EUS-guided celiac plexus neurolysis and celiac plexus block

Celiac plexus radiosurgery for pain management in advanced cancer: a multicentre, single-arm, phase 2 trial

BACKGROUND

Refractory upper abdominal pain or lower back pain (retroperitoneal pain syndrome) related to celiac plexus involvement characterises pancreatic and other upper gastrointestinal malignancies and is an unmet need. We hypothesised that ablative radiation delivered to the celiac plexus would decrease pain.

METHODS

This multicentre, single-arm, phase 2 study was done at eight hospitals in five countries (Israel, Poland, Canada, the USA, and Portugal). Eligible patients aged 18 years or older with an average pain level of 5-10 on the Brief Pain Inventory short form (BPI-SF), an Eastern Cooperative Oncology Group performance status score of 0-2, and either pancreatic cancer or other tumours involving the celiac axis, received a single fraction of 25 Gy of external-beam photons to the celiac plexus. The primary endpoint was complete or partial pain response based on a reduction of the BPI-SF average pain score of 2 points or more from baseline to 3 weeks after treatment. All evaluable patients with stable pain scores were included in response assessment. The trial is registered with ClinicalTrials.gov, NCT03323489, and is complete.

FINDINGS

Between Jan 3, 2018, and Dec 28, 2021, 125 patients were treated, 90 of whom were evaluable. Patients were followed up until death. Median age was 65·5 years (IQR 58·3-71·8), 50 (56%) were female and 40 (44%) were male, 83 (92%) had pancreatic cancer, and 77 (86%) had metastatic disease. Median baseline BPI-SF average pain score was 6 (IQR 5-7). Of the 90 evaluable patients at 3 weeks, 48 (53%; 95% CI 42-64) had at least a partial pain response. The most common grade 3-4 adverse events, irrespective of attribution, were abdominal pain (35 [28%] of 125) and fatigue (23 [18%]). 11 serious adverse events of grade 3 or worse were recorded. Two grade 3 serious adverse events were probably attributed to treatment by the local investigators (abdominal pain [n=1] and nausea [n=1]), and nine were possibly attributed to treatment (seven were grade 3: blood bilirubin increased [n=1], duodenal haemorrhage [n=2], abdominal pain [n=2], and progressive disease [n=2]; and two were grade 5: gastrointestinal bleed from suspected varices 24 days after treatment [n=1] and progressive disease [advanced pancreatic cancer] 89 days after treatment [n=1]).

INTERPRETATION

Celiac plexus radiosurgery could potentially be a non-invasive palliative option for patients with retroperitoneal pain syndrome. Further investigation by means of a randomised comparison with conventional celiac block or neurolysis is warranted.

FUNDING

Gateway for Cancer Research and the Israel Cancer Association.

Sympathetic nerve blocks for persistent pain in adults with inoperable abdominopelvic cancer

BACKGROUND

Persistent visceral pain is an unpleasant sensation coming from one or more organs within the body. Visceral pain is a common symptom in those with advanced cancer. Interventional procedures, such as neurolytic sympathetic nerve blocks, have been suggested as additional treatments that may play a part in optimising pain management for individuals with this condition.

OBJECTIVES

To evaluate the benefits and harms of neurolytic sympathetic nerve blocks for persistent visceral pain in adults with inoperable abdominopelvic cancer compared to standard care or placebo and comparing single blocks to combination blocks.

SEARCH METHODS

We searched the following databases without language restrictions on 19 October 2022 and ran a top-up search on 31 October 2023: CENTRAL; MEDLINE via Ovid; Embase via Ovid; LILACS. We searched trial registers without language restrictions on 2 November 2022: ClinicalTrials.gov; WHO International Clinical Trials Registry Platform (ICTRP). We searched grey literature, checked reference lists of reviews and retrieved articles for additional studies, and performed citation searches on key articles. We also contacted experts in the field for unpublished and ongoing trials. Our trial protocol was preregistered in the Cochrane Database of Systematic Reviews on 21 October 2022.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs) comparing any sympathetic nerve block targeting sites commonly used to treat abdominal pelvic pain from inoperable malignancies in adults to standard care or placebo.

DATA COLLECTION AND ANALYSIS

We independently selected trials based on predefined inclusion criteria, resolving any differences via adjudication with a third review author. We used a random-effects model as some heterogeneity was expected between the studies due to differences in the interventions being assessed and malignancy types included in the study population. We chose three primary outcomes and four secondary outcomes of interest. We sought consumer input to refine our review outcomes and assessed extracted data using Cochrane's risk of bias 2 tool (RoB 2). We assessed the certainty of evidence using the GRADE system.

MAIN RESULTS

We included 17 studies with 1025 participants in this review. Fifteen studies with a total of 951 participants contributed to the quantitative analysis. Single block versus standard care Primary outcomes No included studies reported our primary outcome, 'Proportion of participants reporting no worse than mild pain after treatment at 14 days'. The evidence is very uncertain about the effect of sympathetic nerve blocks on reducing pain to no worse than mild pain at 14 days when compared to standard care due to insufficient data (very low-certainty evidence). Sympathetic nerve blocks may provide small to 'little to no' improvement in quality of life (QOL) scores at 14 days after treatment when compared to standard care, but the evidence is very uncertain (standardised mean difference (SMD) -0.73, 95% confidence interval (CI) -1.70 to 0.25; I² = 87%; 4 studies, 150 participants; very low-certainty evidence). The evidence is very uncertain about the risk of serious adverse events as defined in our review as only one study contributed data to this outcome. Sympathetic nerve blocks may have an 'increased risk' to 'no additional risk' of harm compared with standard care (very low-certainty evidence). Secondary outcomes Sympathetic nerve blocks showed a small to 'little to no' effect on participant-reported pain scores at 14 days using a 0 to 10 visual analogue scale (VAS) for pain compared with standard care, but the evidence is very uncertain (mean difference (MD) -0.44, 95% CI -0.98 to 0.11; I² = 56%; 5 studies, 214 participants; very low-certainty evidence). There may be a 'moderate to large' to 'little to no' reduction in daily consumption of opioids postprocedure at 14 days with sympathetic nerve blocks compared with standard care, but the evidence is very uncertain (change in daily consumption of opioids at 14 days as oral milligrams morphine equivalent (MME): MD -41.63 mg, 95% CI -78.54 mg to -4.72 mg; I² = 90%; 4 studies, 130 participants; very low-certainty evidence). The evidence is very uncertain about the effect of sympathetic nerve blocks on participant satisfaction with procedure at 0 to 7 days and time to need for retreatment or treatment effect failure (or both) due to insufficient data. Combination block versus single block Primary outcomes There is no evidence about the effect of combination sympathetic nerve blocks compared with single sympathetic nerve blocks on the proportion of participants reporting no worse than mild pain after treatment at 14 days because no studies reported this outcome. There may be a small to 'little to no' effect on QOL score at 14 days after treatment, but the evidence is very uncertain (very low-certainty evidence). The evidence is very uncertain about the risk of serious adverse events with combination sympathetic nerve blocks compared with single sympathetic nerve blocks due to limited reporting in the included studies (very low-certainty evidence). Secondary outcomes The evidence is very uncertain about the effect of combination sympathetic nerve blocks compared with single sympathetic nerve blocks on participant-reported pain score and change in daily consumption of opioids postprocedure, at 14 days. There may be a small to 'little to no' effect, but the evidence is very uncertain (very low-certainty evidence). There is no evidence about the effect on participant satisfaction with procedure at 0 to 7 days and time to need for retreatment or treatment effect failure (or both) due to these outcomes not being measured by the studies. Risk of bias The risk of bias was predominately high for most outcomes in most studies due to significant concerns regarding adequate blinding. Very few studies were deemed as low risk across all domains for any outcome.

