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Xuan M, Li N, Wu C. A meta-analysis on the efficacy of endoscopic ultrasonography for treatment of pancreatic cancer. Clinics (Sao Paulo) 2024; 79:100348. [PMID: 38552386 PMCID: PMC10998044 DOI: 10.1016/j.clinsp.2024.100348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 02/21/2024] [Accepted: 03/12/2024] [Indexed: 04/09/2024] Open
Abstract
OBJECTIVE This study aimed to systematically evaluate the efficacy and safety of Endoscopic Ultrasonography (EUS) for the treatment of pancreatic cancer. METHODS The PubMed, Embase, Web of Science, and Google Scholar databases were searched from the inception of the databases to June 2022. RevMan 5.3.0 software was utilized for data analysis. In total, 13 self-descriptive studies, which enrolled 382 patients, were finally included. RESULTS It was revealed that EUS for the treatment of pancreatic cancer exhibited a lower incidence of adverse reactions (Relative Risk Ration [RR = 0.23], 95 % Confidence interval [95 % CI 0.23-0.23]), a higher success rate (RR = 0.90, 95 % CI 0.90-0.90), and a low failure rate (RR = 0.06, 95 % CI 0.06-0.06). Moreover, EUS-guided Celiac Plexus Neurolysis (EUS-CPN) not only significantly relieved pancreatic cancer patients' pain (RR = 0.83, 95 % CI 0.83-0.83), but also significantly eliminated pain in some patients (RR = 0.09, 95 % CI 0.09-0.09). The effects of EUS on pancreatic cancer treatment were satisfactory, and few adverse reactions were found. CONCLUSION Owing to the restricted sample size in this meta-analysis, primarily consisting of descriptive studies, it was imperative to conduct more rigorously designed, multi-center, long-term follow-up, larger sample, and Randomized Controlled Trials (RCTs) to validate the findings.
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Affiliation(s)
- Min Xuan
- Department of Ultrasound, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Jiangsu Province, China
| | - Na Li
- Department of Ultrasound, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Jiangsu Province, China
| | - Chunyan Wu
- Department of Ultrasound, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Jiangsu Province, China.
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Zhang PP, Su XJ, Li L, Wang YL, Zhu DQ, Yang T, Wang T, Jin ZD, Wang KX. Clinical efficacy of EUS-guided celiac plexus neurolysis versus EUS-guided celiac ganglion irradiation with iodine-125 seeds for pain relief in advanced pancreatic cancer: A long-term retrospective study. Endosc Ultrasound 2024; 13:100-106. [PMID: 38947749 PMCID: PMC11213610 DOI: 10.1097/eus.0000000000000048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2024] Open
Abstract
Background and Objective To compare the efficacy of EUS-guided celiac plexus neurolysis (CPN) and celiac plexus irradiation with iodine-125 (125I) seeds with absolute ethanol for relieving pain in patients with advanced pancreatic cancer. Methods We retrospectively analyzed data of 81 patients with advanced pancreatic cancer who underwent EUS-CPN or EUS-125I implantation between January 2017 and December 2020. Postoperative pain was assessed using visual analog scale (VAS) scores; self-assessments of quality of life and the median survival time were compared between the 2 groups. Results EUS-CPN and 125I implantation were performed in 43 and 38 patients, respectively. Postoperative VAS scores were significantly lower than the preoperative levels in both groups. One week after the operation, 26 patients (60.5%) in the EUS-CPN group achieved partial pain relief, whereas no patients in the EUS-125I seed group experienced pain relief. However, after 4 weeks postoperatively, VAS scores had decreased, and the rate of partial pain relief was higher for EUS-125I seeds than for EUS-CPN. Self-assessments of quality of life were similar in both groups during the first 1 month after the procedure. Conclusions Both EUS-CPN and EUS-125I seeds can safely and effectively relieve pain in patients with advanced pancreatic cancer. Although EUS-125I seeds take additional time to show effects, the extent and duration of pain relief are better compared with CPN, and interestingly, the median survival time was different.
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Affiliation(s)
- Ping-Ping Zhang
- Department of Gastroenterology, Changhai Hospital, Naval Military Medical University, Shanghai 200433, China
| | - Xiao-Ju Su
- Department of Gastroenterology, Changhai Hospital, Naval Military Medical University, Shanghai 200433, China
| | - Li Li
- Department of Spleen and Stomach & Rheumatology, Affiliated Hospital of Traditional Chinese Medicine, Southwest Medical University, Lu Zhou 646000, Sichuang Province, China
| | - Yu-Ling Wang
- Department of Gastroenterology, Changhai Hospital, Naval Military Medical University, Shanghai 200433, China
| | - Dong-Qing Zhu
- Department of Radiology, Changzheng Hospital, Naval Military Medical University, Shanghai 200003, China
| | - Ting Yang
- Department of Gastroenterology, Changhai Hospital, Naval Military Medical University, Shanghai 200433, China
| | - Teng Wang
- Department of Gastroenterology, Changhai Hospital, Naval Military Medical University, Shanghai 200433, China
| | - Zhen-Dong Jin
- Department of Gastroenterology, Changhai Hospital, Naval Military Medical University, Shanghai 200433, China
| | - Kai-Xuan Wang
- Department of Gastroenterology, Changhai Hospital, Naval Military Medical University, Shanghai 200433, China
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Dai S, Zhao L, Wang G, Chen C, Li C, Xiao B, Miao Y. Celiac ganglia neurolysis suppresses high blood pressure in rats. Hypertens Res 2023; 46:1771-1781. [PMID: 37173429 DOI: 10.1038/s41440-023-01305-y] [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] [Received: 11/19/2022] [Revised: 04/13/2023] [Accepted: 04/17/2023] [Indexed: 05/15/2023]
Abstract
The efficacy of renal denervation in the treatment of resistant hypertension has been controversial, and new strategies for its therapy are urgently needed. We performed the celiac ganglia neurolysis (CGN) or sham surgery on both spontaneously hypertensive rat (SHR) and Dahl salt-sensitive rat models of hypertension. Following CGN surgery in both strains, systolic blood pressure, diastolic blood pressure and mean arterial pressure were all lower than the levels in the respective sham surgery rats, which were maintained until the end of the study, 18 weeks postoperatively in SHRs and 12 weeks postoperatively in Dahl rats. CGN therapy destroyed ganglion cell structure and significantly inhibited celiac ganglia nerve viability. Four and twelve weeks after CGN, the plasma renin, angiotensin II and aldosterone levels were markedly attenuated, and the nitric oxide content was significantly increased in the CGN group compared with the respective sham surgery rats. However, CGN did not result in statistical difference in malondialdehyde levels compared with sham surgery in both strains. The CGN has efficacy in reducing high blood pressure and may be an alternative for resistant hypertension. Minimally invasive endoscopic ultrasound-guided celiac ganglia neurolysis (EUS-CGN) and percutaneous CGN are safe and convenient treatment approaches. Moreover, for hypertensive patients who need surgery due to abdominal disease or pain relief from pancreatic cancer, intraoperative CGN or EUS-CGN will be a good choice for hypertension therapy. The graphical abstract of antihypertensive effect of CGN.
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Affiliation(s)
- Shangnan Dai
- Pancreas Center, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute, Nanjing Medical University, Nanjing, China
| | - Li Zhao
- Pancreas Center, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute, Nanjing Medical University, Nanjing, China
| | - Guangfu Wang
- Pancreas Center, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute, Nanjing Medical University, Nanjing, China
| | - Chongfa Chen
- Pancreas Center, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute, Nanjing Medical University, Nanjing, China
| | - Chenchen Li
- Pancreas Center, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute, Nanjing Medical University, Nanjing, China
| | - Bin Xiao
- Pancreas Center, First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
- Pancreas Institute, Nanjing Medical University, Nanjing, China.
| | - Yi Miao
- Pancreas Center, First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
- Pancreas Institute, Nanjing Medical University, Nanjing, China.
- Pancreas Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China.
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4
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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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du Plessis M, Loukas M. A Comprehensive study of the Abdominal Ganglia Part 3: An overview of the most commonly observed ganglion patterns, with particular emphasis on inferior mesenteric and gonadal ganglia. Clin Anat 2022; 35:1014-1024. [PMID: 35883221 DOI: 10.1002/ca.23940] [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: 07/12/2022] [Accepted: 07/24/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Chronic pain from untreatable abdominal cancers or pancreatitis can severely decrease an individual's quality of life due to accompanying neuropathic pain, the most difficult pain mechanism to treat. Current treatment modalities focus on peripheral block or neurolysis procedures of the sympathetic ganglia in an attempt to curb the pain and improve quality of life. Reports indicated that these treatments are ineffective with patients either experiencing no relief or return the pain in a few weeks. The aim of this study was to investigate the location, macro- and microscopic morphology and interconnections of the abdominal ganglia. METHODS The abdominal sympathetic ganglia of nine adult cadavers were investigated. The locations, morphology, interconnections and microscopic structure was studied in 108 potential abdominal ganglia. Particular emphasis was placed on direct interconnectivity between the ganglia and histological morphology. RESULTS A total of 100 ganglia were confirmed histologically to contain ganglion cells. The number and locations of most of the ganglia identified in our study does not correspond to that described by previous reports. Numerous interconnections between the different ganglia, as well as direct communications with the lumbar sympathetic chain ganglia were observed. CONCLUSIONS The interconnections and presence of ganglion cells the nerves connecting the ganglia lead to the belief that the system should be considered as a unit and that pain fibers may be transmitted via alternative previously undiscovered pathways. If the pain treatments are to be reassessed with this information in mind, we believe that greater success could be achieved. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- M du Plessis
- Department of Anatomical Sciences, St George's University, True Blue, Grenada West Indies
| | - M Loukas
- Department of Anatomical Sciences, St George's University, True Blue, Grenada West Indies.,Department of Anatomy, Varmia and Mazury Medical School, Olsztyn, Poland
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du Plessis M, Loukas M. A Comprehensive study of the Abdominal Ganglia Part 1: Celiac, phrenic and superior mesenteric ganglia. Clin Anat 2022; 35:998-1006. [PMID: 35484764 DOI: 10.1002/ca.23894] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 04/20/2022] [Accepted: 04/20/2022] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Patients with pancreatic cancer, chronic pancreatitis and other abdominal pain syndromes may develop debilitating pain throughout the course of their illness with little to no relief by most conventional methods. While some form of relief is experienced by patients, not all benefit from these procedures and side effects, while transitory in most cases are severe and often not expected. Our aim was therefore to investigate the anatomy surrounding the abdominal sympathetic ganglia, the target for the invasive procedures in an attempt to understand the variations in results. MATERIALS AND METHODS The abdominal cavities of nine individuals were dissected and the ganglia investigated, harvested and histologically and immunochemical stained. RESULTS The phrenic ganglion was found inconsistently and more often in the left than the right. If present it was located in association with the inferior phrenic artery and often connected to the celiac ganglion. The celiac ganglion was located anterior to the diaphragmatic crus on both sides and specifically posteromedial to the suprarenal gland and superior to the renal artery on the left. On the right it was located posterior to the suprarenal gland and inferior vena cava also superior to the renal vessels. The superior mesenteric ganglion was only positively identified in one individual and was located on the left lateral aspect of the superior mesenteric artery. CONCLUSION The blockade procedures for treatment of pain are developed to target the area around the celiac artery where the ganglion is commonly described to be located. However, based on our results of its location and interconnections the ganglion is not located in the targeted area.
