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Joseph M, Liu E, Mark JA. Outcomes of pediatric endoscopic ultrasound-guided celiac plexus block: A single center pilot study. J Pediatr Gastroenterol Nutr 2024. [PMID: 39118490 DOI: 10.1002/jpn3.12348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 06/28/2024] [Accepted: 07/01/2024] [Indexed: 08/10/2024]
Abstract
Celiac plexus blocks (CPB) using endoscopic ultrasound (EUS) guidance provide significant pain relief in adults with chronic pancreatitis. We present on EUS-guided CPB for pediatric patients with abdominal pain from chronic pancreatitis or severe functional dyspepsia necessitating clinically assisted nutrition and hydration. Patients who underwent EUS-CPB were included and followed prospectively at 2-, 4-, and 8-weeks postprocedure about pain, enteral tolerance, and school/activity attendance. Thirteen patients underwent EUS-guided CPB with a total of 21 procedures. In the pancreatitis cohort, mean pain relief was 11.7 weeks for those who responded. In the functional dyspepsia cohort, mean improvement (in either pain or enteral tolerance) was 4.8 weeks. Symptom improvement varied between the two cohorts. Acute recurrent/chronic pancreatitis patients demonstrated more sustained relief than the functional dyspepsia cohort. This study adds to the limited data investigating the utility of EUS-CPB as part of a multimodal treatment plan in pediatrics.
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Affiliation(s)
- Michael Joseph
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Colorado, Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Edwin Liu
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Colorado, Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Jacob A Mark
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Colorado, Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado, USA
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2
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Han S, Conwell DL, Easler JJ, Yang Y, Andersen DK, Fisher WE, Fogel EL, Forsmark C, Hart PA, Hughes SJ, Li L, Pandol SJ, Park WG, Serrano J, Van Den Eeden SK, Vege SS, Yadav D. Use of pancreatic endotherapy in patients with chronic pancreatitis: results from a multicenter cohort study in the United States. Gastrointest Endosc 2024; 100:262-272.e1. [PMID: 38583544 DOI: 10.1016/j.gie.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 03/19/2024] [Accepted: 04/01/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND AND AIMS Although pancreatic endotherapy (PET) is commonly used for treating adverse events of chronic pancreatitis, data on the frequency and factors associated with the use of PET are limited. Our aim was to define the use of and factors predictive for receiving PET in a well-characterized chronic pancreatitis cohort. METHODS This is a cross-sectional analysis of data from PROCEED, a multicenter U.S. cohort study of chronic pancreatitis. PET modalities primarily consisted of ERCP. A treatment course was defined as the number of sessions performed for a specific indication. A repeat course was defined as PET >1 year after completion of the last course. Multivariable logistic regression identified predictive factors for receiving PET, and proportional rates model assessed risk factors for repeat PET. RESULTS Of 681 subjects, 238 (34.9%) received PET. Factors associated with receiving PET included female sex (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.03-1.53), lower education (OR, 1.30; 95% CI, 1.04-1.62), income ≤$50,000 per year (OR, 1.35; 95% CI, 1.07-1.71), and prior acute pancreatitis (OR, 1.74; 95% CI, 1.31-2.32). Of 238 subjects, 103 (43.3%) underwent repeat PET at a median duration of 2 years, with 23.1% receiving 2 courses, 9.7% receiving 3 courses, and 10.4% receiving ≥4 courses. CONCLUSIONS Nearly half of patients with chronic pancreatitis who undergo PET received 1 or more repeat courses within 2 to 3 years. In addition to a prior history of acute pancreatitis, demographic and socioeconomic factors were associated with receiving PET.
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Affiliation(s)
- Samuel Han
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Darwin L Conwell
- Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Jeffrey J Easler
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Yunlong Yang
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas, USA
| | - Dana K Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - William E Fisher
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Evan L Fogel
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Chris Forsmark
- Division of Gastroenterology, University of Florida, Gainesville, Florida, USA
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Steven J Hughes
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Liang Li
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas, USA
| | - Stephen J Pandol
- Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Walter G Park
- Division of Gastroenterology & Hepatology, Stanford University, Stanford, California, USA
| | - Jose Serrano
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Santhi Swaroop Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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3
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Myles AN, Okiye P, Akhdar G, Robertson R, Hewlett D. Pancreatic pseudocyst, gastric outlet obstruction, superior mesenteric artery syndrome and renal vein entrapment syndrome in groove pancreatitis: a case report. Gastroenterol Rep (Oxf) 2024; 12:goae079. [PMID: 39086504 PMCID: PMC11290811 DOI: 10.1093/gastro/goae079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 07/21/2024] [Accepted: 07/23/2024] [Indexed: 08/02/2024] Open
Affiliation(s)
- Amanda N Myles
- Division of Internal Medicine, Department of Medicine, Piedmont Athens Regional Medical Center, Athens, GA, USA
| | - Porsha Okiye
- Divisin of General Internal Medicine, Department of Medicine, Medical College of Georgia at Augusta University, Augusta University Medical Center, GA, USA
| | - Ghida Akhdar
- Division of Internal Medicine, Department of Medicine, Piedmont Athens Regional Medical Center, Athens, GA, USA
| | - Raheem Robertson
- Division of Internal Medicine, Department of Medicine, Piedmont Athens Regional Medical Center, Athens, GA, USA
| | - Dylan Hewlett
- Division of Internal Medicine, Department of Medicine, Piedmont Athens Regional Medical Center, Athens, GA, USA
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Kundra A, Strand DS, Shami VM. Endoscopic Management of Pain due to Chronic Pancreatitis. Gastrointest Endosc Clin N Am 2024; 34:433-448. [PMID: 38796291 DOI: 10.1016/j.giec.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Pain secondary to chronic pancreatitis is a poorly understood and complex phenomenon. Current endoscopic treatments target pancreatic duct decompression secondary to strictures, stones, or inflammatory and neoplastic masses. When there is refractory pain and other treatments have been unsuccessful, one can consider an endoscopic ultrasound-guided celiac plexus block. Data on the latter are underwhelming.
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Affiliation(s)
- Arjun Kundra
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Daniel S Strand
- Department of Gastroenterology, University of Virginia, Charlottesville, VA, USA
| | - Vanessa M Shami
- Department of Medicine, University of Virginia, Charlottesville, VA, USA.
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Rana SS. Evaluating the role of endoscopic ultrasound in pancreatitis. Expert Rev Gastroenterol Hepatol 2022; 16:953-965. [PMID: 36263489 DOI: 10.1080/17474124.2022.2138856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Endoscopic ultrasound (EUS) provides high-resolution images of both pancreatic parenchyma and duct and therefore is an integral component of evaluating and treating patients with pancreatitis and its complications. The development of enhanced EUS imaging techniques and newer EUS-specific accessories has expanded the diagnostic and therapeutic role of EUS in patients with acute and chronic pancreatitis (CP). AREAS COVERED This review discusses the current diagnostic and therapeutic role of EUS in acute pancreatitis (AP), CP, and autoimmune pancreatitis (AIP). EXPERT OPINION EUS plays a vital role in patients with AP by confirming the presence of common bile duct (CBD) stones in patients with acute biliary pancreatitis and intermediate probability of CBD stones. It plays an important role in the etiological evaluation of patients with idiopathic acute and recurrent pancreatitis. EUS is also an essential modality for diagnosing and managing pancreatico-biliary as well as gastroduodenal complications associated with CP. EUS-guided FNB using newer generation core biopsy needles has made possible accurate diagnosis of AIP by providing tissue samples with preserved architecture.