AUTHORS' CONCLUSIONS

There is limited evidence to support or refute the use of sympathetic nerve blocks for persistent abdominopelvic pain due to inoperable malignancy. We are very uncertain about the effect of combination sympathetic nerve blocks compared with single sympathetic nerve blocks. The certainty of the evidence is very low and these findings should be interpreted with caution.

Celiac ganglia neurolysis suppresses high blood pressure in rats

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.

Coeliac plexus radiosurgery for pain management in patients with advanced cancer : study protocol for a phase II clinical trial

INTRODUCTION

Pancreatic cancer is characterised by severe mid-back and epigastric pain caused by tumour invasion of the coeliac nerve plexus. This pain is often poorly managed with standard treatments. This clinical trial investigates a novel approach in which high-dose radiation (radiosurgery) is targeted to the retroperitoneal coeliac plexus nerve bundle. Preliminary results from a single institution pilot trial are promising: pain relief is substantial and side effects minimal. The goals of this study are to validate these findings in an international multisetting, and investigate the impact on quality of life and functional status among patients with terminal cancer.

METHODS AND ANALYSIS

A single-arm prospective phase II clinical trial. Eligible patients are required to have severe coeliac pain of at least five on the 11-point BPI average pain scale and Eastern Cooperative Oncology Group performance status of two or better. Non-pancreatic cancers invading the coeliac plexus are also eligible. The intervention involves irradiating the coeliac plexus using a single fraction of 25 Gy. The primary endpoint is the complete or partial pain response at 3 weeks. Secondary endpoints include pain at 6 weeks, analgesic use, hope, qualitative of life, caregiver burden and functional outcomes, all measured using validated instruments. The protocol is expected to open at a number of cancer centres across the globe, and a quality assurance programme is included. The protocol requires that 90 evaluable patients" be accrued, based upon the assumption that a third of patients are non-evaluable (e.g. due to death prior to 3-weeks post-treatment assessment, or spontaneous improvement of pain pre-treatment), it is estimated that a total of 120 patients will need to be accrued. Supported by Gateway for Cancer Research and the Israel Cancer Association.

ETHICS AND DISSEMINATION

Ethic approval for this study has been obtained at eight academic medical centres located across the Middle East, North America and Europe. Results will be disseminated through conference presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT03323489.

Interobserver Reliability of Endoscopic Ultrasonography: Literature Review

Endoscopic ultrasonography (EUS) has been applied to the diagnosis of various digestive disorders. Although it has been widely accepted and its diagnostic value is high, the dependence of EUS diagnosis on image interpretation done by the endosonographer has persisted as an important difficulty. Consequently, high interobserver reliability (IOR) in EUS diagnosis is important to demonstrate the reliability of EUS diagnosis. We reviewed the literature on the IOR of EUS diagnosis for various diseases such as chronic pancreatitis, pancreatic solid/cystic mass, lymphadenopathy, and gastrointestinal and subepithelial lesions. The IOR of EUS diagnosis differs depending on the disease; moreover, EUS findings with high IOR and those with IOR that was not necessarily high were used as diagnostic criteria. Therefore, to further increase the value of EUS diagnosis, EUS diagnostic criteria with high diagnostic characteristics based on EUS findings with high IOR must be established.

Combined Celiac Ganglia and Plexus Neurolysis Shortens Survival, Without Benefit, vs Plexus Neurolysis Alone

BACKGROUND & AIMS

Pancreatic cancer produces debilitating pain that opioids often ineffectively manage. The suboptimal efficacy of celiac plexus neurolysis (CPN) might result from brief contact of the injectate with celiac ganglia. We compared the effects of endoscopic ultrasound-guided celiac ganglia neurolysis (CGN) vs the effects of CPN on pain, quality of life (QOL), and survival.

METHODS

We performed a randomized, double-blind trial of patients with unresectable pancreatic ductal adenocarcinoma and abdominal pain; 60 patients (age 66.4±11.6 years; male 66%) received CPN and 50 patients (age 66.8±10.0 years; male 56%) received CGN. Primary outcomes included pain control and QOL at week 12 and survival (overall median and 12 months). Secondary outcomes included morphine response, performance status, secondary neurolytic effects, and adverse events.

RESULTS

Rates of pain response at 12 weeks were 46.2% for CGN and 40.4% for CPN (P = .84). There was no significant difference in improvement of QOL between the techniques. The median survival time was significantly shorter for patients receiving CGN (5.59 months) compared to (10.46 months) (hazard ratio for CGN, 1.49; 95% CI, 1.02-2.19; P = .042), particularly for patients with non-metastatic disease (hazard ratio for CGN, 2.95; 95% CI, 1.61-5.45; P < .001). Rates of survival at 12 months were 42% for patients who underwent CPN vs 26% for patients who underwent CGN. The number of adverse events did not differ between techniques.

CONCLUSION

In a prospective study of patients with unresectable pancreatic ductal adenocarcinoma and abdominal pain, we found CGN to reduce median survival time without improving pain, QOL, or adverse events, compared to CPN. The role of CGN must be therefore be reassessed. Clinicaltrials.gov no: NCT01615653.

Celiac Plexus Block and Neurolysis: A Review

Pain is often associated with chronic pancreatitis and pancreatic cancer. Often times opioids are used to treat pain; however, the use of opioids is frequently difficult. Endoscopic ultrasound-guided celiac plexus block and celiac plexus nuerolysis are safe and effective modalities used to alleviate pain. Celiac plexus block is a transient interruption of the plexus by local anesthetic, while celiac plexus neurolysis is prolonged interruption of the transmission of pain from the celiac plexus using chemical ablation. Celiac plexus block is generally performed in the unilateral position, while celiac plexus neurolysis is performed in the unilateral or bilateral position.

Alleviating Pancreatic Cancer-Associated Pain Using Endoscopic Ultrasound-Guided Neurolysis

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.

EUS-guided celiac ganglia neurolysis: a clinical and human cadaver study (with video)

BACKGROUND AND AIMS

There is little evidence that structures targeted during EUS-guided celiac ganglia neurolysis (EUS-CGN) are celiac ganglia and that selective ethanol injection into ganglia is feasible. We aimed to visualize celiac ganglia, confirm that these structures are ganglia, and visualize ethanol spread after EUS-CGN and EUS-guided celiac plexus neurolysis (EUS-CPN).