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Affiliation(s)
- Maira du Plessis
- Department of Anatomical Sciences, St George's University, True Blue, Grenada, West Indies
| | - Marios Loukas
- Department of Anatomical Sciences, St George's University, True Blue, Grenada, West Indies.,Department of Anatomy, Varmia and Mazury Medical School, Olsztyn, Poland
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Efficacy of EUS-guided celiac plexus neurolysis in combination with EUS-guided celiac ganglia neurolysis for pancreatic cancer-associated pain: a multicenter prospective trial. Int J Clin Oncol 2022; 27:1196-1201. [PMID: 35412211 DOI: 10.1007/s10147-022-02160-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/29/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVES This study evaluated the efficacy of endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) in combination with EUS-guided celiac ganglia neurolysis (EUS-CGN) for pancreatic cancer-associated pain. METHODS This multicenter prospective trial was registered in the University Hospital Medical Information Network (UMIN000031228). Fifty-one consecutive patients with pancreatic cancer-associated pain who presented at one of five Japanese referral centers between February 2018 and March 2021 were enrolled. EUS-CGN was added in cases of visible celiac ganglia. The primary endpoint was effectiveness, defined as a decrease in the numerical rating scale (NRS) by ≥ 3 points. NRS data were prospectively acquired at 1 week after the procedure to evaluate its effectiveness and the extent of pain relief. RESULTS The technical success rates of EUS-CPN and EUS-CGN were 100% and 80.4%, respectively. The overall efficacy rate was 82.4% [90% confidence interval (CI) 71.2-90.5, P < 0.0001]. The complete pain relief rate was 27.4%. The adverse events rate was 15.7%. The average pain relief period was 72 days. The efficacy rate was higher in the EUS-CPN plus EUS-CGN group than in the EUS-CPN alone group. EUS-CPN plus EUS-CGN was superior to EUS-CPN alone for achieving complete pain relief (P = 0.045). EUS-CGN did not improve the average length of the pain relief period. CONCLUSIONS EUS-CPN combined with EUS-CGN is safe, feasible, and effective for pain relief in patients with pancreatic cancer. The patients who received additional EUS-CGN had a better short-term response. CLINICAL TRIAL NUMBER UMIN000031228.
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Okada H, Takahashi K, Yaku H, Kobiyama K, Iwaisako K, Zhao X, Shiokawa M, Uza N, Kodama Y, Ishii KJ, Seno H. In situ vaccination using unique TLR9 ligand K3-SPG induces long-lasting systemic immune response and synergizes with systemic and local immunotherapy. Sci Rep 2022; 12:2132. [PMID: 35136110 PMCID: PMC8825851 DOI: 10.1038/s41598-022-05702-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 01/18/2022] [Indexed: 02/08/2023] Open
Abstract
Although checkpoint inhibitors (CPIs) have changed the paradigm of cancer therapy, low response rates and serious systemic adverse events remain challenging. In situ vaccine (ISV), intratumoral injection of immunomodulators that stimulate innate immunity at the tumor site, allows for the development of vaccines in patients themselves. K3-SPG, a second-generation nanoparticulate Toll-like receptor 9 (TLR9) ligand consisting of K-type CpG oligodeoxynucleotide (ODN) wrapped with SPG (schizophyllan), integrates the best of conventional CpG ODNs, making it an ideal cancer immunotherapy adjuvant. Focusing on clinical feasibility for pancreaticobiliary and gastrointestinal cancers, we investigated the antitumor activity of K3-SPG-ISV in preclinical models of pancreatic ductal adenocarcinoma (PDAC) and colorectal cancer (CRC). K3-SPG-ISV suppressed tumor growth more potently than K3-ISV or K3-SPG intravenous injections, prolonged survival, and enhanced the antitumor effect of CPIs. Notably, in PDAC model, K3-SPG-ISV alone induced systemic antitumor effect and immunological memory. ISV combination of K3-SPG and agonistic CD40 antibody further enhanced the antitumor effect. Our results imply that K3-SPG-based ISV can be applied as monotherapy or combined with CPIs to improve their response rate or, conversely, with CPI-free local immunotherapy to avoid CPI-related adverse events. In either strategy, the potency of K3-SPG-based ISV would provide the rationale for its clinical application to puncturable pancreaticobiliary and gastrointestinal malignancies.
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Affiliation(s)
- Hirokazu Okada
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, 54-Syogoin Kawara-cho, Sakyoku, Kyoto, 606-8507, Japan
| | - Ken Takahashi
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, 54-Syogoin Kawara-cho, Sakyoku, Kyoto, 606-8507, Japan.
| | - Hiroaki Yaku
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, 54-Syogoin Kawara-cho, Sakyoku, Kyoto, 606-8507, Japan
| | - Kouji Kobiyama
- Division of Vaccine Science, The Institute of Medical Science, The University of Tokyo, 4-6-1 Shirokanedai, Minato-ku, Tokyo, 108-8639, Japan
| | - Keiko Iwaisako
- Department of Medical Life Systems, Faculty of Life and Medical Sciences, Doshisha University, 1-3 Tatara Miyakodani, Kyotanabe-shi, 610-0394, Japan
| | - Xiangdong Zhao
- Division of HBP Surgery and Transplantation, Department of Surgery, Kyoto University, 54-Shogoin Kawahara-cho, Sakyoku, Kyoto, 606-8507, Japan
| | - Masahiro Shiokawa
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, 54-Syogoin Kawara-cho, Sakyoku, Kyoto, 606-8507, Japan
| | - Norimitsu Uza
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, 54-Syogoin Kawara-cho, Sakyoku, Kyoto, 606-8507, Japan
| | - Yuzo Kodama
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Ken J Ishii
- Division of Vaccine Science, The Institute of Medical Science, The University of Tokyo, 4-6-1 Shirokanedai, Minato-ku, Tokyo, 108-8639, Japan
| | - Hiroshi Seno
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, 54-Syogoin Kawara-cho, Sakyoku, Kyoto, 606-8507, Japan
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Pérez-Aguado G, de la Mata DMA, Valenciano CML, Sainz IFU. Endoscopic ultrasonography-guided celiac plexus neurolysis in patients with unresectable pancreatic cancer: An update. World J Gastrointest Endosc 2021; 13:460-472. [PMID: 34733407 PMCID: PMC8546561 DOI: 10.4253/wjge.v13.i10.460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/27/2021] [Accepted: 09/08/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer produces disabling abdominal pain, and the pain medical management for pancreatic cancer is often challenging because it mainly relies on the use of narcotics (major opioids). However, opioids often provide suboptimal pain relief, and the use of opioids can lead to patient tolerance and several side effects that considerably reduce the quality of life of pancreatic cancer patients. Endosonography-guided celiac plexus neurolysis (EUS-CPN) is an alternative for pain control in patients with nonsurgical pancreatic cancer; EUS-CPN consists of the injection of alcohol and a local anesthetic into the area of the celiac plexus to achieve chemical ablation of the nerve tissue. EUS-CPN via the transgastric approach is a safer and more accessible technique than the percutaneous approach. We have reviewed most of the studies that evaluate the efficacy of EUS-CPN and that have compared the different approaches that have been performed by endosonographers. The efficacy of EUS-CPN varies from 50% to 94% in the different studies, and EUS-CPN has a pain relief duration of 4–8 wk. Several factors are involved in its efficacy, such as the onset of pain, previous use of chemotherapy, presence of metastatic disease, EUS-CPN technique, type of needle or neurolytic agent used, etc. According to this review, injection into the ganglia may be the best technique, and a good visualization of the ganglia is the best predictor for a good EUS-CPN response, although more studies are needed. However, any of the 4 different techniques could be used to perform EUS-CPN effectively with no differences in terms of complications between the techniques, but more studies are needed. The effect of EUS-CPN on pain improvement, patient survival and patient quality of life should be evaluated in well-designed randomized clinical trials. Further research also needs to be performed to clarify the best time frame in performing a EUS-CPN.
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Affiliation(s)
- Guillermo Pérez-Aguado
- Department of Gastroenterology, Complejo Hospitalario Insular Materno Infantil de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas 35016, Spain
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Li M, Wang Z, Chen Y, Wu Z, Huang X, Wu C, Tian B. EUS-CGN versus EUS-CPN in pancreatic cancer: A qualitative systematic review. Medicine (Baltimore) 2021; 100:e27103. [PMID: 34731101 PMCID: PMC8519191 DOI: 10.1097/md.0000000000027103] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/12/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Comparison between endosonographic ultrasonography (EUS)-guided celiac ganglia neurolysis (CGN) and EUS-guided celiac plexus neurolysis (CPN) in pain management for pancreatic cancer has engendered controversy. To analyze the effectiveness and safety of EUS-CGN and figure out whether EUS-CGN is better than EUS-CPN, a qualitative systematic review was conducted. METHODS Studies were searched from Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE up to April 2020. We only included studies with full-text and in English and assessed study quality with Newcastle-Ottawa Scale or Cochrane risk-of-bias tool. We recorded details of study design, participants, procedure performed, protocol of follow-up, pain response, quality of life, survival, and adverse events. The study was conducted under Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement 2009. RESULTS Five studies involving 319 patients were included. Short-term pain response rates ranged from 65.0% to 88.46% in EUS-CGN group and most studies reported its superiority over EUS-CPN. As for adverse events, the incidence of transient hypotension and gastrointestinal symptoms seemed comparable, while results of initial pain exacerbation varied among studies. Besides, EUS-CGN might provide a shorter survival. CONCLUSION EUS-CGN can be safely performed while it may shorten survival. In terms of short-term pain response, EUS-CGN is better than EUS-CPN while no conclusion of long-term pain control can be drawn.
