Endoscopic Ultrasound-Guided Ablation of Pancreatic Cystic Neoplasms: A Systematic Review and Meta-Aanalysis: Presidential Poster Award

Introduction: Pancreatic Cystic Neoplasms (PCN) are increasingly detected with enhanced imaging modalities. While surgical resection is the recommendation for mucinous cystic lesions meeting high risk or certain worrisome criteria (International Consensus Guidelines 2017), EUS-guided pancreatic cyst ablation (PCA) is performed as an alternative for poor surgical candidates. We sought to determine the pooled Complete Resolution (CR) rate after PCA and review associated complications. Methods: Literature search was performed using Embase and PubMed database. Relevant articles were selected based on availability of data for analysis regardless of the primary objectives. Quality of the selected articles was assessed using the Newcastle Ottawa Scale for observational studies. Random effect model was used for all analyses. The summary measure of CR rate was defined by absence of cyst or <5% cyst volume on repeat imaging after PCA. CR was expressed in percentages of ablated cyst with 95% confidence interval (CI). Heterogeneity was assessed using the Cochrane Q-test and I-squared. Publication bias was assessed with Egger’s regression model and Funnel plot. Results: A total of 533 subjects from 11 studies were included in the final analysis (Table 1). For “all cyst types”, combination of Ethanol and Paclitaxel had the highest CR (66.4%, 95% CI 59.5-72.6%) compared to ethanol alone (35.9%, 95% CI 23.0-51.2%). Compared to mucinous cystic neoplasms (MCNs), Branch Duct (BD)-IPMN had lower CR after PCA with ethanol (24.1%, 95% CI 12.5-41.3%) vs. 40.2%, 95% CI 17.2-68.5%) or Ethanol with Paclitaxel (45.5%, 95% CI 20.3-73.2% vs. 58.6%, 95% CI 19.0-89.5%) (Table 2). The overall complication rate was 15.4% (95% CI 6.1-33.6%), with an acute pancreatitis (AP) rate of 4.4% (2.6-6.9%). Studies used were of moderate quality. While heterogeneity was high for “all Cyst types”, it was low for ethanol with paclitaxel subgroup. The Forest plots are show in in Figure 1. There was no evidence of publication bias by visual inspection of funnel plot and by Egger’s regression model (p=0.62).14_A Figure 1. Characteristics of Studies Included in the Systematic Review and Meta-analysisConclusion: EUS-guided pancreatic cyst ablation appears to be a safe and feasible management option for PCNs in select patients; however, BD-IPMN, which is the commonest form of mucinous cyst, has relatively low rates of complete resolution. Further application of other chemotherapeutic drug combinations and novel drug delivery mechanisms need to be explored.14_B Figure 2. Meta-analysis of Cyst Resolution (CR) in “All Cyst Types”. CR is expressed here in decimals.14_C Figure 3. Summary of Outcome of Pancreatic Cyst Ablation Using Different Ablative Agents

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