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Affiliation(s)
- Surinder Singh Rana
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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6
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Nakano R, Shiomi H, Ota S, Iijima H. Endoscopic ultrasound-guided celiac plexus neurolysis for managing abdominal pain related with advanced cancer. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2022. [DOI: 10.18528/ijgii220026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Ryota Nakano
- Division of Gastroenterology and Hepato-Biliary-Pancreatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Japan
| | - Hideyuki Shiomi
- Division of Gastroenterology and Hepato-Biliary-Pancreatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Japan
| | - Shogo Ota
- Division of Gastroenterology and Hepato-Biliary-Pancreatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Japan
| | - Hiroko Iijima
- Division of Gastroenterology and Hepato-Biliary-Pancreatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Japan
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Perito ER, Pohl JF, Bakker C, Armfield MA, Barth B, Cuneo A, Mascarenhas M, Mehta M, Schwarzenberg SJ. Outpatient Pain Management in Children With Chronic Pancreatitis: A Scoping Systematic Review. Pancreas 2022; 51:135-147. [PMID: 35404888 PMCID: PMC9009154 DOI: 10.1097/mpa.0000000000001973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Although pain management is central to pediatric chronic pancreatitis (CP) care, no evidence-based guidelines exist. In this scoping systematic review, we sought promising strategies for CP pain treatment in children. METHODS We systematically reviewed literature on pain management in children and adults with CP, and 2 conditions with similar pain courses: juvenile idiopathic arthritis and sickle cell disease. RESULTS Of 8997 studies identified, 287 met inclusion criteria. There are no published studies of analgesic medications, antioxidants, dietary modification, integrative medicine, or regional nerve blocks in children with CP. In adults with CP, studies of nonopioid analgesics, pancreatic enzymes, and dietary interventions have mixed results. Retrospective studies suggest that endoscopic retrograde cholangiopancreatography and surgical procedures, most durably total pancreatectomy with islet autotransplant, improve pain for children with CP. Follow-up was short relative to a child's life. Large studies in adults also suggest benefit from endoscopic therapy and surgery, but lack conclusive evidence about optimal procedure or timing. Studies on other painful pediatric chronic illnesses revealed little generalizable to children with CP. CONCLUSIONS No therapy had sufficient high-quality studies to warrant untempered, evidence-based support for use in children with CP. Multicenter studies are needed to identify pain management "best practices."
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Affiliation(s)
- Emily R Perito
- From the Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - John F Pohl
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | | | - Matthew A Armfield
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Bradley Barth
- Department of Pediatrics, University of Texas Southwestern and Children's Medical Center Dallas, Dallas, TX
| | - Addison Cuneo
- From the Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Maria Mascarenhas
- Department of Pediatrics, Children's Hospital of Philadelphia/University of Pennsylvania, Philadelphia, PA
| | - Megha Mehta
- Department of Pediatrics, University of Texas Southwestern and Children's Medical Center Dallas, Dallas, TX
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Cammarano CA, Sandhu NS, Villaluz JE. Localizing the Pain: Continuous Paravertebral Nerve Blockade in a Patient with Acute Pancreatitis. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e934189. [PMID: 34958656 PMCID: PMC8721992 DOI: 10.12659/ajcr.934189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patient: Female, 41-year-old
Final Diagnosis: Pancreatitis
Symptoms: Abdominal pain • nausea • vomiting
Medication: —
Clinical Procedure: —
Specialty: Anesthesiology
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9
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Mann R, Boregowda U, Vyas N, Gajendran M, Umapathy CP, Sayana H, Echavarria J, Patel S, Saligram S. Current advances in the management of chronic pancreatitis. Dis Mon 2021; 67:101225. [PMID: 34176572 DOI: 10.1016/j.disamonth.2021.101225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Chronic pancreatitis is characterized by irreversible destruction of pancreatic parenchyma and its ductal system resulting from longstanding inflammation, leading to fibrosis and scarring due to genetic, environmental, and other risk factors. The diagnosis of chronic pancreatitis is made based on a combination of clinical features and characteristic findings on computed tomography or magnetic resonance imaging. Abdominal pain is the most common symptom of chronic pancreatitis. The main aim of treatment is to relieve symptoms, prevent disease progression, and manage complications related to chronic pancreatitis. Patients who do not respond to medical treatment or not a candidate for surgical treatment are usually managed with endoscopic therapies. Endoscopic therapies help with symptoms such as abdominal pain and jaundice by decompression of pancreatic and biliary ducts. This review summarizes the risk factors, pathophysiology, diagnostic evaluation, endoscopic treatment of chronic pancreatitis, and complications. We have also reviewed recent advances in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided therapies for pancreatic duct obstruction due to stones, strictures, pancreatic divisum, and biliary strictures.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, 1303 E Herndon Ave, Fresno, CA 93720, USA
| | - Umesha Boregowda
- Department of Internal Medicine, Bassett Healthcare Network, Columbia Bassett Medical School, 1 Atwell Road, Cooperstown, NY 13326, USA
| | - Neil Vyas
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Mahesh Gajendran
- Department of Internal Medicine, Texas Tech University Health Science Center El Paso, 2000B Transmountain Road, El Paso, TX 79911, USA
| | - Chandra Prakash Umapathy
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Hari Sayana
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Juan Echavarria
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Sandeep Patel
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Shreyas Saligram
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.
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Molero X, Ayuso JR, Balsells J, Boadas J, Busquets J, Casteràs A, Concepción M, Cuatrecasas M, Fernàndez Esparrach G, Fort E, Garcia Borobia F, Ginès À, Ilzarbe L, Loras C, Masachs M, Merino X, Olsina JJ, Puig-Diví V, Salord S, Serrano T, Vaquero EC. Chronic pancreatitis for the clinician. Part 2: Treatment and follow-up. Interdisciplinary Position Paper of the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees. GASTROENTEROLOGIA Y HEPATOLOGIA 2021; 45:304-314. [PMID: 34171422 DOI: 10.1016/j.gastrohep.2021.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/11/2021] [Accepted: 05/25/2021] [Indexed: 02/07/2023]
Abstract
Chronic pancreatitis is associated with impaired quality of life, high incidence of comorbidities, serious complications and mortality. Healthcare costs are exorbitant. Some medical societies have developed guidelines for treatment based on scientific evidence, but the gathered level of evidence for any individual topic is usually low and, therefore, recommendations tend to be vague or weak. In the present position papers on chronic pancreatitis from the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees we aimed at providing defined position statements for the clinician based on updated review of published literature and on multidisciplinary expert agreement. The final goal is to propose the use of common terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 51 sections related to chronic pancreatitis were reviewed by 21 specialists from 6 different fields to generate 88 statements altogether. Statements were designed to harmonize concepts or delineate recommendations. Part 2 of these paper series discuss topics on treatment and follow-up. The therapeutic approach should include assessment of etiological factors, clinical manifestations and complications. The complexity of these patients advocates for detailed evaluation in multidisciplinary committees where conservative, endoscopic, interventional radiology or surgical options are weighed. Specialized multidisciplinary units of Pancreatology should be constituted. Indications for surgery are refractory pain, local complications, and suspicion of malignancy. Enzyme replacement therapy is indicated if evidence of exocrine insufficiency or after pancreatic surgery. Response should be evaluated by nutritional parameters and assessment of symptoms. A follow-up program should be planned for every patient with chronic pancreatitis.