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Hickman K, Godfrey E, Ajithkumar T. Endoscopic ultrasound-guided neurolysis in advanced pancreatic cancer: current status. BMJ Support Palliat Care 2021; 12:22-28. [PMID: 34635545 DOI: 10.1136/bmjspcare-2021-002905] [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: 02/19/2021] [Accepted: 07/11/2021] [Indexed: 11/04/2022]
Abstract
Pancreatic cancer has a very poor prognosis with patients often presenting with locally advanced, inoperable or metastatic disease. A significant proportion of patients have visceral pain due to perineural infiltration or coeliac plexus involvement by the tumour. This pain is difficult to control and may become refractory to conventional pain management. Therefore, coeliac plexus neurolysis (CPN) has been proposed to ablate the neuronal transmission pathway of pain permanently. CPN is recommended for those who have uncontrolled pain, are experiencing unacceptable opioid adverse effects or are receiving escalating doses of analgesics. It is not known whether CPN performed at diagnosis as the first-line treatment ('early') would impact short-term and long-term pain control and quality of life. NICE has recommended (2018) a randomised trial comparing early endoscopic ultrasound-guided coeliac plexus neurolysis (EUS-CPN) with on-demand EUS-CPN in pancreatic cancer. In this context, we will review the current evidence on its clinical benefits.
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Affiliation(s)
- Katy Hickman
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Edmund Godfrey
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Thankamma Ajithkumar
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Wang J, Chen Y, Li X, Zou X. Perineural Invasion and Associated Pain Transmission in Pancreatic Cancer. Cancers (Basel) 2021; 13:4594. [PMID: 34572820 PMCID: PMC8467801 DOI: 10.3390/cancers13184594] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/10/2021] [Accepted: 09/10/2021] [Indexed: 12/18/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is one of the cancers with the highest incidence of perineural invasion (PNI), which often indicates a poor prognosis. Aggressive tumor cells invade nerves, causing neurogenic inflammation; the tumor microenvironment also induces nerves to undergo a series of structural and functional reprogramming. In turn, neurons and the surrounding glial cells promote the development of pancreatic cancer through autocrine and/or paracrine signaling. In addition, hyperalgesia in PDAC patients implies alterations of pain transmission in the peripheral and central nervous systems. Currently, the studies on this topic are relatively limited. This review will elaborate on the mechanisms of tumor-neural interactions and its possible relationship with pain from several aspects that have been focused on in recent years.
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Affiliation(s)
| | | | | | - Xiaoping Zou
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China; (J.W.); (Y.C.); (X.L.)
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Asif AA, Walayat SK, Bechtold ML, Revanur V, Puli SR. EUS-guided celiac plexus neurolysis for pain in pancreatic cancer patients - a meta-analysis and systematic review. J Community Hosp Intern Med Perspect 2021; 11:536-542. [PMID: 34211665 PMCID: PMC8221153 DOI: 10.1080/20009666.2021.1929049] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Endoscopic ultrasound guided celiac plexus neurolysis (EUS- CPN) has been reported to be an effective way to help with pain in pancreatic cancer patient. The aim of our updated meta-analysis is to assess the efficacy of pain relief in patients with pancreatic cancer who underwent EUS guided neurolysis. Methods: Pooled proportions were calculated using both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity among studies was tested using Cochran’s Q test based upon inverse variance weights. Results: Initial search identified 176 reference articles, of which 34 were selected and reviewed in detail. Sixteen studies that met the inclusion criteria were included in this analysis. The mean age of patients undergoing neurolysis was 56.31 ± 19.72 years. Number of males, N = 563 (57.4%), was higher than the number of females, N = 417 (42.5%). The pooled proportion of patients who showed pain relief with EUS-guided neurolysis was 71% (95% CI = 68–74). Bias calculated using Begg–Mazumdar was not significant (p = 0.8). In a subgroup analysis, when comparing the central and bilateral techniques, the pooled proportion of patients with pain relief was 66% (95% CI = 61–71) and 57% (95% CI = 48–67), respectively. Conclusions: Our results show that EUS guided CPN could provide relief in as much as 70% of patients with central neurolysis technique having some edge over peripheral neurolysis. Further larger scale randomized controlled trials may further help to elaborate the efficacy of central vs peripheral neurolysis.
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Affiliation(s)
- Abuzar A Asif
- Department of Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Saqib K Walayat
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Matthew L Bechtold
- Division of Gastroenterology and Hepatology, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Vakya Revanur
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Srinivas R Puli
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
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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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Han CQ, Tang XL, Zhang Q, Nie C, Liu J, Ding Z. Predictors of pain response after endoscopic ultrasound-guided celiac plexus neurolysis for abdominal pain caused by pancreatic malignancy. World J Gastroenterol 2021; 27:69-79. [PMID: 33505151 PMCID: PMC7789068 DOI: 10.3748/wjg.v27.i1.69] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 08/15/2020] [Accepted: 11/12/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) has gained popularity as a minimally invasive approach and is currently widely used to treat pancreatic cancer-associated pain. However, response to treatment is variable.
AIM To identify the efficacy of EUS-CPN and explore determinants of pain response in EUS-CPN for pancreatic cancer-associated pain.
METHODS A retrospective study of 58 patients with abdominal pain due to inoperable pancreatic cancer who underwent EUS-CPN were included. The efficacy for palliation of pain was evaluated based on the visual analog scale pain score at 1 wk and 4 wk after EUS-CPN. Univariable and multivariable logistic regression analyses were performed to explore predictors of pain response.
RESULTS A good pain response was obtained in 74.1% and 67.2% of patients at 1 wk and 4 wk, respectively. Tumors located in the body/tail of the pancreas and patients receiving bilateral treatment were weakly associated with a good outcome. Multivariate analysis revealed patients with invisible ganglia and metastatic disease were significant factors for a negative response to EUS-CPN at 1 wk and 4 wk, respectively, particularly for invasion of the celiac plexus (odds ratio (OR) = 13.20, P = 0.003 for 1 wk and OR = 15.11, P = 0.001 for 4 wk). No severe adverse events were reported.
CONCLUSION EUS-CPN is a safe and effective form of treatment for intractable pancreatic cancer-associated pain. Invisible ganglia, distant metastasis, and invasion of the celiac plexus were predictors of less effective response in EUS-CPN for pancreatic cancer-related pain. For these patients, efficacy warrants attention.
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Affiliation(s)
- Chao-Qun Han
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Xue-Lian Tang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Qin Zhang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Chi Nie
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Jun Liu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Zhen Ding
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
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Yasuda I, Hanaoka T, Takahashi K, Araki Y, Doi S, Iwashita T, Iwata K, Mukai T. Recent topics on endoscopic ultrasonography-guided celiac plexus neurolysis. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii200033] [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)
- Ichiro Yasuda
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Tatsuyuki Hanaoka
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Kosuke Takahashi
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Yasuhiro Araki
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Shinpei Doi
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University, Gifu, Japan
| | - Keisuke Iwata
- Department of Gastroenterology, Gifu Prefectural Medical Center, Gifu, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
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Abstract
AbstractEndoscopic ultrasound (EUS)-guided celiac plexus intervention comprises EUS-guided celiac plexus block (EUS-CPB) and EUS-guided celiac plexus neurolysis (EUS-CPN). EUS-CPB and EUS-CPN are one of the used methods of pain management in patients of pancreatic cancer and chronic pancreatitis, respectively, along with medical therapy. Both the procedures are associated with minimal complications and improves quality of life. The role of EUS-guided celiac plexus intervention is increasing in gall bladder carcinoma for pain control.
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Affiliation(s)
- Zubin Dev Sharma
- Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Rinkesh Kumar Bansal
- Department of Gastroenterology & Hepatology, Fortis Memorial Research Institute, Gurgaon, Haryana, India
| | - Rajesh Puri
- Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, Haryana, India
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Kanno Y, Koshita S, Masu K, Ogawa T, Kusunose H, Murabayashi T, Sakai T, Kozakai F, Ito K. Efficacy of EUS-guided celiac plexus neurolysis compared with medication alone for unresectable pancreatic cancer in the oxycodone/fentanyl era: a prospective randomized control study. Gastrointest Endosc 2020; 92:120-130. [PMID: 31953188 DOI: 10.1016/j.gie.2020.01.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 01/02/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The efficacy of celiac plexus neurolysis (CPN) with EUS guidance (EUS-CPN) has not been confirmed in the era of developed opioids. The aim of this study was to evaluate the efficacy of EUS-CPN for patients with pancreatic cancer-associated pain to compare medication using oxycodone and/or fentanyl with and without EUS-CPN. METHODS In this randomized control study involving patients who underwent EUS-CPN and those who did not, pain, quality of life (QOL), and opioid consumption were compared. Standard medicinal treatment using oxycodone and/or fentanyl was performed for both groups. The primary endpoint was defined as the pain evaluated by using a visual analog scale (VAS) rated from a 0 to 10, 4 weeks after the baseline. RESULTS For 48 registered patients, the outcomes of 24 patients in the EUS-CPN group and 22 patients in the control group were analyzed. EUS-CPN was successfully performed and did not induce severe procedure-related adverse events for all patients in the EUS-CPN group. Although the average pain VAS scores for both groups significantly decreased in comparison with baseline, scores were not statistically different between the groups at week 4 (1.3 ± 1.3 for the EUS-CPN group vs 2.3 ± 2.3 for the control group, P = .10). There was no statistical difference or tendency in favor of EUS-CPN at evaluation points of weeks 1, 2, 8, and 12. Moreover, the average VAS scores for QOL and the average opioid consumption between the groups were not different at all evaluation points. CONCLUSIONS EUS-CPN for patients with pancreatic cancer-associated pain did not appear to improve pain, QOL, or opioid consumption compared with those who did not undergo EUS-CPN and medicated with oxycodone/fentanyl. Although EUS-CPN can be an option, it was not found to have a large enough impact to be routinely performed for all patients with pain. (Clinical trial registration number: UMIN 000037172.).