METHODS

First, celiac ganglia were sought during 97 consecutive EUS procedures. Second, ganglia were identified in a prosected human cadaver by placing a linear echoendoscope next to the celiac trunk and removing the underlying tissue for histology. Finally, various EUS-CGN and EUS-CPN techniques were performed in human cadavers; EUS-CGN was performed with 1 mL ethanol in 1 ganglion, 1 mL per ganglion (both low volume), and 4 mL per ganglion (high volume). EUS-CPN was performed with a central (20 mL) and a bilateral (2*10 mL) approach. Transverse sections (75 μm) were obtained and photographed to allow visualization of the spread of ethanol.

RESULTS

A total of 204 ganglia were detected in 83 patients. Mean (± standard deviation) size of the long axis was 8.1 mm (± 7.4 mm). Histology of the removed region in the cadaver showed only nerve cell bodies. After low-volume EUS-CGN in cadavers, ethanol spread well beyond the targeted ganglion. After high-volume EUS-CGN in cadavers, a larger ethanol spread was seen, which also reached unidentified ganglia; the spread was comparable to the spread after EUS-CPN.

CONCLUSIONS

Specific EUS-CGN is not feasible because ethanol spreads well beyond the targeted ganglion. Unidentified celiac ganglia are better reached with high-volume EUS-CGN, and this would likely result in a more thorough neurolysis. High-volume EUS-CGN should be preferred to low-volume EUS-CGN.

Tolerance and efficacy of palliative radiotherapy for advanced pancreatic cancer: A retrospective analysis of single-institutional experiences

This study was conducted to investigate hypofractionated radiotherapy (RT) in patients with locally advanced or metastatic adenocarcinoma of the pancreas. A total of 31 patients were enrolled in this study, 26 of whom had locally advanced (M0) pancreatic cancer and 5 had metastatic (M1) disease. The patients were treated with palliative RT (6-30 Gy in 1-10 fractions over a period of 1 day-2 weeks). Treatment-related toxicity was classified according to the Common Terminology Criteria for Adverse Events, version 3.0. Early mild toxicity was observed. A total of 17 patients (55%) achieved good pain control without pharmacological therapy, and 12 patients (39%) reduced their use of analgesics; in the remaining 2 patients (6%), there was no change in analgesic use. Late high-grade (>3) toxicity was not observed. The average survival time for the 31 patients was 9 months. The 1-year overall survival rate was 16%. Palliative RT was well-tolerated and was able to prolong the survival time. The majority of the patients achieved better pain control with palliative RT.

Evidence-based Clinical Practice Guidelines for Interventional Pain Management in Cancer Pain

Intractable cancer pain not amenable to standard oral or parenteral analgesics is a horrifying truth in 10-15% of patients. Interventional pain management techniques are an indispensable arsenal in pain physician's armamentarium for severe, intractable pain and can be broadly classified into neuroablative and neuromodulation techniques. An array of neurolytic techniques (chemical, thermal, or surgical) can be employed for ablation of individual nerve fibers, plexuses, or intrathecalneurolysis in patients with resistant pain and short life-expectancy. Neuraxial administration of drugs and spinal cord stimulation to modulate or alter the pain perception constitutes the most frequently employed neuromodulation techniques. Lately, there is a rising call for early introduction of interventional techniques in carefully selected patients simultaneously or even before starting strong opioids. After decades of empirical use, it is the need of the hour to head towards professionalism and standardization in order to secure credibility of specialization and those practicing it. Even though the interventional management has found a definite place in cancer pain, there is a dearth of evidence-based practice guidelines for interventional therapies in cancer pain. This may be because of paucity of good quality randomized controlled trials (RCTs) evaluating their safety and efficacy in cancer pain. Laying standardized guidelines based on existing and emerging evidence will act as a foundation step towards strengthening, credentialing, and dissemination of the specialty of interventional cancer pain management. This will also ensure an improved decision-making and quality of life (QoL) of the suffering patients.

The therapeutic use of endoscopic ultrasonography in pediatric patients is safe: A case series

BACKGROUND/AIM

Despite the safety and high diagnostic yield of endoscopic ultrasound guided fine needle aspiration (EUS FNA) for the evaluation of gastrointestinal diseases in adults, literature discussing the therapeutic use of EUS FNA in pediatrics remains limited. This study reports our experience with the use of EUS in children with pancreaticobiliary disorders.

PATIENTS AND METHODS

A retrospective study was conducted to evaluate safety, clinical utility, and impact of therapeutic EUS on the management of children (<18 years) at a tertiary referral center. Data were collected from January 1, 2011, to April 30, 2014. Patient demographics, clinical characteristics, and EUS procedure data were reviewed. Continuous variables were described using the mean and standard deviation. Categorical variables were described using frequencies and percentages.

RESULTS

A total of 6 therapeutic EUS procedures were performed in 5 children (3 F/2 M). The mean age was 13 years (range 6-17) with a mean body mass index of 28.2 (range 18.5-38.8). The indications for EUS procedures were abdominal pain with chronic pancreatitis (3) and management of symptomatic pancreaticobiliary cysts/pseudocysts observed on previous imaging (3). All procedures were performed under general anesthesia. The 6 therapeutic procedures performed were celiac plexus block (3), cyst gastrostomy with stents placement (2), and cyst aspiration using EUS FNA (1). A celiac plexus block effectively relieved abdominal pain in 2 patients with chronic pancreatitis. Cyst gastrostomy successfully resulted in pseudocyst resolution in the follow up imaging of 2 patients (up to 6 months after the procedure). Cyst aspiration with EUS guided FNA resulted in cyst resolution and confirmation of the benign nature of the cyst in 1 patient. All the procedures were successfully completed with no reported complications.

CONCLUSION

The therapeutic use of endoscopic ultrasound in the pediatric population is safe and has a high success rate.

Therapeutic endoscopy and endoscopic ultrasound for gastrointestinal malignancies

Gastrointestinal endoscopy and endoscopic ultrasound not only provide strategies to diagnose and stage malignancy, but also to administer palliative and definitive care. Options for anticancer therapy include endoscopic mucosal resection, photodynamic therapy, thermal therapy, self-expanding metal stents and recently, endoscopic ultrasound-guided therapy, such as intratumoral injection. This review summarizes the available endoscopic techniques with a discussion of indications and recent clinical data pertaining to gastrointestinal malignancy. This review will inform the reader of emerging treatment options and stress the importance of incorporating gastroenterologists into the multidisciplinary approach in the management of gastrointestinal cancers.

Celiac plexus neurolysis for abdominal cancer pain: a systematic review

OBJECTIVE

This systematic review assesses the effectiveness and side effects of celiac plexus neurolysis (CPN) in the treatment of upper abdominal cancer pain, and evaluates whether there are any differences between the percutaneous and endoscopic ultrasound-guided (EUS) denervation techniques.

METHODS

Five databases were searched, expanded by assessing the reference lists of all retrieved papers. Sixty-six publications fulfilled the inclusion/exclusion criteria and were included in the systematic review. Randomized controlled trials were available for the percutaneous CPN, and therefore meta-analyses were performed for pain, opioid consumption, and specific side effects. The quality of life data were too heterogeneous to be assessed by a meta-analysis, and evidence for EUS CPN could only be evaluated by observational studies.