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Affiliation(s)
- Xavier Molero
- Servei d'Aparell Digestiu, Hospital Universitari Vall d'Hebron, Barcelona, España; Exocrine Pancreas Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España; Campus de la UAB, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, España; CIBERehd, Instituto de Salud Carlos III, Madrid, España.
| | - Juan Ramon Ayuso
- Servei de Radiologia, Centre de Diagnòstic per la Imatge Clínic, Hospital Clínic, Barcelona, España; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España
| | - Joaquim Balsells
- Campus de la UAB, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, España; Servei de Cirurgia Hepato-Bilio-Pancreàtica, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Jaume Boadas
- Servei de Digestologia, Hospital de Terrassa, Consorci Sanitari de Terrassa, Terrassa, Barcelona, España
| | - Juli Busquets
- Unitat de Cirurgia Hepatobiliar i Pancreàtica, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - Anna Casteràs
- Servei d'Endocrinologia, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Mar Concepción
- Campus de la UAB, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, España; Servei de Gastroenterologia, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Míriam Cuatrecasas
- CIBERehd, Instituto de Salud Carlos III, Madrid, España; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España; Servei d'Anatomia Patològica, Hospital Clínic, Barcelona, España
| | - Gloria Fernàndez Esparrach
- CIBERehd, Instituto de Salud Carlos III, Madrid, España; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España; Unitat d'Endoscòpia, Servei de Gastroenterologia, ICMDiM, Hospital Clínic, Universitat de Barcelona, Barcelona, España
| | - Esther Fort
- Servei de Gastroenterologia, Hospital Universitari Doctor Josep Trueta, Girona, España; Universitat de Girona (UdG), Girona, España
| | - Francisco Garcia Borobia
- Unitat de Cirurgia Hepatobiliopancreàtica, Servei de Cirurgia General i de l'Aparell Digestiu, Hospital Universitari Parc Taulí, Sabadell, Barcelona, España
| | - Àngels Ginès
- CIBERehd, Instituto de Salud Carlos III, Madrid, España; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España; Servei de Gastroenterologia, Hospital Universitari Doctor Josep Trueta, Girona, España
| | - Lucas Ilzarbe
- Servei de Digestiu, Hospital del Mar Parc Salut Mar, Barcelona, España
| | - Carme Loras
- CIBERehd, Instituto de Salud Carlos III, Madrid, España; Servei de Gastroenterologia, Unitat d'Endoscòpia, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España
| | - Miquel Masachs
- Servei d'Endoscòpia Digestiva, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Xavier Merino
- Unitat d'Imatge Abdominal, Servei de Radiologia, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Jorge J Olsina
- Servei de Cirurgia Gerenal i Aparell Digestiu, Hospital Universitari Arnau de Vilanova, Lleida, España
| | - Valentí Puig-Diví
- Campus de la UAB, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, España; Servei de Digestiu, Corporació Sanitària Universitaria Parc Taulí, Sabadell, Barcelona, España
| | - Sílvia Salord
- Servei de Gastroenterologia, Hospital Universitari de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, España
| | - Teresa Serrano
- CIBERehd, Instituto de Salud Carlos III, Madrid, España; Servei d'Anatomia Patològica, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - Eva Cristina Vaquero
- CIBERehd, Instituto de Salud Carlos III, Madrid, España; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España; Servei de Gastroenterologia, ICMDiM, Hospital Clínic, Barcelona, España; Gastrointestinal and Pancreatic Oncology Research Group, Hospital Clínic, Barcelona, España
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11
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Koulouris AI, Alexandre L, Hart AR, Clark A. Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) technique and analgesic efficacy in patients with pancreatic cancer: A systematic review and meta-analysis. Pancreatology 2021; 21:434-442. [PMID: 33461931 DOI: 10.1016/j.pan.2020.12.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/19/2020] [Accepted: 12/21/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic Ultrasound-guided Celiac Plexus Neurolysis (EUS-CPN) for the treatment of abdominal pain in pancreatic cancer can be administered in three different ways, depending on the site of needle insertion: central injection (CI), bilateral injection (BI) and celiac ganglia neurolysis (CGN). This meta-analysis aimed to (1) estimate the overall efficacy of the EUS-CPN; (2) compare the efficacy of each of the three techniques; and (3) investigate demographic and disease characteristics as potential predictors of treatment response. METHODS We searched MEDLINE and EMBASE for studies that reported the proportion of treatment responders to EUS-CPN overall, and according to the technique used. We performed a random effects meta-analysis of proportions, and meta-regression was used to estimate the association between technique and clinical characteristics on treatment response. The safety profile was reviewed through narrative synthesis. RESULTS Overall response rate to EUS-CPN was 68% (95% CI 61%-74%) at week two and 53% (95% CI 45%-62%) at week four. There was no evidence of a significant difference in the response rates between the three techniques. Demographics and disease characteristics were not associated with treatment response. Serious complications have been reported for BI and CGN but not for CI. Moderate to high risk of bias was observed. DISCUSSION EUS-CPN is a useful adjunct to opioids in the management of pain. There is no evidence of a difference in the efficacy among the three techniques, however, CI is the only one for which serious complications have not been reported. Future research should focus on the appropriate timing of EUS-CPN (early versus on demand) and randomised comparison to establish the comparative efficacy of each technique.
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Affiliation(s)
- A I Koulouris
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk NR4 7TJ, United Kingdom; Norfolk and Norwich University Hospital. Norwich, Colney Lane, NR4 7UY, United Kingdom.
| | - Leo Alexandre
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk NR4 7TJ, United Kingdom; Norfolk and Norwich University Hospital. Norwich, Colney Lane, NR4 7UY, United Kingdom
| | - A R Hart
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk NR4 7TJ, United Kingdom; Norfolk and Norwich University Hospital. Norwich, Colney Lane, NR4 7UY, United Kingdom
| | - A Clark
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk NR4 7TJ, United Kingdom
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12
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Moutinho-Ribeiro P, Costa-Moreira P, Caldeira A, Leite S, Marques S, Moreira T, Nunes N, Bispo M. Endoscopic Ultrasound-Guided Celiac Plexus Interventions. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2021; 28:32-38. [PMID: 33564702 DOI: 10.1159/000508293] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 04/23/2020] [Indexed: 12/26/2022]
Abstract
Abdominal pain related to pancreatic disease is often extremely disabling. Endoscopic ultrasound (EUS)-guided celiac plexus block (CPB) is used to control pain associated with chronic pancreatitis. EUS-guided celiac plexus neurolysis (CPN) is typically used to reduce pain associated with pancreatic cancer and can be considered early at the time of diagnosis of inoperable disease. EUS-guided celiac plexus interventions have been shown to be significantly effective in pancreatic pain relief, which is achieved in approximately 70-80% of patients with pancreatic cancer and in 50-60% of those with chronic pancreatitis. Serious complications from CPB and CPN are rare. Most frequent adverse events are diarrhoea, orthostatic hypotension, and a transient increase in abdominal pain. In this article, the Portuguese Group for Ultrasound in Gastroenterology (GRUPUGE) presents an updated perspective of the potential role of EUS-guided celiac plexus interventions, addressing the selection criteria and technical issues of different techniques and analysing recent data on their safety and efficacy.