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Affiliation(s)
- Yoshihide Kanno
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Shinsuke Koshita
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Kaori Masu
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Takahisa Ogawa
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Hiroaki Kusunose
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Toji Murabayashi
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Toshitaka Sakai
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Fumisato Kozakai
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Kei Ito
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
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Moutinho-Ribeiro P, Liberal R, Macedo G. Endoscopic ultrasound in pancreatic cancer treatment: Facts and hopes. Clin Res Hepatol Gastroenterol 2019; 43:513-521. [PMID: 30935904 DOI: 10.1016/j.clinre.2019.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 02/12/2019] [Accepted: 02/16/2019] [Indexed: 02/04/2023]
Abstract
Pancreatic ductal adenocarcinoma is one of the most common causes of cancer-related deaths. Since most patients present with advanced disease, its prognosis is dismal. New and more effective therapeutic strategies are needed. Endoscopic ultrasound is currently an indispensable tool for the diagnosis and staging of pancreatic ductal adenocarcinoma. In recent years, endoscopic ultrasound has evolved to become also a therapeutic procedure. On one hand, the role of endoscopic ultrasound in the management of pancreatic cancer-related symptoms (pain, obstructive jaundice, and gastric outlet obstruction) is now well established. On the other hand, its use as a mean to the delivery of anti-tumor therapies (injecting anti-tumor agents, assisting in radiotherapy, and guiding ablative therapies) is still mostly experimental, despite growing evidence supporting its feasibility, safety and efficacy.
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Affiliation(s)
- Pedro Moutinho-Ribeiro
- Gastroenterology and Hepatology Department, Centro Hospitalar Sao Joao and World Gastroenterology Organisation (WGO) Porto Training Center, Porto, Portugal.
| | - Rodrigo Liberal
- Gastroenterology and Hepatology Department, Centro Hospitalar Sao Joao and World Gastroenterology Organisation (WGO) Porto Training Center, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology and Hepatology Department, Centro Hospitalar Sao Joao and World Gastroenterology Organisation (WGO) Porto Training Center, Porto, Portugal
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20
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Malikowski T, Lehrke HD, Henry MR, Gleeson FC, Topazian MD, Harmsen WS, Takahashi N, Inoue D, Gara N, Abu Dayyeh BK, Chari ST, Iyer PG, Rajan E, Wang KK, Levy MJ. Accuracy of Endoscopic Ultrasound Imaging in Distinguishing Celiac Ganglia From Celiac Lymph Nodes. Clin Gastroenterol Hepatol 2019; 17:148-155.e3. [PMID: 29857152 DOI: 10.1016/j.cgh.2018.05.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 05/01/2018] [Accepted: 05/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic ultrasound (EUS) allows visualization of celiac lymph nodes (CLNs) and celiac ganglia (CG). Reliably distinguishing these structures is important for tumor staging and CG ablative therapies. We aimed to evaluate the accuracy of EUS in distinguishing CLNs from CG using a strict cytopathology reference standard. We also determined the rate of detection of CLN and CG by conventional cross-sectional imaging. METHODS From EUS and cytopathology databases, we identified all patients who underwent EUS-FNA of a presumed CLN or CG from October 1, 2004, through March 1, 2017, and compared the findings with those from cytology (reference standard). Indeterminate cytology results were re-reviewed. EUS imaging (ie, index test) results were compared with those from the reference standard. An expert radiologist re-reviewed computed tomography and magnetic resonance images from 100 lesions, from 94 randomly selected patients with a reference standard, to determine the rates of CLN and CG detection. RESULTS A total of 504 patients (mean age, 63.4 ± 13.2 years; 292 men) underwent a median of 7 EUS-FNA passes (range, 1-13) for a total of 566 lesions perceived to be either a CLN or CG; the cytology reference standard was available for 521 lesions (92.1%). When we excluded indeterminate cytology results, the EUS accurately identified 281/286 CLNs (98.3%) and 166/186 CGs (89.2%), for an overall accuracy of 447/472 (94.7%). EUS-FNA distinguished CG from CLNs with a 93.3% sensitivity, 93.7% specificity, a positive predictive value of 96.2%, and a negative predictive value of 89.2%. Of 100 lesions in 94 patients randomly selected for a second expert radiology review, computed tomography and magnetic resonance imaging detected 59/67 CLNs (88.1%) and 13/33 CG (39.4%). CONCLUSION EUS accurately distinguishes CLNs from CG. EUS might therefore be used to increase the accuracy of tumor staging, to select tumor stage-appropriate therapy, and to guide CG-ablative therapies.
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Affiliation(s)
| | - Heidi D Lehrke
- Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Michael R Henry
- Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Ferga C Gleeson
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Mark D Topazian
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - William S Harmsen
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | | | - Dai Inoue
- Department of Radiology, Kanazawa University, Kanazawa, Japan
| | - Naveen Gara
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | | | - Suresh T Chari
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Prasad G Iyer
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth Rajan
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Kenneth K Wang
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Michael J Levy
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota.
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21
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Bang JY, Sutton B, Hawes RH, Varadarajulu S. EUS-guided celiac ganglion radiofrequency ablation versus celiac plexus neurolysis for palliation of pain in pancreatic cancer: a randomized controlled trial (with videos). Gastrointest Endosc 2019; 89:58-66.e3. [PMID: 30120957 DOI: 10.1016/j.gie.2018.08.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 08/04/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Although EUS-guided celiac plexus neurolysis (EUS-CPN) is frequently performed, its efficacy for palliation of pain in pancreatic cancer is suboptimal. Recently, EUS-guided radiofrequency ablation (EUS-RFA) has been proposed as a palliative treatment option for pancreatic neoplasms. We performed a single-blind, randomized trial to compare the effectiveness of EUS-CPN and EUS-RFA for palliation of pain in pancreatic cancer. METHODS Patients with abdominal pain because of locally advanced or metastatic pancreatic cancer underwent EUS-CPN (n = 14) or EUS-RFA (n = 12). EUS-RFA was performed using a 1F monopolar probe passed via a 19-gauge FNA needle, by targeting the area of celiac plexus or visualized ganglia. Primary outcome was pain severity as measured by the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire pancreatic cancer module (PAN26) administered pretreatment and at 2 and 4 weeks post-treatment. Secondary outcome measures were comparison of quality of life as determined by the PAN26 and EORTC Quality of Life Questionnaire core questionnaire (C30) and opioid analgesia use between the 2 groups. RESULTS Both the PAN26 (49.0 vs 57.0, P < .001) and C30 (51.9 vs 64.4, P = .032) revealed less pain for EUS-RFA than for EUS-CPN. Also, the EUS-RFA cohort experienced significantly less-severe GI symptoms, were able to plan more for the future, and had better emotional functioning compared with the EUS-CPN group. CONCLUSIONS Compared with EUS-CPN, EUS-RFA provided more pain relief and improved the quality of life for patients with pancreatic cancer. (Clinical trials registration number: NCT03152487.).
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Affiliation(s)
- Ji Young Bang
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Bryce Sutton
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Robert H Hawes
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
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Abstract
PURPOSE OF REVIEW Pain is the most common symptom of chronic pancreatitis, having a profound effect on patients and a broad socioeconomic impact. Endoscopy is guideline recommended as first-line management for chronic pancreatitis pain in certain clinical scenarios. Herein, we provide an evidence-based review of the endoscopic treatment of pain due to chronic pancreatitis while highlighting some important confounders in the measurement of this outcome in clinical practice and research. RECENT FINDINGS Multiple recent studies have reported on the efficacy of current endoscopic therapies for chronic pancreatitis pain. Despite the high technical success rates of these procedures, pain outcomes remain disappointing. Complex mechanisms beyond ductal hypertension, such as central sensitization, visceral hypersensitivity and inflammatory neuritis account for some of the discordance observed between the rates of technical and clinical success. In addition, the sham effect is increasingly recognized as a confounder when interpreting the procedural benefit. Nevertheless, there are multiple promising innovations in the field of pancreatic endoscopy that are aimed to improve technical and clinical outcomes, but rigorous investigation is necessary to establish their role in clinical practice. SUMMARY Endoscopic therapy for chronic pancreatitis pain appears to be safe and effective in certain contexts and recent innovations in the field will hopefully further improve outcomes. In addition to evaluating the technical success of endotherapy in chronic pancreatitis, methodologically rigorous research focusing on patient-centered outcomes and accounting for the sham effect is necessary to advance this field.
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23
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Teoh AYB, Dhir V, Kida M, Yasuda I, Jin ZD, Seo DW, Almadi M, Ang TL, Hara K, Hilmi I, Itoi T, Lakhtakia S, Matsuda K, Pausawasdi N, Puri R, Tang RS, Wang HP, Yang AM, Hawes R, Varadarajulu S, Yasuda K, Ho LKY. Consensus guidelines on the optimal management in interventional EUS procedures: results from the Asian EUS group RAND/UCLA expert panel. Gut 2018; 67:1209-1228. [PMID: 29463614 DOI: 10.1136/gutjnl-2017-314341] [Citation(s) in RCA: 138] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 12/22/2017] [Accepted: 01/17/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Interventional endoscopic ultrasonography (EUS) procedures are gaining popularity and the most commonly performed procedures include EUS-guided drainage of pancreatic pseudocyst, EUS-guided biliary drainage, EUS-guided pancreatic duct drainage and EUS-guided celiac plexus ablation. The aim of this paper is to formulate a set of practice guidelines addressing various aspects of the above procedures. METHODS Formulation of the guidelines was based on the best scientific evidence available. The RAND/UCLA appropriateness methodology (RAM) was used. Panellists recruited comprised experts in surgery, interventional EUS, interventional radiology and oncology from 11 countries. Between June 2014 and October 2016, the panellists met in meetings to discuss and vote on the clinical scenarios for each of the interventional EUS procedures in question. RESULTS A total of 15 statements on EUS-guided drainage of pancreatic pseudocyst, 15 statements on EUS-guided biliary drainage, 12 statements on EUS-guided pancreatic duct drainage and 14 statements on EUS-guided celiac plexus ablation were formulated. The statements addressed the indications for the procedures, technical aspects, pre- and post-procedural management, management of complications, and competency and training in the procedures. All statements except one were found to be appropriate. Randomised studies to address clinical questions in a number of aspects of the procedures are urgently required. CONCLUSIONS The current guidelines on interventional EUS procedures are the first published by an endoscopic society. These guidelines provide an in-depth review of the current evidence and standardise the management of the procedures.