RESULTS

Meta-analyses show that percutaneous CPN significantly improves pain in patients with upper abdominal cancer, with a decrease in opioid consumption and side effects. It is unclear whether there is any change in quality of life. Case series suggest that EUS CPN improves pain. No conclusion can be made about EUS CPN's influence on opioid consumption. Although CPN is a safe procedure, side effects and complications can occur with both the percutaneous and EUS techniques.

CONCLUSIONS

Following this review, evidence suggests that CPN should be considered in patients with upper abdominal cancer where the pain is not adequately controlled with systemic analgesics or when significant opioid-induced side effects are present. The percutaneous approach remains the standard technique as robust evidence for EUS CPN is lacking.

Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis in Pancreatic Cancer: A Prospective Pilot Study of Safety Using 10 mL versus 20 mL Alcohol

Background. The dose of alcohol used in EUS-CPN is not standardized. The objective was to compare the safety of 20 mL alcohol versus 10 mL alcohol during EUS-CPN for patients with pancreatic cancer-related pain. Methods. 20 patients were selected to receive 10 mL or 20 mL of alcohol during EUS-CPN. Followup was done at baseline, 24 hours, and weekly. Health-related quality of life (HRQoL) was assessed at baseline, week 2, week 4, and every 4 weeks thereafter until pain returned. Results. There were no major complications in both groups. Minor self-limited adverse effects were seen in 6 (30%) subjects and included lightheadedness in 1 (5%), transient diarrhea in 2 (10%), and transient nausea and vomiting in 3. Pain relief was similar in both groups: 80% in the 10 mL group and 100% in the 20 mL group (P = 0.21). The mean (± SD) duration of pain relief in the 10 mL and 20 mL groups was 7.9 ± 10.8 and 8.4 ± 9.2 weeks, respectively. 30% of patients in each group had complete pain relief. Conclusions. EUS-CPN using 20 mL of alcohol is safe. Similar clinical outcomes were seen in both groups. Further investigations to confirm these findings are warranted.

EUS-guided celiac ganglion irradiation with iodine-125 seeds for pain control in pancreatic carcinoma: a prospective pilot study

BACKGROUND

Celiac plexus neurolysis for the palliative reduction of pain in unresectable pancreatic carcinoma (PC) is safe but provides limited relief. In a previous study, we found that EUS-guided implantation of iodine-125 ((125)I) around the celiac ganglia is a safe procedure and can induce apoptosis of local neurons in a porcine model.

OBJECTIVE

To evaluate the safety and efficacy of direct celiac ganglion irradiation with (125)I seeds for the relief of moderate to severe pain secondary to unresectable PC.

DESIGN

Prospective study.

SETTING

Single, tertiary care referral center.

PATIENTS

This study enrolled consecutive patients who had moderate to severe pain resulting from biopsy-proven unresectable PC.

INTERVENTION

All patients underwent EUS-guided direct celiac ganglion irradiation with (125)I seeds. Follow-up was conducted at least once weekly until death.

MAIN OUTCOME MEASUREMENTS

Blood parameters, Visual Analog Scale (VAS) score, mean analgesic (MS Contin [morphine sulfate]) consumption, and complications were evaluated during follow-up.

RESULTS

Twenty-three patients with unresectable PC underwent the procedure. The mean number of seeds implanted in the celiac ganglion per patient was 4 (range 2-6). Immediately after the procedure, pain relief and analgesic consumption showed no significant changes compared with preoperative values. Six patients (26%) reported pain exacerbation. Two weeks later, the VAS score and mean analgesic consumption were significantly less than preoperative values. No procedure-related deaths or major complications occurred.

LIMITATIONS

Uncontrolled study.

CONCLUSIONS

EUS-guided direct celiac ganglion irradiation with (125)I seeds can reduce the VAS score and analgesic drug consumption in patients with unresectable PC.

Endoscopic ultrasound-guided celiac neurolysis

Intractable abdominal pain commonly develops in patients with pancreatic cancer. Oral pharmacologic therapy is ineffective for many patients and side effects commonly occur. Celiac neurolysis (CN) is sometimes performed to enhance pain relief. Percutaneous approaches were initially described, with endoscopic ultrasound (EUS)-guided CN more recently introduced. There is uncertainty regarding the efficacy and role of CN in managing pancreatic cancer pain, but CN should still be considered in this difficult-to-treat cohort of patients. EUS-guided approaches may be favored when EUS is otherwise indicated for diagnostic or staging purposes. When EUS is not otherwise indicated, percutaneous approaches are likely favored.

The endoscopic management of pain in chronic pancreatitis

Pain resulting from chronic pancreatitis is often debilitating and difficult to manage. Many approaches have been used to treat these patients, including narcotic analgesia, antidepressants, pancreatic enzymes, octreotide, denervation procedures, such as celiac plexus block, and various palliative, decompression, or drainage procedures. Many of these procedures can be performed endoscopically, while others require a more invasive, surgical approach. The effectiveness of these therapies is not only highly variable but also often controversial. This review will discuss the endoscopic options for pain management in patients with chronic pancreatitis and their utility in treating this difficult disease.

L-cysteine administration attenuates pancreatic fibrosis induced by TNBS in rats by inhibiting the activation of pancreatic stellate cell

BACKGROUND AND AIMS

Recent studies have shown that activated pancreatic stellate cells (PSCs) play a major role in pancreatic fibrogenesis. We aimed to study the effect of L-cysteine administration on fibrosis in chronic pancreatitis (CP) induced by trinitrobenzene sulfonic acid (TNBS) in rats and on the function of cultured PSCs.

METHODS

CP was induced by TNBS infusion into rat pancreatic ducts. L-cysteine was administrated for the duration of the experiment. Histological analysis and the contents of hydroxyproline were used to evaluate pancreatic damage and fibrosis. Immunohistochemical analysis of α-SMA in the pancreas was performed to detect the activation of PSCs in vivo. The collagen deposition related proteins and cytokines were determined by western blot analysis. DNA synthesis of cultured PSCs was evaluated by BrdU incorporation. We also evaluated the effect of L-cysteine on the cell cycle and cell activation by flow cytometry and immunocytochemistry. The expression of PDGFRβ, TGFβRII, collagen 1α1 and α-SMA of PSCs treated with different concentrations of L-cysteine was determined by western blot. Parameters of oxidant stress were evaluated in vitro and in vivo. Nrf2, NQO1, HO-1, IL-1β expression were evaluated in pancreas tissues by qRT-PCR.

RESULTS

The inhibition of pancreatic fibrosis by L-cysteine was confirmed by histological observation and hydroxyproline assay. α-SMA, TIMP1, IL-1β and TGF-β1 production decreased compared with the untreated group along with an increase in MMP2 production. L-cysteine suppressed the proliferation and extracellular matrix production of PSCs through down-regulating of PDGFRβ and TGFβRII. Concentrations of MDA+4-HNE were decreased by L-cysteine administration along with an increase in GSH levels both in tissues and cells. In addition, L-cysteine increased the mRNA expression of Nrf2, NQO1 and HO-1 and reduced the expression of IL-1β in L-cysteine treated group when compared with control group.

CONCLUSION

L-cysteine treatment attenuated pancreatic fibrosis in chronic pancreatitis in rats.