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Affiliation(s)
- Pedro Moutinho-Ribeiro
- Gastroenterology Department, Centro Hospitalar e Universitário São João, Porto, Portugal.,Faculty of Medicine, University of Porto, Porto, Portugal
| | - Pedro Costa-Moreira
- Gastroenterology Department, Centro Hospitalar e Universitário São João, Porto, Portugal.,Faculty of Medicine, University of Porto, Porto, Portugal
| | - Ana Caldeira
- Department of Gastroenterology, Hospital Amato Lusitano, Castelo Branco, Portugal
| | - Sílvia Leite
- Department of Gastroenterology, Hospital da Senhora da Oliveira, Guimarães, Portugal
| | - Susana Marques
- Department of Gastroenterology and Digestive Endoscopy, Champalimaud Foundation, Lisbon, Portugal
| | - Teresa Moreira
- Department of Gastroenterology, Centro Hospitalar Universitário do Porto, Hospital de Santo António, Porto, Portugal
| | - Nuno Nunes
- Department of Gastroenterology, Hospital do Divino Espírito Santo de Ponta Delgada, Ponta Delgada, Portugal
| | - Miguel Bispo
- Department of Gastroenterology and Digestive Endoscopy, Champalimaud Foundation, Lisbon, Portugal
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Voiosu T, Boškoski I, Tringali A, Quero G, Voiosu A, Costamagna G. Chronic pancreatitis: an overview of diagnosis and management. Expert Rev Gastroenterol Hepatol 2020; 14:515-526. [PMID: 32511055 DOI: 10.1080/17474124.2020.1774365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Chronic pancreatitis entails a heavy burden on the healthcare system because of its often protracted evolution, requiring complex diagnostic and therapeutic procedures. AREAS COVERED This review focuses on novel imaging and endoscopic diagnostic and therapeutic interventions that have changed the management of patients with chronic pancreatitis. We have conducted an extensive search of original papers and guidelines, in order to provide a comprehensive and up to date review of available evidence in these areas of interest. EXPERT OPINION The traditional challenges in managing chronic pancreatitis patients stemmed from the limitations of diagnostic modalities, which could not correctly identify patients in an early stage of the disease, as well as from the scarcity of therapeutic options available. Advances in imaging of CT-scan, MRI, and EUS have opened the way for early diagnosis and staging. This has allowed more aggressive and tailored therapeutic modalities, particularly in endoscopic therapy and minimally invasive surgical interventions. Although high-quality data from large RCTs is still scarce, evidence-based algorithms for diagnosis and therapy are now changing the way we address this chronic disease. In the near future, we can expect a tailored approach based on patient and disease-related predictive factors, relying on a vast armamentarium of endoscopic and surgical solutions.
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Affiliation(s)
- Theodor Voiosu
- Internal Medicine, Carol Davila School of Medicine , Bucharest, Romania.,Gastroenterology Department, Colentina Clinical Hospital , Bucharest, Romania
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS , Rome, Italy.,Centre for Endoscopic Research, Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore Di Roma , Rome, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS , Rome, Italy.,Centre for Endoscopic Research, Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore Di Roma , Rome, Italy
| | - Giuseppe Quero
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS , Rome, Italy
| | - Andrei Voiosu
- Gastroenterology Department, Colentina Clinical Hospital , Bucharest, Romania
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS , Rome, Italy.,Centre for Endoscopic Research, Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore Di Roma , Rome, Italy
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A Comprehensive Review of the Celiac Plexus Block for the Management of Chronic Abdominal Pain. Curr Pain Headache Rep 2020; 24:42. [PMID: 32529305 DOI: 10.1007/s11916-020-00878-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Chronic abdominal pain (CAP) is a significant health problem that can dramatically affect quality of life and survival. Pancreatic cancer is recognized as one of the most painful malignancies with 70-80% suffering from substantial pain, often unresponsive to typical medical management. Celiac plexus neurolysis and celiac plexus block (CPB) can be performed to mitigate pain through direct destruction or blockade of visceral afferent nerves. The objective of this manuscript is to provide a comprehensive review of the CPB as it pertains to CAP with a focus on the associated anatomy, indications, techniques, neurolysis/blocking agents, and complications observed in patients who undergo CPB for the treatment of CAP. RECENT FINDINGS The CAP is difficult to manage due to lack of precision in diagnosis and limited evidence from available treatments. CAP can arise from both benign and malignant causes. Treatment options include pharmacologic, interventional, and biopsychosocial treatments. Opioid therapy is typically utilized for the treatment of CAP; however, opioid therapy is associated with multiple complications. CPB has successfully been used to treat a variety of conditions resulting in CAP. The majority of the literature specifically related to CPB is surrounding chronic pain associated with pancreatic cancer. The literature shows emerging evidence in managing CAP with CPB, specifically in pancreatic cancer. This review provides multiple aspects of CAP and CPB, including anatomy, medical necessity, indications, technical considerations, available evidence, and finally complications related to the management.
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Abstract
Pain is often associated with chronic pancreatitis and pancreatic cancer. Often times opioids are used to treat pain; however, the use of opioids is frequently difficult. Endoscopic ultrasound-guided celiac plexus block and celiac plexus nuerolysis are safe and effective modalities used to alleviate pain. Celiac plexus block is a transient interruption of the plexus by local anesthetic, while celiac plexus neurolysis is prolonged interruption of the transmission of pain from the celiac plexus using chemical ablation. Celiac plexus block is generally performed in the unilateral position, while celiac plexus neurolysis is performed in the unilateral or bilateral position.
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Affiliation(s)
- Amit H Sachdev
- Division of Digestive and Liver Diseases, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY 10032, USA.
| | - Frank G Gress
- Division of Digestive and Liver Diseases, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY 10032, USA
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Abstract
The inputs from sympathetic ganglia have been known to be involved in the pathophysiology of various painful conditions such as complex regional pain syndrome, cancer pain of different origin, and coccygodynia. Sympathetic ganglia blocks are used to relieve patients who suffer from these conditions for over a century. Many numbers of local anesthetics such as bupivacaine or neurolytic agents such as alcohol can be chosen for a successful block. The agent is selected according to its duration of effect and the purpose of the injection. Most commonly used sympathetic blocks are stellate ganglion block, lumbar sympathetic block, celiac plexus block, superior hypogastric block, and ganglion Impar block. In this review, indications, methods, effectiveness, and complications of these blocks are discussed based on the data from the current literature.
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Affiliation(s)
- Osman Hakan Gunduz
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Ozge Kenis-Coskun
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Marmara University, Istanbul, Turkey
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Faulx A, Lee PJ. Endoscopic ultrasound celiac plexus block and neurolysis. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lu F, Dong J, Tang Y, Huang H, Liu H, Song L, Zhang K. Bilateral vs. unilateral endoscopic ultrasound-guided celiac plexus neurolysis for abdominal pain management in patients with pancreatic malignancy: a systematic review and meta-analysis. Support Care Cancer 2017; 26:353-359. [PMID: 28956176 DOI: 10.1007/s00520-017-3888-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 09/11/2017] [Indexed: 02/05/2023]
Abstract
CONTEXT Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) by bilateral or unilateral approach is widely used in palliative abdominal pain management in pancreatic cancer patients, but the analgesic effect and relative risks of the two different puncture routes remain controversial. OBJECTIVES The aim of this systematic review was to evaluate the analgesic efficacy and safety of bilateral EUS-CPN compared with unilateral EUS-CPN. METHODS An electronic database search was performed for randomized controlled trials comparing bilateral and unilateral approaches of EUS-CPN using the Pubmed, Cochrane Library, Web of Science, Google Scholar, and CNKI databases. Meta-analysis was performed using RevMan 5.3 after screening and methodological evaluation of the selected studies. Outcomes included pain relief, treatment response, analgesic reduction, complications, and quality of life (QOL). RESULTS Six eligible studies involving 437 patients were included. No significant difference was found in short-term pain relief [SMD = 0.31, 95% CI (- 0.20, 0.81), P = 0.23] and response to treatment [RR = 0.99, 95% CI (0.77, 1.41), P = 0.97] between the bilateral and unilateral neurolysis groups. However, only the bilateral approach was associated with a statistically significant reduction in the postoperative use of analgesics [RR = 0.66, 95% CI (0.47, 0.94), P = 0.02] compared to the unilateral approach. A descriptive analysis was performed for complications and QOL. CONCLUSION The short-term analgesic effect and general risk of bilateral EUS-CPN are comparable with those of unilateral EUS-CPN, but our evidence supports the conclusion that the bilateral approach significantly reduces postoperative analgesic use.