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Affiliation(s)
- Anthony Y B Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Vinay Dhir
- Baldota Institute of Digestive Sciences, Mumbai, Maharashtra, India
| | - Mitsuhiro Kida
- Department of Gastroenterology, Kitasato University Hospital, Sagamihara City, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Zhen Dong Jin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Dong Wan Seo
- Department of Gastroenterology, Asan Medical Center, Seoul, Republic of Korea
| | - Majid Almadi
- Department of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Ida Hilmi
- Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Takao Itoi
- Department of Gastroenterology, Tokyo Medical University, Tokyo, Japan
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Koji Matsuda
- St Marianna University School of Medicine, Yokohama City Seibu Hospital, Kawasaki, Japan
| | - Nonthalee Pausawasdi
- Department of Internal Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Rajesh Puri
- Department of Gastroenterology, Institute of Digestive and Hepatobiliary Sciences Medanta, The Medicity, Gurgaon, India
| | - Raymond S Tang
- Institute of Digestive Disease, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Ai Ming Yang
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Dongcheng-qu, Beijing, China
| | - Robert Hawes
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Kenjiro Yasuda
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
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Pain in pancreatic ductal adenocarcinoma: A multidisciplinary, International guideline for optimized management. Pancreatology 2018; 18:446-457. [PMID: 29706482 DOI: 10.1016/j.pan.2018.04.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 04/18/2018] [Accepted: 04/20/2018] [Indexed: 02/07/2023]
Abstract
Abdominal pain is an important symptom in most patients with pancreatic ductal adenocarcinoma (PDAC). Adequate control of pain is often unsatisfactory due to limited treatment options and significant variation in local practice, emphasizing the need for a multidisciplinary approach. This review contends that improvement in the management of PDAC pain will result from a synthesis of best practice and evidence around the world in a multidisciplinary way. To improve clinical utility and evaluation, the evidence was rated according to the GRADE guidelines by a group of international experts. An algorithm is presented, which brings together all currently available treatment options. Pain is best treated early on with analgesics with most patients requiring opioids, but neurolytic procedures are often required later in the disease course. Celiac plexus neurolysis offers medium term relief in a substantial number of patients, but other procedures such as splanchnicectomy are also available. Palliative chemotherapy also provides pain relief as a collateral benefit. It is stressed that the assessment of pain must take into account the broader context of other physical and psychological symptoms. Adjunctive treatments for pain, depression and anxiety as well as radiotherapy, endoscopic therapy and neuromodulation may be required in selected patients. There are few comparative studies to help define which combination and order of these treatment options should be applied. New pain therapies are emerging and could for example target neural transmitters. However, until better methods are available, management of pain should be individualized in a multidisciplinary setting to ensure optimal care.
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Alleviating Pancreatic Cancer-Associated Pain Using Endoscopic Ultrasound-Guided Neurolysis. Cancers (Basel) 2018; 10:cancers10020050. [PMID: 29462851 PMCID: PMC5836082 DOI: 10.3390/cancers10020050] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 02/09/2018] [Accepted: 02/12/2018] [Indexed: 12/17/2022] Open
Abstract
The most common symptom in patients with advanced pancreatic cancer is abdominal pain. This has traditionally been treated with nonsteroidal anti-inflammatory drugs and opioid analgesics. However, these treatments result in inadequate pain control or drug-related adverse effects in some patients. An alternative pain-relief modality is celiac plexus neurolysis, in which the celiac plexus is chemically ablated. This procedure was performed percutaneously or intraoperatively until 1996, when endoscopic ultrasound (EUS)-guided celiac plexus neurolysis was first described. In this transgastric anterior approach, a neurolytic agent is injected around the celiac trunk under EUS guidance. The procedure gained popularity as a minimally invasive approach and is currently widely used to treat pancreatic cancer-associated pain. We focus on two relatively new techniques of EUS-guided neurolysis: EUS-guided celiac ganglia neurolysis and EUS-guided broad plexus neurolysis, which have been developed to improve efficacy. Although the techniques are safe and effective in general, some serious adverse events including ischemic and infectious complications have been reported as the procedure has gained widespread popularity. We summarize reported clinical outcomes of EUS-guided neurolysis in pancreatic cancer (from the PubMed and Embase databases) with a goal of providing information useful in developing strategies for pancreatic cancer-associated pain alleviation.
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Mukewar S, Muthusamy VR. Recent Advances in Therapeutic Endosonography for Cancer Treatment. Gastrointest Endosc Clin N Am 2017; 27:657-680. [PMID: 28918804 DOI: 10.1016/j.giec.2017.06.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Therapeutic endosonography (EUS) may play an important role in the management of cancers. EUS-guided fiducial placement has a high success rate and can aid in stereotactic radiotherapy. EUS-guided tumor ablation therapies can help in palliation of locally advanced tumors. EUS-guided antitumor injection seems to be feasible and safe in animals; initial human studies suffer from small sample size and lack of controls. Randomized, controlled trials have not shown benefit over conventional therapy. EUS celiac plexus neurolysis has gained popularity and is performed by interventional endosonographers. Large trials are needed to determine the most appropriate indications and overall usefulness of these therapies.
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Affiliation(s)
- Saurabh Mukewar
- The Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 200 UCLA Medical Plaza, Room 330-37, Los Angeles, CA 90095, USA
| | - Venkataraman Raman Muthusamy
- The Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 200 UCLA Medical Plaza, Room 330-37, Los Angeles, CA 90095, USA.
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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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A case of pancreatic cancer with severe vomiting treated by endoscopic ultrasound-guided celiac ganglia neurolysis. Clin J Gastroenterol 2017; 10:464-468. [PMID: 28815450 DOI: 10.1007/s12328-017-0761-0] [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] [Received: 12/27/2016] [Accepted: 07/06/2017] [Indexed: 10/19/2022]
Abstract
A 50-year-old man with advanced pancreatic cancer was admitted for intractable severe vomiting 5-6 times a day, continuing over a week. He had been treated for advanced pancreatic cancer with chemotherapy for 6 months, and had undergone self-expandable metalic stent placement for obstructive jaundice due to the pancreatic cancer 4 months before admission. No abnormal findings suggesting gastrointestinal obstruction or brain metastasis were revealed on diagnostic imaging. We performed endoscopic ultrasound-guided celiac ganglia neurolysis twice by injecting ethanol into the celiac ganglion. After the treatments, the vomiting disappeared, and his eating habits gradually returned to normal. The patient died 7 months after treatment due to the advanced pancreatic cancer without recurrence of the vomiting.
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Abstract
OPINION STATEMENT Pancreas cancer is a fourth-leading cause of cancer death in the USA and its incidence is rising as the population is aging. The majority of patients present at an advanced stage due to the silent nature of the disease and treatment have focused more on palliation than curative intent. Gastroenterologists have become integral in the multidisciplinary care of these patients with a focus on providing endoscopic palliation of pancreas cancer. The three most common areas that gastroenterologists palliate endoscopically are biliary obstruction, cancer-related pain, and gastric outlet obstruction. To palliate biliary obstruction, the procedure of choice is to perform endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement. We tend to place covered self-expandable metal stents (SEMS) due to their longer patency and removability unless the patient has resectable disease. Pancreas cancer pain is a result of tumor infiltration of the celiac plexus and can be severe and poorly responsive to narcotics. To improve pain control, neurolysis of the celiac plexus has been performed for decades. Since 1996, neurolysis of the celiac area has been performed endoscopically by Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis. This has proven to be as safe and effective as traditional non-endoscopic methods and has allowed the patients to decrease their narcotic use and improve their pain control. This should be done early on in the course of the disease to have maximal effect. Gastric outlet obstruction (GOO) occurs in approximately 15-20% of patients with pancreas cancer. Endoscopic palliation of GOO can be performed by placing uncovered metal enteral stents across the obstruction. This procedure has proven to be very effective in patients who have a short life expectancy (less than two to 6 months) while surgical bypass should be considered for patients with longer life expectancies because it offers better long-term symptom relief. This chapter will review the current literature, latest advancements, and optimal techniques for endoscopic palliation of pancreatic cancer.
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Affiliation(s)
- Vishal B Gohil
- Gastrointestinal Tumor Program, Section of Endoscopic Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL, 33612, USA
| | - Jason B Klapman
- Gastrointestinal Tumor Program, Section of Endoscopic Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL, 33612, USA.
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Yasuda I, Wang HP. Endoscopic ultrasound-guided celiac plexus block and neurolysis. Dig Endosc 2017; 29:455-462. [PMID: 28160344 DOI: 10.1111/den.12824] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 01/30/2017] [Indexed: 12/13/2022]
Abstract
Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) is widely used for reducing pain originating from upper abdominal organs. It is mainly indicated to treat pancreatic cancer pain, but also to relieve pain as a result of chronic pancreatitis. Real-time guidance and color Doppler imaging by EUS made the procedure easier and safer, resulting in greater pain relief. Currently, two techniques are used for EUS-CPN. The classic approach, known as the central technique, involves injection of a neurolytic agent at the base of the celiac axis. In the bilateral technique, the neurolytic agent is injected on both sides of the celiac axis. In addition, EUS-guided direct celiac ganglia neurolysis (EUS-CGN) was introduced recently. Pain relief is achieved by EUS-CPN in 70-80% of patients with pancreatic cancer and in 50-60% of those with chronic pancreatitis. The bilateral technique may be more efficient than the central technique, although the central technique is easier and possibly safer. Moreover, EUS-CGN may provide greater pain relief than conventional EUS-CPN. Procedure-related complications include transient pain exacerbation, transient hypotension, transient diarrhea, and inebriation. Although most complications are not serious, major adverse events such as retroperitoneal bleeding, abscess, and ischemic complications occasionally occur.
