Successful endoscopic ultrasound-guided ethanol ablation of a sporadic insulinoma

Objective : Most insulinomas are benign sporadic tumours that require complete resection to avoid recurrent symptoms of hypo- glycaemia. Alternate minimally invasive therapies are seeked in elderly patients in whom extensive surgery might be life-threaten- ing. We wanted to evaluate the feasibility, safety and efficacy of ethanol injection using endoscopic ultrasound (EUS) guidance to ablate a pancreatic insulinoma. Patient and methods : A 78-yr-old female patient was referred in our academic medical centre for symptomatic hypoglycaemia. Laboratory and imaging work-up confirmed the diagnosis of an insulinoma presenting as a small tumour located deeply in the pan- creas head, in close vicinity with the Wirsung's duct. Major pan- creatic resection was contra-indicated due to the poor condition of the patient. Endosonography using a linear-array endoscope allowed injection of 3.5 ml of 98% ethanol in the pancreatic tumour after endoprosthetic stenting of the biliary and pancreatic ducts. Results : There was no recurrence of hypoglycemia, and fasting tests performed 12 days and 3 months after the procedure showed complete remission of endogenous hyperinsulinism. Complications included a mild and asymptomatic elevation of pancreatic enzymes for 2 days and the later occurrence of medically-controlled hematoma and ulceration of the duodenal wall. Complete normal- ization of pancreatic head morphology was confirmed by imaging at 3 months and the patient remains currently asymptomatic and normoglycemic more than two years after the procedure. Conclusions : EUS-guided ethanol ablation of sporadic insulino- ma is a new feasible and efficient therapy to be considered for small and localized lesions in poor surgical candidates. (Acta gastro- enterol. belg., 2008, 71, 333-337).