The efficacy and safety of endoscopic ultrasound-guided celiac plexus neurolysis for treatment of pain in patients with pancreatic cancer

Introduction. Celiac plexus neurolysis is used in pain management of patients with advanced and unresectable pancreatic cancer. We retrospectively analyzed efficacy and safety of endoscopic ultrasound- (EUS-) guided celiac plexus neurolysis in patients treated in our unit. Methods. Twenty nine subjects with unresectable pancreatic cancer and severe pain despite pharmacological treatment underwent EUS-guided celiac plexus neurolysis with 98% ethanol. Patients scored their pain according to a 0-10 point scale and were interviewed 1-2 weeks and 2-3 months after the procedure. Results. Twenty five (86%) patients reported improvement in their pain at 1-2 weeks following the procedure. Of these, 7 (24%) reported substantial improvement (decrease in pain by more than 50%) and 4 (14%) complete disappearance of pain. Pain relief was still present in 76% of patients after 2-3 months. Treatment-related side effects included hypotonia in 1 patient, severe pain immediately postprocedure in 2 patients, and short episodes of diarrhea in 3 patients. Conclusion. Endoscopic ultrasound- (EUS-) guided celiac plexus neurolysis is a safe and effective treatment of severe pain from advanced pancreatic cancer.

Adding triamcinolone to endoscopic ultrasound-guided celiac plexus blockade does not reduce pain in patients with chronic pancreatitis

BACKGROUND & AIMS

The efficacy of endoscopic ultrasound-guided celiac plexus blockade (EUS-CPB) for painful chronic pancreatitis (CP) is uncertain. Triamcinolone is often mixed with bupivacaine to lengthen the analgesic effect. We investigated whether addition of triamcinolone increases and lengthens pain relief compared with EUS-CPB with only bupivacaine.

METHODS

We performed a single-center, blinded, randomized, controlled trial of 40 adult patients referred for EUS-CPB for treatment of painful CP. Patients were assigned randomly to groups that received EUS-CPB with triamcinolone and bupivacaine or EUS-CPB with only bupivacaine (control). Questionnaires were collected when the study began (baseline) and 1 month later. The primary end point was a decrease in the pain disability index of 10 or more points at 1 month after the procedure. Secondary end points included change in visual analogue scale, narcotic requirements, and quality of life at 1 month.

RESULTS

There were no significant differences in primary outcomes between groups (14.3% for patients who received triamcinolone vs 15.8% for controls; P = .64). The trial was stopped for futility. There was no significant difference between groups in immediate response rates (85.7% for patients who received triamcinolone vs 68.4% for control; P = .10), or other secondary end points, including change in pain visual analogue scale (0.4 vs 1.0; P = .83), treatment with morphine equivalents at 1 month (-7.8 vs 0.0; P = .35), change in quality of life at 1 month (SF-12 mental component: 1.3 vs -2.1; P = .44; and physical component: -0.2 vs 1.7; P = .54), or adverse events. The duration of response was shorter in the triamcinolone group (mean, 5.3 vs 0.6 mo; P = .01).

CONCLUSIONS

Triamcinolone does not increase pain relief or lengthen the effects of EUS-CPB.

Pancreatic cancer: an endoscopic perspective

Pancreatic cancer continues to be a diagnostic and therapeutic challenge. The advent of endoscopic ultrasound-guided interventions have brought about a paradigm shift in the endoscopic approach to diagnosis, treatment and palliation of this common malignancy. The last decade has witnessed significant advances in techniques of endoscopic biliary drainage, endoluminal stenting, celiac plexus neurolysis and image-guided radiation therapy, which have transformed the scope of palliation in pancreatic cancer. Moreover, endoscopic ultrasound-aided intratumoral delivery of fiducials, radioisotopes and chemotherapeutic agents have shown promising results and warrant further investigation. This review summarizes the recent advances in endoscopic applications for the management of pancreatic neoplasms.

Endoscopic ultrasound-guided fine needle injection for cancer therapy: the evolving role of therapeutic endoscopic ultrasound

Endoscopic ultrasound (EUS) is central to the diagnosis and staging of many malignancies, but now has an evolving role in cancer therapy. EUS-guided fine needle injection (FNI) is already used for palliative interventions such as treatment of pain through nerve blockade and to guide biliary decompression when conventional ERCP is not possible. More recently, EUS-FNI has been used to deliver specific anti-tumor agents for pancreatic cyst ablation and local control of tumor growth in patients with unresectable solid malignancies. The agents used to date include ethanol, brachytherapy seeds, and chemotherapeutic agents such as paclitaxel. In addition, FNI of new immunomodulating cell cultures such as mixed lymphocyte and dendritic cell cultures has also been reported, as has FNI of several different viral vectors for antitumor therapy. Although experience with these agents remains preliminary, EUS-FNI is a minimally invasive approach to deliver local antitumor agents, and is likely to have an expanding role in cancer therapy.

Interventional endoscopic ultrasonography for pancreatic cancer

Endoscopic ultrasonography (EUS) represents the combination of endoscopy and intraluminal ultrasonography. This allows use of a high-frequency transducer (5-20 MHz) that, due to the short distance to the target lesion, provides ultrasonographic images of higher resolution than those obtained from other imaging modalities, including multiple-detector-row-computed tomography, magnetic resonance imaging, and positron emission tomography. EUS is now a widely accepted modality for diagnosing pancreatic diseases. However, the most important limitation of EUS has been the lack of specificity in differentiating between benign and malignant changes. In 1992, EUS-guided fine needle aspiration (FNA) of lesions in the pancreas head was introduced into clinical practice, using a curved linear-array echoendoscope. Since then, EUS has evolved from EUS imaging to EUS-FNA and wider applications. Interventional EUS for pancreatic cancer includes EUS-FNA, EUS-guided fine needle injection, EUS-guided biliary drainage and anastomosis, EUS-guided celiac neurolysis, radiofrequency ablation, brachytherapy, and delivery of a growing number of anti-tumor agents. This review focuses on interventional EUS, including EUS-FNA and therapeutic EUS for pancreatic cancer.

A review of the thoracic splanchnic nerves and celiac ganglia

Anatomical variation of the thoracic splanchnic nerves is as diverse as any structure in the body. Thoracic splanchnic nerves are derived from medial branches of the lower seven thoracic sympathetic ganglia, with the greater splanchnic nerve comprising the more cranial contributions, the lesser the middle branches, and the least splanchnic nerve usually T11 and/or T12. Much of the early anatomical research of the thoracic splanchnic nerves revolved around elucidating the nerve root level contributing to each of these nerves. The celiac plexus is a major interchange for autonomic fibers, receiving many of the thoracic splanchnic nerve fibers as they course toward the organs of the abdomen. The location of the celiac ganglia are usually described in relation to surrounding structures, and also show variation in size and general morphology. Clinically, the thoracic splanchnic nerves and celiac ganglia play a major role in pain management for upper abdominal disorders, particularly chronic pancreatitis and pancreatic cancer. Splanchnicectomy has been a treatment option since Mallet-Guy became a major proponent of the procedure in the 1940s. Splanchnic nerve dissection and thermocoagulation are two common derivatives of splanchnicectomy that are commonly used today. Celiac plexus block is also a treatment option to compliment splanchnicectomy in pain management. Endoscopic ultrasonography (EUS)-guided celiac injection and percutaneous methods of celiac plexus block have been heavily studied and are two important methods used today. For both splanchnicectomies and celiac plexus block, the innovation of ultrasonographic imaging technology has improved efficacy and accuracy of these procedures and continues to make pain management for these diseases more successful.