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Affiliation(s)
- Fan Lu
- Department of Anesthesiology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, No. 55 Renmin Road South, Chengdu, 610000, Sichuan Province, People's Republic of China
| | - Jifu Dong
- Department of Anesthesiology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, No. 55 Renmin Road South, Chengdu, 610000, Sichuan Province, People's Republic of China
| | - Yuming Tang
- Department of Anesthesiology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, No. 55 Renmin Road South, Chengdu, 610000, Sichuan Province, People's Republic of China
| | - He Huang
- Department of Anesthesiology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, No. 55 Renmin Road South, Chengdu, 610000, Sichuan Province, People's Republic of China
| | - Hui Liu
- Department of Pain Management, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Li Song
- Department of Pain Management, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Kexian Zhang
- Department of Anesthesiology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, No. 55 Renmin Road South, Chengdu, 610000, Sichuan Province, People's Republic of China.
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Adler JM, Gardner TB. Endoscopic Therapies for Chronic Pancreatitis. Dig Dis Sci 2017; 62:1729-1737. [PMID: 28258377 DOI: 10.1007/s10620-017-4502-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 02/11/2017] [Indexed: 12/14/2022]
Abstract
Chronic pancreatitis is a fibroinflammatory disease of the pancreas leading to varying degrees of endocrine and exocrine dysfunction. Treatment options are generally designed to control the pain of chronic pancreatitis, and endoscopic therapy is one of the main treatment modalities. Herein, we describe the endoscopic management of pancreatic duct calculi and strictures, entrapment of the intrapancreatic bile duct, celiac plexus interventions, and drainage of pancreatic pseudocysts.
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Affiliation(s)
- Jeffrey M Adler
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03756, USA
| | - Timothy B Gardner
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03756, USA.
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Coronel E, DaVee T, Lee JH. Advances in endotherapy in chronic pancreatitis. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii170001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Emmanuel Coronel
- Department of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA
| | - Tomas DaVee
- Department of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey H. Lee
- Department of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, Houston, TX, USA
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Membrillo-Romero A, Rascón-Martínez DM. [Celiac block in paediatric patients using endoscopic ultrasound for management of severe pain due to chronic pancreatitis. Review of the technique in 2 cases]. CIR CIR 2016; 85:264-268. [PMID: 27131980 DOI: 10.1016/j.circir.2016.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 11/10/2015] [Accepted: 02/26/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pancreatic diseases such as cancer, idiopathic recurrent pancreatitis, and chronic pancreatitis, can cause pain that is difficult to control. Pain is one of the most debilitating symptoms and demands increasing doses of analgesics and narcotics, as well as the number of hospital admissions, with a direct implication in the costs of medical treatments. OBJECTIVE To describe the experience with 2 paediatric patients who were subjected to an ultrasound-guided endoscopic celiac ganglion block for difficult pain management, secondary to chronic pancreatitis disease. CLINICAL CASES The first case concerns a 9-year-old male with a diagnosis of chronic pancreatitis, and the second case is a 12-year-old female who developed episodes of intermittent acute pancreatitis. Both cases suffered from chronic abdominal pain, which was difficult to control with stronger painkillers, such as opioids. The pain decreased after patients were subjected to an ultrasound-guided endoscopic celiac ganglion block. CONCLUSIONS This technique showed that both patients obtained satisfactory pain relief, with significant improvements in general symptomatology and the stopping of almost all analgesic medication. The authors suggest that celiac ganglion block must be considered, and implemented early before the usual complications, such as a consumption syndrome that is frequent in paediatric patients with chronic pancreatitis.
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Affiliation(s)
- Alejandro Membrillo-Romero
- Servicio de Endoscopias y Ultrasonido Endoscópico, Hospital de Especialidades Dr. Manuel Bernardo Sepúlveda, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México.
| | - Dulce María Rascón-Martínez
- Servicio de Anestesiología y Medicina del Dolor, Hospital de Especialidades Dr. Manuel Bernardo Sepúlveda, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
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Fujii-Lau LL, Bamlet WR, Eldrige JS, Chari ST, Gleeson FC, Abu Dayyeh BK, Clain JE, Pearson RK, Petersen BT, Rajan E, Topazian MD, Vege SS, Wang KK, Wiersema MJ, Levy MJ. Impact of celiac neurolysis on survival in patients with pancreatic cancer. Gastrointest Endosc 2015; 82:46-56.e2. [PMID: 25800661 PMCID: PMC6017988 DOI: 10.1016/j.gie.2014.12.036] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 12/01/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pancreatic cancer (PC) often produces pain that is difficult to control. Celiac neurolysis (CN) is performed with the goal of improving pain control and quality of life while reducing opioid-related side effects. OBJECTIVE We aimed to evaluate whether CN provides a survival advantage for PC patients. DESIGN Retrospective case-control study. SETTING Single tertiary-care referral center. PATIENTS Review of a prospectively maintained database identified patients with unresectable PC who underwent CN over a 12-year period. Each patient was matched to 2 control patients with unresectable PC. INTERVENTION CN, which included both celiac plexus neurolysis (CPN) and celiac ganglia neurolysis (CGN). MAIN OUTCOME MEASUREMENTS Median survival in Kaplan-Meier curves and hazard ratios. RESULTS A total of 417 patients underwent CN and were compared with 840 controls with PC. Baseline characteristics were similar except the CN group had greater weight loss and pain requiring opioids. A mean of 16.6 ± 5.8 mL of alcohol was administered. For patients who underwent CN, the median survival from the time of presentation was shorter compared with controls (193 vs 246 days; hazard ratio 1.32; 95% confidence interval, 1.13-1.54). There was no difference in survival with unilateral or bilateral injection. However, EUS-guided CN was associated with longer survival compared with non-EUS approaches, and those who received CPN had longer survival compared with CGN. LIMITATIONS Single center, retrospective. CONCLUSION Our study suggests that CN is an independent predictor of shortened survival in PC patients. A prospective study is needed to verify the findings and determine whether shortened survival results from CN or from other features such as performance status and tumor-related characteristics. It is also imperative to verify our finding that EUS-guided CN provides a survival advantage over other approaches and whether CPN prolongs survival compared with CGN.