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Affiliation(s)
- Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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Pain in Patients with Pancreatic Cancer: Prevalence, Mechanisms, Management and Future Developments. Dig Dis Sci 2017; 62:861-870. [PMID: 28229252 DOI: 10.1007/s10620-017-4488-z] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 02/01/2017] [Indexed: 12/18/2022]
Abstract
Pain affects approximately 80% of patients with pancreatic cancer, with half requiring strong opioid analgesia, namely: morphine-based drugs on step three of the WHO analgesic ladder (as opposed to the weak opioids: codeine and tramadol). The presence of pain is associated with reduced survival. This article reviews the literature regarding pain: prevalence, mechanisms, pharmacological, and endoscopic treatments and identifies areas for research to develop individualized patient pain management pathways. The online literature review was conducted through: PubMed, Clinical Key, Uptodate, and NICE Evidence. There are two principal mechanisms for pain: pancreatic duct obstruction and pancreatic neuropathy which, respectively, activate mechanical and chemical nociceptors. In pancreatic neuropathy, several histological, molecular, and immunological changes occur which correlate with pain including: transient receptor potential cation channel activation and mast cell infiltration. Current pain management is empirical rather etiology-based and is informed by the WHO analgesic ladder for first-line therapies, and then endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) in patients with resistant pain. For EUS-CPN, there is only one clinical trial reporting a benefit, which has limited generalizability. Case series report pancreatic duct stenting gives effective analgesia, but there are no clinical trials. Progress in understanding the mechanisms for pain and when this occurs in the natural history, together with assessing new therapies both pharmacological and endoscopic, will enable individualized care and may improve patients' quality of life and survival.
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Maple JT, Pannala R, Abu Dayyeh BK, Aslanian HR, Enestvedt BK, Goodman A, Komanduri S, Manfredi M, Navaneethan U, Parsi MA, Smith ZL, Thosani N, Sullivan SA, Banerjee S. Interventional EUS (with videos). Gastrointest Endosc 2017; 85:465-481. [PMID: 28117034 DOI: 10.1016/j.gie.2016.11.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 11/18/2016] [Indexed: 02/08/2023]
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Facciorusso A, Di Maso M, Serviddio G, Larghi A, Costamagna G, Muscatiello N. Echoendoscopic ethanol ablation of tumor combined with celiac plexus neurolysis in patients with pancreatic adenocarcinoma. J Gastroenterol Hepatol 2017; 32:439-445. [PMID: 27356212 DOI: 10.1111/jgh.13478] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/23/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM Endoscopic ultrasonography guided-celiac plexus neurolysis relieves pain in patients with pancreatic cancer but with often suboptimal and transient results. The study aims to compare the efficacy and safety of endoscopic ultrasound-guided tumor ethanol ablation combined with celiac plexus neurolysis with respect to celiac plexus neurolysis alone for pain management in patients with pancreatic cancer. METHODS Among 123 patients with unresectable pancreatic cancer referred to our Institution between 2006 and 2014, 58 treated with endoscopic ultrasound-guided celiac plexus neurolysis (Group 1) and 65 with the combined approach (Group 2) were compared. Logistic regression models were applied to identify predictors of pain relief. RESULTS The two groups presented similar baseline clinical and tumoral parameters. Pre-procedural visual analog scale score was 7 in both groups (P = 0.8), and tumor max diameter was 38 mm (range 25-59) in Group 1 and 43 mm (22-59) in Group 2 (P = 0.4). The combined treatment increased pain relief and complete pain response rate (P = 0.005 and 0.003, respectively). Median duration of pain relief was 10 (7-14) and 18 (13-20) weeks in the two groups, respectively (P = 0.004). At multivariate regression, initial visual analog scale score and endoscopic technique adopted resulted significantly associated with pain relief. No severe treatment-related adverse events were reported. Median overall survival was 6.5 months (5.1-8.6) in Group 1 and 8.3 months (6-11.4) in Group 2 (P = 0.05). CONCLUSIONS Endoscopic ultrasound-guided tumor ablation combined with celiac plexus neurolysis appears to be superior to celiac plexus neurolysis alone in terms of pain control and overall survival.
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Affiliation(s)
- Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Marianna Di Maso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | | | - Alberto Larghi
- Digestive Endoscopic Unit, Catholic University, Rome, Italy
| | | | - Nicola Muscatiello
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
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Maluf-Filho F, de Oliveira JF, Mendonça EQ, Carbonari A, Maciente BA, Salomão BC, Medrado BF, Dotti CM, Lopes CV, Braga CU, M Dutra DA, Retes F, Nakao F, de Sousa GB, de Paulo GA, Ardengh JC, Dos Santos JB, Sampaio LM, Okawa L, Rossini L, de Brito Cardoso MC, Ribeiro Camunha MA, Clarêncio M, Lera Dos Santos ME, Franco M, Schneider NC, Mascarenhas R, Roda R, Matuguma S, Guaraldi S, Figueiredo V. II Brazilian consensus statement on endoscopic ultrasonography. Endosc Ultrasound 2017; 6:359-368. [PMID: 29251269 PMCID: PMC5752757 DOI: 10.4103/eus.eus_32_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES At the time of its introduction in the early 80s, endoscopic ultrasonography (EUS) was indicated for diagnostic purposes. Recently, EUS has been employed to assist or to be the main platform of complex therapeutic interventions. METHODS From a series of relevant new topics in the literature and based on the need to complement the I Brazilian consensus on EUS, twenty experienced endosonographers identified and reviewed the pertinent literature in databases. The quality of evidence, strength of recommendations, and level of consensus were graded and voted on. RESULTS Consensus was reached for eight relevant topics: treatment of gastric varices, staging of nonsmall cell lung cancer, biliary drainage, tissue sampling of subepithelial lesions (SELs), treatment of pancreatic fluid collections, tissue sampling of pancreatic solid lesions, celiac neurolysis, and evaluation of the incidental pancreatic cysts. CONCLUSIONS There is a high level of evidence for staging of nonsmall cell lung cancer; biopsy of SELs as the safest method; unilateral and bilateral injection techniques are equivalent for EUS-guided celiac neurolysis, and in patients with visible ganglia, celiac ganglia neurolysis appears to lead to better results. There is a moderate level of evidence for: yield of tissue sampling of pancreatic solid lesions is not influenced by the needle shape, gauge, or employed aspiration technique; EUS-guided and percutaneous biliary drainage present similar clinical success and adverse event rates; plastic and metallic stents are equivalent in the EUS-guided treatment of pancreatic pseudocyst. There is a low level of evidence in the routine use of EUS-guided treatment of gastric varices.
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Affiliation(s)
- Fauze Maluf-Filho
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED); Department of Gastroenterology, Endoscopy Unit, Cancer Institute of São Paulo - ICESP, University of São Paulo, São Paulo, Brazil
| | - Joel Fernandez de Oliveira
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED); Department of Gastroenterology, Endoscopy Unit, Cancer Institute of São Paulo - ICESP, University of São Paulo, São Paulo, Brazil
| | - Ernesto Quaresma Mendonça
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED); Department of Gastroenterology, Endoscopy Unit, Cancer Institute of São Paulo - ICESP, University of São Paulo, São Paulo, Brazil
| | - Augusto Carbonari
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - Bruno Antônio Maciente
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - Bruno Chaves Salomão
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - Bruno Frederico Medrado
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - Carlos Marcelo Dotti
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - César Vivian Lopes
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - Cláudia Utsch Braga
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - Daniel Alencar M Dutra
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - Felipe Retes
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - Frank Nakao
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - Giovana Biasia de Sousa
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - Gustavo Andrade de Paulo
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED); Department of Gastroenterology, Endoscopy Unit, Cancer Institute of São Paulo - ICESP, University of São Paulo, São Paulo, Brazil
| | - Jose Celso Ardengh
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - Juliana Bonfim Dos Santos
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - Luciana Moura Sampaio
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - Luciano Okawa
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - Lucio Rossini
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | | | | | - Marcos Clarêncio
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | | | - Matheus Franco
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - Nutianne Camargo Schneider
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - Ramiro Mascarenhas
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - Rodrigo Roda
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - Sérgio Matuguma
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - Simone Guaraldi
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - Viviane Figueiredo
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
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Bang JY, Hasan MK, Sutton B, Holt BA, Navaneethan U, Hawes R, Varadarajulu S. Intraprocedural increase in heart rate during EUS-guided celiac plexus neurolysis: Clinically relevant or just a physiologic change? Gastrointest Endosc 2016; 84:773-779.e3. [PMID: 27048974 DOI: 10.1016/j.gie.2016.03.1496] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Accepted: 03/26/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Although EUS-guided celiac plexus neurolysis (EUS-CPN) is performed frequently for palliation of pain in pancreatic cancer, response to treatment is variable. Although intraprocedural increases in heart rate during alcohol injection are observed frequently, their significance and relationship to treatment outcome are unknown. The objective of this study was to examine whether a correlation exists between an increase in heart rate and treatment outcomes in patients undergoing EUS-CPN for pain relief in pancreatic cancer. METHODS This is a prospective observational study of patients with abdominal pain caused by inoperable pancreatic cancer who underwent EUS-CPN. Heart rate change was defined as an increase of ≥15 beats per minute (bpm) for ≥30 seconds during alcohol injection. Main outcome measures were to compare pain, quality of life, opioid use, and survival between heart rate change and no-change groups. RESULTS Heart rate change was observed in 25 of 51 patients (49.0%) who underwent EUS-CPN over a 12-month period. Although the heart rate change cohort had significantly better adjusted scores for pain (60 vs 73; P = .042) and components of quality of life such as nausea and/or vomiting (65 vs 81; P = .004), financial difficulties (41 vs 57; P = .02), weight loss (45 vs 65; P = .007), and satisfaction with body image (52 vs 62; P = .035), there was no significant difference in postprocedural opioid use or survival between groups. CONCLUSIONS Because patients with an increase in intraprocedural heart rate experienced significant improvement in pain and quality of life components, this observation must be further explored in order to improve the technique and outcomes of EUS-CPN.