Endoscopic ultrasound in the papilla and the periampullary region

Endoscopic ultrasound (EUS) provides relevant information when an ampullary or periampullary tumor is suspected. Early detection, T and N staging and Fine Needle Aspiration plus cithologic confirmation, are some of the expected benefits. Exclusion of benign findings like choledocholithiasis or chronic pancreatitis is also important. A correct understanding of the complex ampullary and periampullary anatomy is needed. Knowledge of the individual clinical history and other previous diagnostic images all contribute to a successful EUS examination. Radial and lineal EUS images are uniquely detailed and, at the moment, it seems to be the best way to exclude or confirm malignant or benign findings. We propose a procedural algorithm, including EUS, for suspected ampullary or periampullary tumors. This review summarizes the vast amount of information to be found spread in the literature, and recognizes this small anatomic area as the origin for a clinical entity with proper clinical presentation, proper imaging and proper therapeutic resolutions. The benefits of performing EUS for its study are highlighted.

Endoscopic ultrasound-guided cholangiopancreatography and rendezvous techniques

Endoscopic ultrasound-guided cholangiopancreatography (EUCP) has become an alternative to percutaneous drainage or surgery in patients with obstructive jaundice or pancreatic obstruction after failed conventional ERCP. The different techniques of biliary and pancreatic drainage are described and the literature is reviewed. Due to the technical complexity associated with this procedure, it should be reserved for endoscopists at tertiary care centers with advanced training in both EUS and ERCP.

Pancreatic cancer: progress made

Pancreatic cancer remains a deadly disease. Despite advances on many fronts, surgeons play a leading role in the diagnosis and management of pancreatic cancer. Preoperative staging is best provided by "pancreas-protocol" abdominal CT, although endoscopic ultrasound and diagnostic laparoscopy can add value in selected patients. Surgical resection, which remains the only curative option, is now accomplished with uniformly low perioperative mortality in high-volume centers (<3%), although complications remain frequent. Unfortunately, the long-term prognosis for pancreatic cancer remains poor with 5-year survival rates only 15-23% with median survival of 13 to 18 months. Recent data from randomized trials have supported the role for adjuvant chemotherapy and questioned the traditional role of radiation. Early diagnosis and targeted multimodality treatments would appear essential to optimizing the results of surgical therapy.

Endoscopic ultrasound-guided celiac plexus neurolysis using a reverse phase polymer

AIM: To assess the feasibility of endoscopic ultrasound (EUS)-guided celiac plexus neurolysis (CPN) using a poloxamer.

METHODS: In this prospective evaluation, six Yorkshire pigs underwent EUS-guided CPN. Three received an injection of 10 mL of 0.25% Lidocaine plus methylene blue (group 1) and three received an injection of 10 mL of 0.25% Lidocaine plus blue colored poloxamer (PS137-25) (group 2). Necropsy was performed immediately after the animals were sacrificed. The abdominal and pelvic cavities were examined for the presence of methylene blue and the blue colored poloxamer.

RESULTS: EUS-guided CPN was successfully performed in all 6 pigs without immediate complication. Methylene blue was identified throughout the peritoneal and retroperitoneal cavity in group 1. The blue colored poloxamer was found in the retroperitoneal cavity immediately adjacent to the aorta, in the exact location of the celiac plexus in group 2.

CONCLUSION: EUS-guided CPN using a reverse phase polymer in a non-survival porcine model was technically feasible. The presence of a poloxamer gel at the site of the celiac plexus at necropsy indicates a precise delivery of the neurolytic agent.

Efficacy of endoscopic ultrasound-guided celiac plexus block and celiac plexus neurolysis for managing abdominal pain associated with chronic pancreatitis and pancreatic cancer

BACKGROUND/GOALS

Endoscopic ultrasound (EUS)-guided celiac plexus block (CPB) and celiac plexus neurolysis (CPN) have become important interventions in the management of pain due to chronic pancreatitis and pancreatic cancer. However, only a few well-structured studies have been performed to evaluate their efficacy. Given limited data, their use remains controversial. Herein, we evaluate the efficacy of EUS-guided CPB and CPN in alleviating chronic abdominal pain due to chronic pancreatitis and pancreatic cancer respectively.

STUDY METHODS

Using Medline, Pubmed, and Embase databases from January 1966 through December 2007, a thorough search of the English literature for studies evaluating the efficacy of EUS-guided CPB and CPN for the management of chronic abdominal pain due to chronic pancreatitis and pancreatic cancer was conducted, along with a hand search of reference lists. Studies that involved less than 10 patients were excluded. Data on pain relief was extracted, pooled, and analyzed.

RESULTS

A total of 9 studies were included in the final analysis. For chronic pancreatitis, 6 relevant studies were identified, comprising a total of 221 patients. EUS-guided CPB was effective in alleviating abdominal pain in 51.46% of patients. For pancreatic cancer, 5 relevant studies were identified with a total of 119 patients. EUS-guided CPN was effective in alleviating abdominal pain in 72.54% of patients.

CONCLUSIONS

EUS-guided CPB was 51.46% effective in managing chronic abdominal pain in patients with chronic pancreatitis, but warrants improvement in patient selection and refinement of technique, whereas EUS-guided CPN was 72.54% effective in managing pain due to pancreatic cancer and is a reasonable option for patients with tolerance to narcotic analgesics.

Relationship between patient symptoms and endosonographic findings in chronic pancreatitis

BACKGROUND/AIMS

The endoscopic ultrasound (EUS) diagnosis of chronic pancreatitis (CP) relies on the presence of up to nine distinct pancreatic parenchymal and ductal abnormalities, without considering other factors such as age, duration of disease or clinical symptoms. Our goal was to examine the impact of patient symptoms on EUS findings in patients with CP.

METHODS

All patients with previously suspected CP who had symptomatic disease referred to our medical center for pancreatic EUS were identified. Patients were stratified into two groups based on their clinical symptoms--pain only and steatorrhea +/- pain. Groups were compared using two-tailed comparative testing.

RESULTS

53 patients (group 1) with pain only and 27 patients with steatorrhea +/- pain (group 2) were identified. Patients in group 1 were younger and more likely female. Compared to group 1 (pain only), group 2 (steatorrhea +/- pain) had more total (5.37 vs. 3.28, p < 0.01) and ductal abnormalities (2.56 vs. 0.83, p < 0.01), although the number of parenchymal abnormalities between groups 1 and 2 (2.45 vs. 2.88, p = 0.07) was not different.

CONCLUSION

The presence of steatorrhea +/- pain in patients with CP undergoing pancreatic EUS examination is associated with more total and ductal abnormalities. Stratification based on underlying patient symptoms may be valuable as an adjunct to endosonographic findings in making or excluding the diagnosis of CP.

