Successful endoscopic ultrasound-guided ethanol ablation of a sporadic insulinoma

Most insulinomas are benign sporadic tumours that require complete resection to avoid recurrent symptoms of hypoglycaemia. Alternate minimally invasive therapies are seeked in elderly patients in whom extensive surgery might be life-threatening. We wanted to evaluate the feasibility, safety and efficacy of ethanol injection using endoscopic ultrasound (EUS) guidance to ablate a pancreatic insulinoma.

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 pancreas head, in close vicinity with the Wirsung's duct. Major pancreatic 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.

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 normalization 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.

EUS-guided ethanol ablation of sporadic insulinoma is a new feasible and efficient therapy to be considered for small and localized lesions in poor surgical candidates.