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Sey MSL, Schmaltz L, Al-Haddad MA, DeWitt JM, Calley CSJ, Juan M, Lasisi F, Sherman S, McHenry L, Imperiale TF, LeBlanc JK. Effectiveness and safety of serial endoscopic ultrasound-guided celiac plexus block for chronic pancreatitis. Endosc Int Open 2015; 3:E56-9. [PMID: 26134773 PMCID: PMC4423296 DOI: 10.1055/s-0034-1377919] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 07/15/2014] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic ultrasound - guided celiac plexus block (EUS-CPB) is an established treatment for pain in patients with chronic pancreatitis (CP), but the effectiveness and safety of repeated procedures are unknown. Our objective is to report our experience of repeated EUS-CPB procedures within a single patient. PATIENTS AND METHODS A prospectively maintained EUS database was retrospectively analyzed to identify patients who had undergone more than one EUS-CPB procedure over a 17-year period. The main outcome measures included number of EUS-CPB procedures for each patient, self-reported pain relief, duration of pain relief, and procedure-related adverse events. RESULTS A total of 248 patients underwent more than one EUS-CPB procedure and were included in our study. Patients with known or suspected CP (N = 248) underwent a mean (SD) of 3.1 (1.6) EUS-CPB procedures. In 76 % of the patients with CP, the median (range) duration of the response to the first EUS-CPB procedure was 10 (1 - 54) weeks. Lack of pain relief after the initial EUS-CPB was associated with failure of the next EUS-CPB (OR 0.17, 95 %CI 0.06 - 0.54). Older age at first EUS-CPB and pain relief after the first EUS-CPB were significantly associated with pain relief after subsequent blocks (P = 0.026 and P = 0.002, respectively). Adverse events included peri-procedural hypoxia (n = 2) and hypotension (n = 1) and post-procedural orthostasis (n = 2) and diarrhea (n = 4). No major adverse events occurred. CONCLUSIONS Repeated EUS-CPB procedures in a single patient appear to be safe. Response to the first EUS-CPB is associated with response to subsequent blocks.
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Affiliation(s)
- Michael S. L. Sey
- Department of Gastroenterology and Hepatology, Western University, London, Ontario, Canada,Corresponding author Michael Sai Lai Sey, MD Western University London Health Sciences Centre–Victoria Hospital800 Commissioners Road EastLondon, Ontario, Canada N6A 5W91-519-667-6820
| | - Leslie Schmaltz
- Department of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Mohammad A. Al-Haddad
- Department of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - John M. DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Cynthia S. J. Calley
- Department of Biostatistics, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Michelle Juan
- Department of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Femi Lasisi
- Department of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Stuart Sherman
- Department of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Lee McHenry
- Department of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Thomas F. Imperiale
- Department of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA,Regenstrief Institute, Indianapolis, Indiana, USA,Center of Innovation, Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Julia K. LeBlanc
- Department of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
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Fusaroli P, Caletti G. Is there a role for celiac plexus block for chronic pancreatitis? Endosc Int Open 2015; 3:E60-2. [PMID: 26134774 PMCID: PMC4423247 DOI: 10.1055/s-0034-1391392] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 12/11/2014] [Indexed: 12/30/2022] Open
Affiliation(s)
- Pietro Fusaroli
- Department of Gastroenterology, University of Bologna, Imola, Italy,Corresponding author Pietro Fusaroli, MD Department of GastroenterologyUniversity of BolognaVia Montericco 4ImolaItaly+39-05-426-62409
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Abstract
Endoscopic therapy in chronic pancreatitis (CP) aims to provide pain relief and to treat local complications, by using the decompression of the pancreatic duct and the drainage of pseudocysts and biliary strictures, respectively. This is the reason for using it as first-line therapy for painful uncomplicated CP. The clinical response has to be evaluated at 6-8 weeks, when surgery may be chosen. This article reviews the main possibilities of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) therapies. Endotherapy for pancreatic ductal stones uses ultrasound wave lithotripsy and sometimes additional stone extractions. The treatment of pancreatic duct strictures consists of a single large stenting for 1 year. If the stricture persists, simultaneous multiple stents are applied. In case of unsuccessful ERCP, the EUS-guided drainage of the main pancreatic duct (MPD) or a rendezvous technique can solve the ductal strictures. EUS-guided celiac plexus block has limited efficiency in CP. The drainage of symptomatic or complicated pancreatic pseudocysts can be performed transpapillarily or transgastrically/transduodenally, preferably by EUS guidance. When the biliary stricture is symptomatic or progressive, multiple plastic stents are indicated. In conclusion, as in many fields of symptomatic treatment, endoscopy remains the first choice, either by using ERCP or EUS-guided procedures, after consideration of a multidisciplinary team with endoscopists, surgeons, and radiologists. However, what is crucial is establishing the right timing for surgery.
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Affiliation(s)
- Andrada Seicean
- Regional Institute of Gastroenterology and Hepatology Cluj-Napoca, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Simona Vultur
- Regional Institute of Gastroenterology and Hepatology Cluj-Napoca, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
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Dhir V, Paramasivam RK, Lazaro JC, Maydeo A. The role of therapeutic endoscopic ultrasound now and for the future. Expert Rev Gastroenterol Hepatol 2014; 8:775-91. [PMID: 24830540 DOI: 10.1586/17474124.2014.917953] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Therapeutic endoscopic ultrasound (EUS) became possible after the advent of the linear echoendoscope and the EUS guided fine needle aspiration. Over the past two decades, the indications for therapeutic EUS have expanded and evidence regarding its utility has been steadily accumulating. Randomized studies have shown EUS to be effective for cancer pain relief (celiac plexus neurolysis), pancreatic fluid collection drainage, and biliary drainage. Prospective studies have shown EUS-guided biliary drainage to be safe and effective in patients with failed ERCP. There is evidence to suggest that EUS is effective for pancreatic duct drainage, gallbladder drainage, and drainage of pelvic collections. EUS may also be useful for targeted cancer treatment via brachytherapy, radiofrequency ablation, or injection therapy. Therapeutic EUS is likely to play an increasingly important role in endoscopic therapy of gastrointestinal diseases in the near future.
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Affiliation(s)
- Vinay Dhir
- Department of Endoscopy and Endosonography, Baldota Institute of Digestive Sciences, Global Hospitals, Parel, Mumbai 400012, India
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Fabbri C, Luigiano C, Lisotti A, Cennamo V, Virgilio C, Caletti G, Fusaroli P. Endoscopic ultrasound-guided treatments: are we getting evidence based--a systematic review. World J Gastroenterol 2014; 20:8424-48. [PMID: 25024600 PMCID: PMC4093695 DOI: 10.3748/wjg.v20.i26.8424] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 01/30/2014] [Accepted: 03/12/2014] [Indexed: 02/07/2023] Open
Abstract
The continued need to develop less invasive alternatives to surgical and radiologic interventions has driven the development of endoscopic ultrasound (EUS)-guided treatments. These include EUS-guided drainage of pancreatic fluid collections, EUS-guided necrosectomy, EUS-guided cholangiography and biliary drainage, EUS-guided pancreatography and pancreatic duct drainage, EUS-guided gallbladder drainage, EUS-guided drainage of abdominal and pelvic fluid collections, EUS-guided celiac plexus block and celiac plexus neurolysis, EUS-guided pancreatic cyst ablation, EUS-guided vascular interventions, EUS-guided delivery of antitumoral agents and EUS-guided fiducial placement and brachytherapy. However these procedures are technically challenging and require expertise in both EUS and interventional endoscopy, such as endoscopic retrograde cholangiopancreatography and gastrointestinal stenting. We undertook a systematic review to record the entire body of literature accumulated over the past 2 decades on EUS-guided interventions with the objective of performing a critical appraisal of published articles, based on the classification of studies according to levels of evidence, in order to assess the scientific progress made in this field.