Clinical trial: a randomized trial comparing fluoroscopy guided percutaneous technique vs. endoscopic ultrasound guided technique of coeliac plexus block for treatment of pain in chronic pancreatitis

BACKGROUND

Coeliac plexus block (CPB) is a management option for pain control in chronic pancreatitis. CPB is conventionally performed by percutaneous technique with fluoroscopic guidance (PCFG). Endoscopic ultrasound (EUS) is increasingly used for CPB as it offers a better visualization of the plexus. There are limited data comparing the two modalities.

AIM

To compare the pain relief in chronic pancreatitis among patients undergoing CPB either by PCFG technique or by EUS guided technique.

METHODS

Chronic pancreatitis patients with abdominal pain requiring daily analgesics for more than 4 weeks were included. Fifty six consecutive patients (41 males, 15 females) participated in the study. EUSG-CPB was performed in 27 and PCFG-CPB in 29 patients. In both the groups, 10 mL of Bupivacaine (0.25%) and 3 mL of Triamcinolone (40 mg) were given on both sides of the coeliac artery through separate punctures.

RESULTS

Pre and post procedure pain scores were obtained using a 0-10 visual analogue scale. Improvement in pain scores was seen in 70% of subjects undergoing EUS-CPB and 30% in Percutaneous- block group (P = 0.044).

CONCLUSIONS

EUS-guided coeliac block appears to be better than PCFG-CPB for controlling abdominal pain in patients with chronic pancreatitis.

Minimizing complications in pancreaticobiliary endoscopy

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound are invaluable tools in the diagnostic and therapeutic evaluation and management of a variety of pancreatobiliary disorders. Along with a significant refinement in the equipment and techniques used has come a recent trend toward aggressive therapeutic interventions. Because of the technical nature of these procedures and the characteristics of the patients, post-procedural complications may occur, ranging from minor (requiring brief hospitalization) to severe (causing permanent disability or death). This review summarizes these complications and outlines strategies to minimize them.

Interventional endoscopic ultrasonography

Endoscopic ultrasonography (EUS) is the combination of endoscopy and intraluminal ultrasonography. This allows use of a high frequency transducer, which, due to the short distance to the target lesion, enables ultrasonographic images of high resolution to be obtained. Endoscopic ultrasonography is now a widely accepted modality for the diagnosis of pancreatobiliary diseases. It can be used to determine the depth of invasion of gastrointestinal malignancies, and often for visualizing lesions more precisely than other imaging modalities. The most important early limitation of EUS was the lack of specificity in the differentiation between benign and malignant changes. In 1992, EUS-guided fine needle aspiration (EUS-FNA) of lesions in the pancreas head has been made possible using a curved linear array echoendoscope. Since then, many researchers have expanded the indication of EUS-FNA to various kinds of lesions and also for a variety of therapeutic purposes. In this review, we particularly focus on the present and future roles of interventional EUS, including EUS-FNA and therapeutic EUS.

Detection of celiac ganglia with radial scanning endoscopic ultrasonography

BACKGROUND/AIMS

It has been recently reported that celiac ganglia can be identified by linear-array endoscopic ultrasonography (EUS). Still, there has been no report on the detection rate of celiac ganglia with radial scanning EUS. The aim of this study was to evaluate the detection rate of celiac ganglia by radial scanning echoendoscopy during a routine examination.

METHODS

We prospectively enrolled 57 consecutive patients (23 men, 34 women; mean age 54 years, range 21-78 years) who were referred for EUS examination from September 2006 to December 2006. EUS was performed using a radial scanning echoendoscope. The size, location and EUS appearance of the celiac ganglia were recorded for each patient.

RESULTS

Celiac ganglia were identified in 51 out of 57 patients (89.4%). They were identified at the left side of the celiac trunk and aorta and between the celiac artery and the left adrenal gland. They appeared as hypoechoic, oblong or lobulated structures, often with an irregular edge, and they often contained a hyperechoic focus or strand. The mean size was 18 mm by 4 mm. Structures corresponding to the visualized celiac ganglia were retrospectively identified on CT scans in 33 among the 37 patients (89.2%).

CONCLUSIONS

The results of this study showed that celiac ganglia could be identified, with radial scanning EUS, in the majority of subjects.

Initial evaluation of the efficacy and safety of endoscopic ultrasound-guided direct Ganglia neurolysis and block

BACKGROUND

Celiac plexus neurolysis and block are considered safe but provide limited pain relief. Standard techniques target the region of the celiac plexus but do not attempt injections directly into celiac ganglia. The recent recognition that celiac ganglia can be visualized by endoscopic ultrasound (EUS) now allows direct injection into celiac ganglia for neurolysis (CGN) and block (CGB).

AIMS

To determine the safety and initial efficacy (at 2-4 wk) of direct ganglia injection in patients with moderate to severe pain secondary to unresectable pancreatic carcinoma or chronic pancreatitis.

METHODS

An EUS database was reviewed to identify patients undergoing CGN and CGB. Data were retrieved from the medical records and phone follow-up.

RESULTS

Thirty-three patients underwent 36 direct celiac ganglia injections for unresectable pancreatic cancer (CGN N = 17, CGB N = 1) or chronic pancreatitis (CGN N = 5, CGB N = 13) with bupivacaine (0.25%) and alcohol (99%) for CGN, or Depo-Medrol (80 mg/2 cc) for CGB. Cancer patients reported pain relief in 16/17 (94%) when alcohol was injected and 0/1 (00%) when steroid was injected. For chronic pancreatitis, 4/5 (80%) who received alcohol reported pain relief versus 5/13 (38%) receiving steroids. Thirteen (34%) patients experienced initial pain exacerbation, which correlated with improved therapeutic response (P < 0.05). Transient hypotension and diarrhea developed in 12 and 6 patients, respectively.

CONCLUSIONS

Initial experience suggests that EUS-guided direct celiac ganglion block or neurolysis is safe. Alcohol injection into ganglia appears to be effective in both cancer and chronic pancreatitis. Prospective trials are needed to confirm the efficacy of this new approach.

Endoscopic evaluation and palliation of pancreatic adenocarcinoma: current and future options

PURPOSE OF REVIEW

To analyze the role of endoscopy in the diagnosis and treatment of pancreatic adenocarcinoma. New developments, including molecular analysis of endoscopic tissue samples and injection of antitumor agents, are discussed.

RECENT FINDINGS

Endoscopic ultrasound is superior to multidetector computed tomography for detection of smaller than 3-cm pancreatic tumors, and for T staging, while they are equivalent for nodal staging and assessment of resectability. Molecular analysis of endoscopic ultrasound-guided fine-needle aspiration samples has the potential to improve cancer detection. Placement of biliary self-expanding metal stents prior to Whipple resection appears to be an option to reduce stent obstruction and allow neo-adjuvant therapy. Endoscopic ultrasound-guided biliary drainage is a new approach to patients who failed to have a biliary stent placed by endoscopic retrograde cholangiopancreatography. Contrast-enhanced endoscopic ultrasound may be useful to differentiate focal inflammation from pancreatic carcinoma. Optical coherence tomography was shown to distinguish nonneoplastic from neoplastic main pancreatic duct tissue. Finally, endoscopic ultrasound-guided interstitial brachytherapy and injection of therapeutic agents into tumors have shown exciting preliminary results.