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Affiliation(s)
- Ji Young Bang
- Division of Gastroenterology-Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Muhammad K Hasan
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Bryce Sutton
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Bronte A Holt
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | | | - Robert Hawes
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
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Hara K, Hara K, Yamao K, Yamao K, Mizuno N, Mizuno N, Hijioka S, Hijioka S, Imaoka H, Imaoka H, Tajika M, Tajika M, Tanaka T, Tanaka T, Ishihara M, Ishihara M, Sato T, Sato T, Okuno N, Okuno N, Hieda N, Hieda N, Yoshida T, Yoshida T, Niwa Y, Niwa Y. Development of a new reagent for endoscopic ultrasound-guided celiac plexus neurolysis and tumor ablation therapy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii150025] [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)
- Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kenji Yamao
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kenji Yamao
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Susumu Hijioka
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Susumu Hijioka
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Hiroshi Imaoka
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Hiroshi Imaoka
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Masahiro Tajika
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Masahiro Tajika
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tutomu Tanaka
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tutomu Tanaka
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Makoto Ishihara
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Makoto Ishihara
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Takamitu Sato
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Takamitu Sato
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nozomi Okuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nozomi Okuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nobuhiro Hieda
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nobuhiro Hieda
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tukasa Yoshida
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tukasa Yoshida
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yasumasa Niwa
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yasumasa Niwa
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
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Zhu J, Jin Z. Interventional Therapy for Pancreatic Cancer. Gastrointest Tumors 2016; 3:81-89. [PMID: 27904860 DOI: 10.1159/000446800] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 05/13/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Palliative therapy and primarily chemoradiotherapy are the mainstream treatments in patients with locally advanced or metastatic pancreatic cancer (PC). Conventional endoscopy and endoscopic ultrasound (EUS)-guided interventional therapy has emerged as an important procedure for PC management. In this review, the progress in conventional endoscopy and EUS for PC management is discussed. SUMMARY For local palliative therapy against PC, EUS-guided fine needle injection (FNI) could deliver different kinds of agents, such as radioactive seeds and fiducials. Although their feasibility and safety have been proven, the long-term efficiency of EUS-FNI is still not established. For pain, EUS-celiac plexus neurolysis (CPN) is effective. However, CPN can only relieve the pain to a limited degree, with short duration. Endoscopy-guided stent placement is the preferred strategy for biliary and duodenal obstruction. Plastic and metal stents are equally effective for the relief of obstructive jaundice. The functional times of metal stents are longer than those of a plastic stent. KEY MESSAGE For biliary obstruction, a metal stent is the first choice. The long-term efficiency of EUS-FNI still needs further study. PRACTICAL IMPLICATIONS Endoscopy and EUS-guided interventions have gradually become the mainstream method for local treatment of PC due to mini-invasiveness and real-time observation. PC is the second most common gastrointestinal malignancy and the sixth leading cause of cancer mortality in the United States, leading to about 4.0% of all cancer deaths [Siegel et al: CA Cancer J Clin 2014;64:9-29]. The only curative approach for patients with PC is surgical resection, but unfortunately 80-90% of patients have a surgically inoperable disease, with 53% having local metastases at the time of diagnosis [Weinberg et al: Oncology (Williston Park) 2015;29:809-820, 886]. Therefore, palliative therapy and primarily chemoradiotherapy are the mainstream of treatment in patients with locally advanced or metastatic PC. Although overall survival has improved from 6 to 8.5-11 months (some of them even survived for a year or more), the overall survival rate has not improved, and the 5-year survival is less than 4% [Weinberg et al: Oncology (Williston Park) 2015;29:809-820, 886; Greenlee et al: CA Cancer J Clin 2001;51:15-36; Zhang et al: Gastroenterol Res Pract 2016;2016:8962321]. Hence, it is crucial to develop more effective local treatment strategies for tumor tissue and symptom palliation. At present, endoscopy has gradually become the mainstream method for local treatment of gastrointestinal cancer due to mini-invasiveness and real-time observation. Conventional endoscopy can be used to manage the complication caused by PC, including endoscopic biliary stent placement for obstructive jaundice, and duodenal stent placement for duodenal obstruction. In addition, in those cases in whom obstructive jaundice failed to be relieved by endoscopic biliary stent placement, EUS-guided biliary drainage has emerged as an alternative procedure. Furthermore, antitumor agents can be delivered into tumor tissue or celiac plexus directly under interventional EUS guided to manage the tumor or the pain caused by the tumor. In this review, the progress in conventional endoscopy and EUS for PC management is discussed.
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Affiliation(s)
- Jianwei Zhu
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhendong Jin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
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Minaga K, Kitano M, Sakamoto H, Miyata T, Imai H, Yamao K, Kamata K, Omoto S, Kadosaka K, Sakurai T, Nishida N, Chiba Y, Kudo M. Predictors of pain response in patients undergoing endoscopic ultrasound-guided neurolysis for abdominal pain caused by pancreatic cancer. Therap Adv Gastroenterol 2016; 9:483-94. [PMID: 27366217 PMCID: PMC4913339 DOI: 10.1177/1756283x16644248] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Interventional endoscopic ultrasound (EUS)-guided procedures such as EUS-guided celiac ganglia neurolysis (EUS-CGN) and EUS-guided broad plexus neurolysis (EUS-BPN) were developed to treat abdominal cancer-associated pain; however, these procedures are not always effective. The aim of this study was to explore predictors of pain response in EUS-guided neurolysis for pancreatic cancer-associated pain. METHODS This was a retrospective analysis of prospectively collected data of 112 consecutive patients who underwent EUS-BPN in our institution. EUS-CGN was added in cases of visible celiac ganglia. The neurolytic-spread area was divided into six sections and evaluated by post-procedural computed tomography scanning. Pain intensity was assessed using a visual analog scale (VAS), and a decrease in VAS scores by ⩾3 points after neurolysis was considered a good pain response. Univariable and multivariable logistic regression analyses were performed to explore predictors of pain response at 1 and 4 weeks, and complications. RESULTS A good pain response was obtained in 77.7% and 67.9% of patients at 1 and 4 weeks, respectively. In the multivariable analysis of these patients, the combination method (EUS-BPN plus CGN) was a significant positive predictive factor at 1 week (odds ratio = 3.69, p = 0.017) and 4 weeks (odds ratio = 6.37, p = 0.043). The numbers of neurolytic/contrast spread areas (mean ± SD) were 4.98 ± 1.08 and 4.15 ± 1.12 in patients treated with the combination method and single method, respectively (p < 0.001). There was no significant predictor of complications. CONCLUSIONS EUS-BPN in combination with EUS-CGN was a predictor of a good pain response in EUS-guided neurolysis for pancreatic cancer-related pain. The larger number of neurolytic/contrast spread areas may lead to better outcomes in patients receiving combination treatment.
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Affiliation(s)
- Kosuke Minaga
- Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
| | | | - Hiroki Sakamoto
- Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
| | - Takeshi Miyata
- Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
| | - Hajime Imai
- Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
| | - Kentaro Yamao
- Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
| | - Ken Kamata
- Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
| | - Shunsuke Omoto
- Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
| | - Kumpei Kadosaka
- Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
| | - Toshiharu Sakurai
- Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
| | - Naoshi Nishida
- Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
| | - Yasutaka Chiba
- Clinical Research Center, Kinki University Hospital, Osaka-Sayama, Japan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
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Oh SY, Irani S, Kozarek RA. What are the current and potential future roles for endoscopic ultrasound in the treatment of pancreatic cancer? World J Gastrointest Endosc 2016; 8:319-329. [PMID: 27076870 PMCID: PMC4823670 DOI: 10.4253/wjge.v8.i7.319] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/15/2015] [Accepted: 02/16/2016] [Indexed: 02/06/2023] Open
Abstract
Pancreatic adenocarcinoma is the fourth leading cause of cancer-related death in the United States. Due to the aggressive tumor biology and late manifestations of the disease, long-term survival is extremely uncommon and the current 5-year survival rate is 7%. Over the last two decades, endoscopic ultrasound (EUS) has evolved from a diagnostic modality to a minimally invasive therapeutic alternative to radiologic procedures and surgery for pancreatic diseases. EUS-guided celiac plexus intervention is a useful adjunct to conventional analgesia for patients with pancreatic cancer. EUS-guided biliary drainage has emerged as a viable option in patients who have failed endoscopic retrograde cholangiopancreatography. Recently, the use of lumen-apposing metal stent to create gastrojejunal anastomosis under EUS and fluoroscopic guidance in patients with malignant gastric outlet obstruction has been reported. On the other hand, anti-tumor therapies delivered by EUS, such as the injection of anti-tumor agents, brachytherapy and ablations are still in the experimental stage without clear survival benefit. In this article, we provide updates on well-established EUS-guided interventions as well as novel techniques relevant to pancreatic cancer.
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Liu S, Fu W, Liu Z, Liu M, Ren R, Zhai H, Li C. MRI-guided celiac plexus neurolysis for pancreatic cancer pain: Efficacy and safety. J Magn Reson Imaging 2016; 44:923-8. [PMID: 27019192 DOI: 10.1002/jmri.25246] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/03/2016] [Accepted: 03/04/2016] [Indexed: 01/29/2023] Open
Abstract
PURPOSE To prospectively determine the efficacy and safety of magnetic resonance imaging (MRI)-guided celiac plexus neurolysis (CPN) for pancreatic cancer pain. MATERIALS AND METHODS In all, 39 patients with pancreatic cancer underwent 0.23T MRI-guided CPN with ethanol via the posterior approach. The pain relief, the opioid intake, and pain interference with appetite, sleep, and communication in patients were assessed after CPN during a 4-month follow-up period. The complications were also evaluated during or after CPN. RESULTS CPN procedures were successfully completed for all patients. Minor complications included diarrhea (9 of 39; 23.1%), orthostatic hypotension (14 of 39; 35.9%), and local backache (20 of 39; 51.3%). No major complication occurred. Pain relief was observed in 36 (92.3%), in 15 (40.5%), and in 11 (35.5%) patients at 1-, 2-, and 3-month visits, respectively. The median duration of pain relief was 2.9 months (95% confidence interval [CI], 2.4-3.4). The opioid intake significantly decreased at the 1-, 2-, and 3-month visits (P < 0.001, < 0.001, = 0.001 respectively), and there was significant improvement in sleep at the 1-, 2-, and 3-month visits (P < 0.001, < 0.001, = 0.001 respectively), and appetite and communication were significantly improved at the 1- and 2-month visits (all P < 0.001); all compared with baseline. CONCLUSION MRI-guided CPN appears to be an effective and minimally invasive procedure for palliative pain management of pancreatic cancer. J. MAGN. RESON. IMAGING 2016;44:923-928.