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D'Haese JG, Ceyhan GO, Demir IE, Tieftrunk E, Friess H. Treatment options in painful chronic pancreatitis: a systematic review. HPB (Oxford) 2014; 16:512-21. [PMID: 24033614 PMCID: PMC4048072 DOI: 10.1111/hpb.12173] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 07/05/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Longlasting and unbearable pain is the most common and striking symptom of chronic pancreatitis. Accordingly, pain relief and improvement in patients' quality of life are the primary goals in the treatment of this disease. This systematic review aims to summarize the available data on treatment options. METHODS A systematic search of MEDLINE/PubMed and the Cochrane Library was performed according to the PRISMA statement for reporting systematic reviews and meta-analysis. The search was limited to randomized controlled trials and meta-analyses. Reference lists were then hand-searched for additional relevant titles. The results obtained were examined individually by two independent investigators for further selection and data extraction. RESULTS A total of 416 abstracts were reviewed, of which 367 were excluded because they were obviously irrelevant or represented overlapping studies. Consequently, 49 full-text articles were systematically reviewed. CONCLUSIONS First-line medical options include the provision of pain medication, adjunctive agents and pancreatic enzymes, and abstinence from alcohol and tobacco. If medical treatment fails, endoscopic treatment offers pain relief in the majority of patients in the short term. However, current data suggest that surgical treatment seems to be superior to endoscopic intervention because it is significantly more effective and, especially, lasts longer.
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Affiliation(s)
- Jan G D'Haese
- Department of Surgery, Rechts der Isar Clinic, Technical University of Munich, Munich, Germany
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Bhatnagar S, Joshi S, Rana SPS, Mishra S, Garg R, Ahmed SM. Bedside ultrasound-guided celiac plexus neurolysis in upper abdominal cancer patients: a randomized, prospective study for comparison of percutaneous bilateral paramedian vs. unilateral paramedian needle-insertion technique. Pain Pract 2014; 14:E63-8. [PMID: 23944980 DOI: 10.1111/papr.12107] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 06/24/2013] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Percutaneous anterior abdominal ultrasound guidance for performing celiac plexus neurolysis is a relatively new but more economical, less time-consuming, more comfortable bedside technique for interventional pain management. Paucity of studies evaluating the efficacy of single-site vs. double-site injections at celiac trunk for ultrasound-guided celiac plexus neurolysis (USCPN) prompted us to conduct a prospective, randomized, single-blind clinical trial to compare USCPN using bilateral paramedian (double needle) technique with unilateral paramedian (single needle) technique. METHODS Sixty patients aged 18 years or older with unresectable upper abdominal cancers were randomized into two groups to receive USCPN. A 20-mL mixture of 50% ethanol with 0.25% bupivacaine was injected either unilaterally (20 mL×1 site) or bilaterally (10 mL×2 sites) depending on the randomization group. Subjects were assessed for the pain relief using Numerical rating scale (NRS) to assess their pain relief. RESULTS Baseline parameters being comparable (P > 0.05), the site of drug injections (single or double needle) had no bearing on the onset of pain relief and patient satisfaction scores (P > 0.05). Pain relief during follow-up visits was comparable between the two groups (P > 0.05). The discomfort score correlated well with the pain relief scoring without any significant difference between the two groups except in the last visit (at 3 month). Incidences of the complications were comparable in the two groups (P > 0.05). CONCLUSION Ultrasound-guided celiac plexus neurolysis using unilateral paramedian (single needle) needle-insertion technique is comparable with bilateral paramedian (double needle) needle-insertion technique with regard to pain relief and side effects.
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Affiliation(s)
- Sushma Bhatnagar
- Department of Anaesthesiology, Pain and Palliative Care, IRCH, AIIMS, New Delhi, India
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Rana MV, Candido KD, Raja O, Knezevic NN. Celiac Plexus Block in the Management of Chronic Abdominal Pain. Curr Pain Headache Rep 2014; 18:394. [DOI: 10.1007/s11916-013-0394-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Recomendaciones del Club Español Pancreático para el diagnóstico y tratamiento de la pancreatitis crónica: parte 2 (tratamiento). GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 36:422-36. [DOI: 10.1016/j.gastrohep.2012.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 12/20/2012] [Accepted: 12/27/2012] [Indexed: 02/08/2023]
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de-Madaria E, Abad-González A, Aparicio JR, Aparisi L, Boadas J, Boix E, de-Las-Heras G, Domínguez-Muñoz E, Farré A, Fernández-Cruz L, Gómez L, Iglesias-García J, García-Malpartida K, Guarner L, Lariño-Noia J, Lluís F, López A, Molero X, Moreno-Pérez O, Navarro S, Palazón JM, Pérez-Mateo M, Sabater L, Sastre Y, Vaquero EC, Martínez J. The Spanish Pancreatic Club's recommendations for the diagnosis and treatment of chronic pancreatitis: part 2 (treatment). Pancreatology 2012; 13:18-28. [PMID: 23395565 DOI: 10.1016/j.pan.2012.11.310] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 11/11/2012] [Accepted: 11/20/2012] [Indexed: 02/07/2023]
Abstract
Chronic pancreatitis (CP) is a complex disease with a wide range of clinical manifestations. This range comprises from asymptomatic patients to patients with disabling symptoms or complications. The management of CP is frequently different between geographic areas and even medical centers. This is due to the paucity of high quality studies and clinical practice guidelines regarding its diagnosis and treatment. The aim of the Spanish Pancreatic Club was to give current evidence-based recommendations for the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. These experts were selected according to clinical and research experience in CP. A list of questions was made and two experts reviewed each question. A draft was later produced and discussed with the entire panel of experts in a face-to-face meeting. The level of evidence was based on the ratings given by the Oxford Centre for Evidence-Based Medicine. In the second part of the consensus, recommendations were given regarding the management of pain, pseudocysts, duodenal and biliary stenosis, pancreatic fistula and ascites, left portal hypertension, diabetes mellitus, exocrine pancreatic insufficiency, and nutritional support in CP.
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Affiliation(s)
- E de-Madaria
- Pancreatic Unit, University General Hospital of Alicante, Spain.
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The endoscopic management of pain in chronic pancreatitis. Gastroenterol Res Pract 2012; 2012:860879. [PMID: 22550479 PMCID: PMC3328929 DOI: 10.1155/2012/860879] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 01/26/2012] [Accepted: 02/10/2012] [Indexed: 12/16/2022] Open
Abstract
Pain resulting from chronic pancreatitis is often debilitating and difficult to manage. Many approaches have been used to treat these patients, including narcotic analgesia, antidepressants, pancreatic enzymes, octreotide, denervation procedures, such as celiac plexus block, and various palliative, decompression, or drainage procedures. Many of these procedures can be performed endoscopically, while others require a more invasive, surgical approach. The effectiveness of these therapies is not only highly variable but also often controversial. This review will discuss the endoscopic options for pain management in patients with chronic pancreatitis and their utility in treating this difficult disease.
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Wilcox CM. Tinkering with a tarnished technique: isn't it time to abandon celiac plexus blockade for the treatment of abdominal pain in chronic pancreatitis? Clin Gastroenterol Hepatol 2012; 10:106-8. [PMID: 22079511 DOI: 10.1016/j.cgh.2011.10.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 10/25/2011] [Accepted: 10/30/2011] [Indexed: 01/16/2023]
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Abstract
Chronic pancreatitis (CP) is a debilitating disease that can result in chronic abdominal pain, malnutrition, and other related complications. The main aims of treatment are to control symptoms, prevent disease progression, and correct any complications. A multidisciplinary approach involving medical, endoscopic, and surgical therapy is important. Endoscopic therapy plays a specific role in carefully selected patients as primary interventional therapy when medical measures fail or in patients who are not suitable for surgery. Endoscopic therapy is also used as a bridge to surgery or as a means to assess the potential response to pancreatic surgery. This review addresses the role of endoscopic therapy in relief of obstruction of the pancreatic duct (PD) and bile du ct, closure of PD leaks, and drainage of pseudocysts in CP. The role of endoscopic ultrasound-guided celiac plexus block for pain in chronic pancreatitis is also discussed.