SUMMARY

Endoscopic approaches for diagnosis and palliation of pancreatic adenocarcinoma are rapidly expanding. These new techniques show promise in the diagnosis, staging, and treatment of pancreatic malignancy.

Endoscopic ultrasonography guided celiac plexus neurolysis and celiac plexus block in the management of pain due to pancreatic cancer and chronic pancreatitis

Pain is a common symptom of pancreatic disease and is frequently difficult to manage. Pain relief provided by narcotics is often suboptimal and is associated with significant side effects. An alternative approach to pain management in pancreatic disease is the use of celiac plexus block (CPB) or neurolysis (CPN). Originally performed by anesthesiologists and radiologists via a posterior approach, recent advances in endoscopic ultrasonography (EUS) have made this technique an attractive alternative. EUS guided celiac plexus block/neurolysis is simple to perform and avoids serious complications such as paraplegia or pneumothorax that are associated with the posterior approach. EUS guided CPN should be considered first line therapy in patients with pain due to pancreatic cancer. It provides superior pain control compared to traditional management with narcotics. A trend for improved survival in pancreatic cancer patients treated with CPN has been reported, but larger studies are needed to confirm this finding. At this time, the use of EUS guided CPB cannot be recommended as routine therapy for pain in chronic pancreatitis since only one-half of the patients experience pain reduction and the beneficial effect tends to be short lived. EUS guided CPB and CPN should be used as part of a multidisciplinary team approach for pain management.

Endoscopic ultrasonography (EUS)-guided access and therapy of pancreatico-biliary disorders: EUS-guided cholangio and pancreatic drainage

Endoscopic ultrasonography (EUS)-guided cholangio pancreatic drainage (ECPD) has been reported as an alternative to surgery or percutaneous transhepatic cholangiography if endoscopic retrograde cholangiopancreatography (ERCP) is unsuccessful. With the development of EUS and the ability to direct a puncture within the field of vision, ECPD has been used increasingly in tertiary centers. Its concept includes EUS-guided access into a dilated biliary tree or main pancreatic duct, creation of a transenteric fistula deployment of a stent across the fistula or the ampulla after a rendezvous-type procedure. EUS-guided cholangio-drainage may be performed in a transhepatic or extrahepatic fashion, whereas EUS-guided pancreatic drainage can be antegrade or retrograde. Their respective efficacy can be measured by resolution of biliary obstruction or pain improvement in case of pancreatic drainage. The current literature, including our own data, shows that ECPD has an acceptable success and complication rate and might be considered as first-line therapy in centers offering expertise in EUS and ERCP. The techniques, efficacy, and complication of ECPD are discussed.

Endoscopic palliation of pancreatic cancer

Endoscopic approaches have revolutionized the palliation of advanced pancreatic cancer. The ideal management consists of a multidisciplinary approach involving surgeons, endoscopists, radiologists, and oncologists. Concurrent advances in the fields of interventional radiology and laparoscopic surgical oncology should be readdressed and directly compared with endoscopic approaches in randomized controlled trials. Exciting novel endoscopic techniques are being developed and evaluated; however, these approaches require further validation with randomized clinical trials to determine the safety and efficacy when compared with more traditional approaches.

Changing trends in endosonography: linear imaging and tissue are increasingly the issue

The indications and uses of endoscopic ultrasound (EUS) are expanding. The role of EUS-guided fine needle aspiration (EUS-FNA) is considered an essential aspect of EUS practice. A significant change in the indications and technology used for EUS has occurred. This study was designed to compare the use of radial, linear, and miniprobe endosonography equipment during a 10-year period in a single, large, EUS practice. A retrospective review of an EUS experience at a single high-volume center was performed. In this single-center experience, there has been an increase in the volume of EUS and EUS-FNA. For luminal cancer-staging cases, the radial echoendoscope is the predominant scope used for examination and has not changed significantly. In contrast, for pancreaticobiliary and mediastinal indications, the use of the linear array echoendoscope alone has increased and currently is the preferred scope for examination (33% vs. 76%, P < 0.001; 46% vs. 96%, P < 0.001). In these cases requiring EUS-FNA, the use of the linear array scope alone has increased from 17% to 73%. In this single-center experience, EUS has shifted from an imaging technology to an image-guided biopsy and therapeutic technology. The use of the linear array EUS alone has increased, especially in the evaluation of pancreatobiliary and mediastinal disease and when fine-needle aspiration is performed.

Neurolytic celiac plexus block for pain control in unresectable pancreatic cancer

BACKGROUND

A major focus of palliation in patients with unresectable pancreatic cancer is pain control. The aim of this systematic review was to examine the efficacy and safety of neurolytic celiac plexus blockade (NCPB) compared with standard treatment in randomized controlled trials (RCTs) involving patients with unresectable pancreatic cancer.

METHODS

An electronic search was completed (1966 through August, 2005) for RCTs comparing NCPB versus control (standard treatment and/or sham NCPB) in patients with unresectable pancreatic cancer. The primary outcome was pain measured on a 10-point visual analogue scale (VAS). Secondary outcomes included opioid usage, adverse effects, quality of life (QOL), and survival. All outcomes were assessed at 2, 4, and 8 wk.

RESULTS

Five RCTs involving 302 patients (NCPB, N = 147; control, N = 155) met the inclusion criteria. Mean age was 61.0 +/- 4.3 yr. Compared with control, NCPB was associated with lower VAS scores for pain at 2, 4, and 8 wk (weighted mean difference [WMD]-0.60, 95% CI -0.82 to -0.37). Opioid usage (in mg/d oral morphine) was also reduced at 2, 4, and 8 wk (WMD -85.9, 95% CI -144.0 to -27.9). NCPB was associated with a reduction in constipation (relative risk 0.67, 95% CI 0.49-0.91), but not other adverse events. No differences in survival were observed. QOL could not be adequately analyzed due to differences in outcome scales among studies.

CONCLUSIONS

In patients with unresectable pancreatic cancer, NCPB is associated with improved pain control, and reduced narcotic usage and constipation compared with standard treatment, albeit with minimal clinical significance.

Predicting unresectability in pancreatic cancer patients: the additive effects of CT and endoscopic ultrasound

BACKGROUND

A standardized method for predicting unresectability in pancreatic cancer has not been defined. We propose a system using CT and endoscopic ultrasound (EUS) to assess patients for unresectable pancreatic cancers.

METHODS

Radiologic and surgical data from 101 patients who underwent exploration/resection for pancreatic cancer were reviewed. Chi-squares were used to identify five factors significantly correlated with unresectability, which were incorporated into a scoring system (one point for each factor).

RESULTS

The resectability rates were 84, 56, and 10% for patients with scores of 0, 1, and 2, respectively. All four patients with three risk factors for unresectability had unresectable tumors. The most accurate results were achieved in patients evaluated with both CT and EUS.

DISCUSSION

This scoring system stratifies pancreatic cancer patients into three groups: (1) patients with a score of zero (likely to undergo successful resection), (2) patients with a score of one (likely to benefit from laparoscopic staging prior to attempting resection), and (3) patients with a score of two or higher (low probability of successful resection, who may be better served by neoadjuvant therapy).