraus ergibt sich die Notwendigkeit für randomisierte Studien bei Insulinom-Patienten mit niedrigem Malignitäts-Risiko.

Keywords

insulinoma - neuroendocrine tumor - interventional endoscopic ultrasound - pancreatic surgery - alcohol

Publication History

Received: 31 January 2023

Accepted after revision: 06 November 2023

Accepted Manuscript online:
06 November 2023

Article published online:
05 January 2024

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