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Affiliation(s)
- Damien Meng Yew Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.
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Abstract
Chronic pancreatitis (CP) remains an important healthcare problem that adversely affects quality of life. Endoscopic ultrasound (EUS) is a preferred test for the diagnosis of early CP. The Rosemont classification strictly defines and assigns weighting to the previously described ductal and parenchymal criteria. Recent histological correlation studies have improved our understanding of the accuracy of EUS criteria. Digital imaging analysis and complementary functional testing may complement endosonographic diagnosis. EUS-directed celiac plexus blockade and ductal access techniques have expanded the therapeutic armamentarium for pain management in CP.
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Affiliation(s)
- Tyler Stevens
- Department of Gastroenterology and Hepatology, Cleveland Clinic, 9500 Euclid Avenue, Desk A31, Cleveland, OH 44195, USA.
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Trevino JM, Varadarajulu S. Endoscopic ultrasonography-guided ablation therapy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2010; 18:304-10. [PMID: 21116656 DOI: 10.1007/s00534-010-0352-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Endoscopic ultrasonography (EUS) imaging has undergone extensive technological advancement since its development in the 1980s, including improvement of echoendoscopes with larger channels and accessories.These advancements enable not only tissue procurement for diagnosis but also therapeutic interventions that hitherto would have required surgery, with its attendant risks. A wide array of interventional procedures are performed under EUS guidance, including celiac plexus neurolysis, drainage of pancreatic and pelvic fluid collections, drainage of obstructive pancreatic-biliary ducts, ablation of cyst neoplasms in the pancreas, and implantation of fiducial markers and radioactive seeds into gastrointestinal tumors. Various experimental procedures are also underway to evaluate the role of EUS in radiofrequency ablation, vascular therapy, and natural orifice transluminal endoscopic surgery. In this review, we examine the various EUS-guided ablation therapies currently undertaken in humans.
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Affiliation(s)
- Jessica M Trevino
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
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Role of endoscopic ultrasound for evaluating gastrointestinal tract disorders in pediatrics: a tertiary care center experience. J Pediatr Gastroenterol Nutr 2010; 51:718-22. [PMID: 20683206 DOI: 10.1097/mpg.0b013e3181dac094] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Endoscopic ultrasound (EUS) with or without fine needle aspiration (FNA) has a well-established role in the evaluation of various gastrointestinal (GI) tract disorders in adults. The clinical impact of EUS on the management of the pediatric population remains less clear. This study evaluates the feasibility, safety, and applications of EUS ± FNA in pediatric GI tract disorders. PATIENTS AND METHODS Using a prospectively maintained EUS database, all patients 18 years of age or younger referred for EUS at our institution were identified. Retrospective chart review was conducted to document procedure indications, type of anesthesia used, EUS findings, final FNA cytology results, and clinical impact of EUS ± FNA on the subsequent management of pediatric patients. RESULTS Fifty-eight EUS procedures were performed in 56 patients (35 girls). Median age was 16 years (range 4-18 years). The main indications for EUS were acute or recurrent pancreatitis, abdominal pain of suspected pancreatobiliary origin, suspected biliary obstruction, upper GI mucosal/submucosal lesions, and evaluation of pancreatic abnormalities seen on prior imaging. Sedation used included nurse-administered propofol sedation in 38 (73%), general anesthesia in 9 (17%), and fentanyl with meperidine in 3 (6%). Five therapeutic procedures performed included celiac plexus blocks in 4 and 1 EUS-guided pancreatogram. In 44 (86%) patients, EUS provided a new diagnosis. The procedure was successfully completed in all patients with no reported complications. CONCLUSIONS EUS ± FNA is feasible and safe and makes a significant impact on most pediatric patients. Nurse-administered propofol sedation appears to be safe and well tolerated in this group.
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Abstract
Chronic pancreatitis (CP) can have debilitating clinical course due to chronic abdominal pain, malnutrition and related complications. Medical, endoscopic and surgical treatment of CP should aim at control of symptoms, prevention of progression of the disease and correction of complications. Endoscopic management plays a specific role in carefully selected patients as primary interventional therapy when medical measures fail or in high-risk surgical candidates. Endotherapy for CP is utilized also as a bridge to surgery or to assess potential response to pancreatic surgery. In this review we address the role of endotherapy for the relief of obstruction of the pancreatic duct (PD) and bile duct, closure of PD leaks and drainage of pseudocysts in the setting of CP. In addition, endotherapy for relief of pancreatic pain by endoscopic ultrasound-guided celiac plexus block for CP is discussed.
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Affiliation(s)
- Haritha Avula
- Division of Gastroenterology/ Hepatology, Indiana University Medical Center, Indianapolis, IN, USA
| | - Stuart Sherman
- Division of Gastroenterology/ Hepatology, Indiana University Medical Center - Internal Medicine, UH 4100, IN 46202, USA
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Abstract
Endoscopic ultrasonography (EUS) is well suited for assessment of the pancreas due to its high resolution and the proximity of the transducer to the pancreas, avoiding air in the gut. Evaluation of chronic pancreatitis (CP) was an early target for EUS, initially just for diagnosis but later for therapeutic purposes. The diagnosis of CP is still accomplished using the standard scoring based on nine criteria, all considered to be of equal value. For diagnosis of any CP, at least three or four criteria must be fulfilled, but for diagnosis of severe CP at least six criteria are necessary. The Rosemont classification, more restrictive, aims to standardize the criteria and assigns different values to different features, but requires further validation. EUS-fine needle aspiration (EUS-FNA) is less advisable for diagnosis of diffuse CP due to its potential side effects. Elastography and contrast-enhanced EUS are orientation in differentiating a focal pancreatic mass in a parenchyma with features of CP, but they cannot replace EUS-FNA. The usefulness of EUS-guided celiac block for painful CP is still being debated with regard to the best technique and the indications. EUS-guided drainage of pseudocysts is preferred in non-bulging pseudocysts or in the presence of portal hypertension. EUS-guided drainage of the main pancreatic duct should be reserved for cases in which endoscopic retrograde cholangiopancreatography has failed owing to difficult cannulation of the papilla or difficult endotherapy. It should be performed only by highly skilled endoscopists, due to the high rate of complications.
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EUS-guided celiac plexus block for chronic pancreatitis: a placebo-controlled trial should be the first priority. Gastrointest Endosc 2010; 71:430-1; author reply 431. [PMID: 20152323 DOI: 10.1016/j.gie.2009.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Accepted: 05/03/2009] [Indexed: 02/08/2023]
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Abstract
Coeliac plexus neurolysis (CPN) has been performed for nearly 100 years to try and control pancreatic pain. In recent years endoscopic ultrasound (EUS)-guided CPN has become the preferred technique for this procedure yet relatively little data exists to support its superiority over other methods. Recent studies have demonstrated the potential for direct EUS-guided injection into coeliac ganglia as a means to improve efficacy of CPN. This article describes the technique of EUS-CPN, the evidence supporting its use and recent advances in this procedure.
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