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Affiliation(s)
- Shangang Liu
- Department of Medical Oncology, Fourth People's Hospital of Zibo City, The affiliated Hospital of Shandong Cancer Hospital and Institute, Zibo, China
| | - Weiwei Fu
- Department of Medical Oncology, Fourth People's Hospital of Zibo City, The affiliated Hospital of Shandong Cancer Hospital and Institute, Zibo, China
| | - Zengjun Liu
- Department of Medical Oncology, Shandong Cancer Hospital and Institute, Jinan, China
| | - Ming Liu
- Department of Interventional MRI, Shandong Medical Imaging Research Institute, Shandong University, Jinan, China
| | - Ruimei Ren
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, China
| | - Huaxu Zhai
- Department of Medical Oncology, Fourth People's Hospital of Zibo City, The affiliated Hospital of Shandong Cancer Hospital and Institute, Zibo, China
| | - Chengli Li
- Department of Interventional MRI, Shandong Medical Imaging Research Institute, Shandong University, Jinan, China.
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Abstract
Over the last 2 decades, endoscopic ultrasound (EUS) has evolved from a noninvasive diagnostic tool to a combined diagnostic and therapeutic modality. The use of EUS complementary to endoscopic retrograde cholangiopancreatography (ERCP) has made possible biliary and pancreatic drainage in situations where conventional ERCP is unsuccessful or unlikely to be feasible. The degree of proximity to the pancreas achieved during the procedure has enabled therapeutic interventions such as drainage of peripancreatic fluid collections, pancreatic cyst ablation, and pancreatic cancer therapy. Real-time visualization of flow in adjacent blood vessels using Doppler ultrasound has allowed endovascular therapy for ablation of gastric varices and feeding vessels. Furthermore, the role of EUS is evolving in a multitude of applications such as bilioenteric and enteroenteric anastomosis in a minimally invasive manner, potentially reducing the need for surgery. This article reviews the role of EUS as an alternative to surgery in selective situations and provides an overview of future directions and evolving uses of EUS.
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Luz LP, Al-Haddad MA, DeWitt JA. EUS-guided celiac plexus interventions in pancreatic cancer pain: An update and controversies for the endosonographer. Endosc Ultrasound 2014; 3:213-20. [PMID: 25485268 PMCID: PMC4247528 DOI: 10.4103/2303-9027.144515] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 06/22/2014] [Indexed: 02/06/2023] Open
Abstract
Patients with pancreatic cancer (pancreatic ductal adenocarcinoma [PDAC]) can develop abdominal pain that can be debilitating. Celiac plexus neurolysis (CPN) is a chemical ablation of the celiac plexus that can be used to treat pain caused by pancreatic malignancy. It can be performed by an anterior or posterior approach, and also can be done percutaneously or under guidance of transabdominal ultrasound, computed tomography, intra-operatively or most recently under linear endoscopic ultrasound (EUS) guidance (EUS-CPN). EUS is well-suited for identification of the celiac plexus due to the close proximity of the gastric wall to the origin of the celiac artery. EUS-CPN is now widely practiced, and different EUS approaches have been developed in order to improve the efficacy of this technique. Our objective is to review the use of EUS-CPN in PDAC, including a description of different techniques, review of its efficacy, predictors of pain response, and describe its limitations and safety, as well as new developments.
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Affiliation(s)
- Leticia Perondi Luz
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, United States ; Gastroenterology Section, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, United States
| | - Mohammad Ali Al-Haddad
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, United States
| | - John A DeWitt
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, United States
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How to improve the efficacy of endoscopic ultrasound-guided celiac plexus neurolysis in pain management in patients with pancreatic cancer: analysis in a single center. Surg Laparosc Endosc Percutan Tech 2014; 24:31-5. [PMID: 24487155 PMCID: PMC4196780 DOI: 10.1097/sle.0000000000000032] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Visceral pain secondary to pancreatic cancer is often difficult to control and poses a challenge to the physician. We retrospectively analyzed the efficacy and safety of endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) in patients with unresectable pancreatic cancer. Forty-one patients with severe pain despite treatment with opioids underwent EUS-CPN with absolute alcohol. Patients scored their pain on a scale of 0 to 10 and were interviewed after the procedure. Of the 41 patients, 33, 37, and 25 patients reported improvement in their pain within 3 days, at 1 week, and at 3 months, respectively, following the procedure. Of all the patients, 19 patients reported substantial improvement and 4 patients showed complete disappearance of pain. Complication appeared in 2 patients with transient hypotension. In our study, EUS-CPN is a safe and effective form of treatment for intractable pain secondary to advanced pancreatic cancer.
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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: 90] [Impact Index Per Article: 9.0] [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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Wyse JM, Chen YI, Sahai AV. Celiac plexus neurolysis in the management of unresectable pancreatic cancer: When and how? World J Gastroenterol 2014; 20:2186-2192. [PMID: 24605017 PMCID: PMC3942823 DOI: 10.3748/wjg.v20.i9.2186] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 12/27/2013] [Accepted: 01/05/2014] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is the second most common abdominal cancer in North America with an estimated 20% resectability at diagnosis, and overall 5-year survival of 5%. Pain is common in pancreatic cancer patients with 70%-80% suffering substantial pain. Celiac plexus neurolysis (CPN) is a technique that can potentially improve pain control in pancreatic cancer while preventing further escalation of opioid consumption. CPN is performed by injecting absolute alcohol into the celiac plexus neural network of ganglia. This review sets out to explore the current status of CPN in non-resectable pancreatic cancer. We will examine: (1) the efficacy and safety of percutaneous-CPN and endoscopic ultrasound guided-CPN; (2) specific technique modifications including bilateral (vs central) injections and celiac ganglia neurolysis; and (3) the issue of CPN timing, early at pancreatic cancer diagnosis vs traditional late use as salvage therapy.
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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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Seicean A. Celiac plexus neurolysis in pancreatic cancer: the endoscopic ultrasound approach. World J Gastroenterol 2014; 20:110-7. [PMID: 24415863 PMCID: PMC3885999 DOI: 10.3748/wjg.v20.i1.110] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 11/01/2013] [Accepted: 11/18/2013] [Indexed: 02/06/2023] Open
Abstract
Pain in pancreatic cancer is often a major problem of treatment. Administration of opioids is frequently limited by side effects or insufficient analgesia. Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) represents an alternative for the palliative treatment of visceral pain in patients with pancreatic cancer. This review focuses on the indications, technique, outcomes of EUS-CPN and predictors of pain relief. EUS-CPN should be considered as the adjunct method to standard pain management. It moderately reduces pain in pancreatic cancer, without eliminating it. Nearly all patients need to continue opioid use, often at a constant dose. The effect on quality of life is controversial and survival is not influenced. The approach could be done in the central position of the celiac axis, which is easy to perform, or in the bilateral position of the celiac axis, with similar results in terms of pain alleviation. The EUS-CPN with multiple intraganglia injection approach seems to have better results, although extended studies are still needed. Further trials are required to enable more confident conclusions regarding timing, quantity of alcohol injected and the method of choice. Severe complications have rarely been reported, and great care should be taken in choosing the site of alcohol injection.
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Interventional endoscopic ultrasonography: an overview of safety and complications. Surg Endosc 2013; 28:712-34. [PMID: 24196551 DOI: 10.1007/s00464-013-3260-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Accepted: 09/27/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND In recent years, endoscopic ultrasonography (EUS)-guided techniques have been developed as alternatives to surgical, radiologic, or conventional endoscopic approaches for the treatment or palliation of several digestive diseases. The use of EUS guidance allows the therapeutic area to be targeting more precisely, with a possible clinical benefit and less morbidity. Nevertheless, the risks persist and must be taken into consideration. This review gives an overview of the complications observed with the most established procedures of therapeutic EUS. METHODS The PubMed and Embase databases were used to search English language articles on interventional EUS. The studies considered for inclusion were those reporting on complications of EUS-guided celiac plexus block (EUS-CPB), EUS-guided celiac plexus neurolysis (EUS-CPN), drainage of fluid pancreatic and pelvic collections, and EUS-guided biliary and pancreatic drainage (EUS-BD and EUS-PD). Variations in methodology and design in most studies made a thorough statistical analysis difficult. Instead, a frequency analysis of complications and a critical discussion were performed. RESULTS Although EUS-guided celiac plexus injection causes mainly mild and transient complications, growing experience shows that EUS-CPN is not as benign a procedure as previously thought. Most of the major complications have been observed in patients with chronic pancreatitis. The findings show that EUS-guided drainage of fluid collections is a safe procedure. Complications occur more often after the drainage of pancreatic abscesses and necrosis. Although the heterogeneity of studies dealing with pancreatobiliary drainage makes the evaluation of risks after these procedures difficult, complications after EUS-BD and EUS-PD are relatively frequent and can be severe. The technical complexity and the lack of specifically designed devices may account for their complication rates. CONCLUSIONS Clinicians can consider EUS-guided celiac injection and EUS-guided drainage of fluid collections to be safe alternatives to surgical and radiologic interventions. Well-designed prospective trials are needed to assess the risks of EUS-BD and EUS-PD accurately before they are broadly advocated after a failed endoscopic retrograde cholangiopancreatography (ERCP).
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