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Table. 3.

Summary of the Position Statement on EUS-Guided Pancreatic Cyst Ablation

Question Statement
Indications for the procedure
When should we perform pancreatic cyst ablation? Patients who are not surgical candidates or refuse surgery with a reasonable life expectancy and suffering from either:
- Unilocular or oligolocular cyst with a presumed or confirmed diagnosis of a mucinous cyst
- Enlarging PCLs with a diameter of > 2 cm or PCLs with diameter of > 3 cm
Which pancreatic cysts respond best to ablation? - PCLs with ≤ 6 locules
- PCLs 2 to 6 cm in diameter
What are the contraindications to the procedure? Absolute contraindications
- Pregnancy
- Irreversible coagulopathy
- Signs of pancreatic malignancy
- Active pancreatitis or pancreatic necrosis
- Short life expectancy
Relative contraindications
- PCLs with enhancing mural nodules
- Cyst with no or low malignant potential
- Dilated main pancreatic duct > 5 mm in size
- Clear open communication with the main pancreatic duct
- > 6 locules comprising the cyst
- Thick walls or septations
- Main pancreatic duct stricture with pancreatic tail atrophy
- Significant solid components
- Past medical history of acute pancreatitis
What level of certainty of diagnosis is required before the procedure? The treating physician should be reasonably certain that the cyst is not a benign asymptomatic pancreatic cyst with no or low malignant potential
Procedural preparations
What investigational modalities are required before EUS cyst ablation is performed? CT (pancreatic protocol), MRI with MRCP (enhancement) ± EUS ± FNA
Are prophylactic antibiotics required? Fluoroquinolones or beta-lactamase are recommended
How long do antibiotics need to be continued if given? 3 to 5 days
Procedural considerations
Should the fluid be aspirated completely or not before ablation? Leave a small rim of fluid around the tip of the needle within the cyst after the initial aspiration
What should be done if the cyst fluid is too viscous to be aspirated out during EUS-FNA? - Use a 19-gauge needle under high suction pressure
- Viscosity can then be lowered by injection of normal saline or alcohol that were aspirated out
What are the available agents for the procedure? - Ethanol lavage only
- Ethanol lavage followed by the infusion of paclitaxel
- Alcohol-free saline lavage followed by an admixture of paclitaxel-gemcitabine
- Lauromacrogol
Is ethanol required for effective pancreatic cyst ablation? - Ethanol is the traditional agent used for ablation
- Ethanol is not required when a chemotherapeutic agent is used
What is the difference between aspiration, lavage, and retention? Are there any differences between the practices? - Aspiration: removal of cyst fluid by the aspiration needle
- Lavage: repetitive aspiration and reinjection of the lavage agent for 3 to 5 minutes
- Retention: retain the injected ethanol for 20 to 40 minutes while rotating the patient’s position, and the injected ethanol is aspirated completely
- Infusion: replacement of the cyst content with an ablation agent, which is then left in place
Outcomes of EUS-guided pancreatic cyst ablation
How should response to therapy be defined after the procedure? Completeness of response: defined by the amount of reduction in the volume of the cyst as measured by the radius of primary imaging modality at initial and 6-month follow-up
- Complete response: 95% or greater reduction in volume
- Partial response: 75% to 95% reduction in volume
- Non-response: < 75% reduction in volume
What are the results of pancreatic cyst ablation? - Ethanol alone: CR in 30% of treated PCLs
- Ethanol + paclitaxel: CR in 60%–79% of treated PCLs
What are the effects of ablation on the cyst epithelium? - Surgery is rarely performed after cyst ablation
- Reported histologic epithelial ablation rates are generally 50%–100%
What are the cytological and genetic changes after the procedure? - Limited data suggesting that genetic changes revert to normal after cyst ablation
Follow-up and monitoring
How should these patients be followed up and monitored? - Followed non-operatively
- Cross-sectional imaging at 6-month intervals for the first year
- Annually until no longer warranted due to patient age and medical conditions
Potential adverse events and management
What are the potential adverse events of the procedure? - The baseline risks of standard EUS-FNA procedures, which are considered safe and rarely associated with adverse events
- Specific adverse events associated with the ablation itself include self-limiting abdominal pain, acute pancreatitis, and VTE
Are there systemic effects from the chemotherapeutic agent during and after the procedure? - Paclitaxel in doses used for pancreatic cyst ablation has been shown without identifiable blood levels of the agent post-procedure

This table was revised from the position statement on EUS-guided ablation of pancreatic cystic neoplasms from an international expert panel.30

EUS, endoscopic ultrasound; PCL, pancreatic cystic lesion; CT, computed tomography; MRI, magnetic resonance imaging; MRCP, magnetic resonance cholangiopancreatography; FNA, fine-needle aspiration; VTE, venous thromboembolism.

Int J Gastrointest Interv 2022;11:119~125 https://doi.org/10.18528/ijgii220027
© Int J Gastrointest Interv