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Background: Celiac plexus neurolysis is an effective mode of long-term palliation of somatic pain in inoperable upper gastro-intestinal neoplasm. CT guidance is the most accepted method of localising the tip of the needle, through which, the neurolytic agent, commonly Absolute Alcohol, is introduced along the celiac ganglion. Three dimensional assessment of the retroperitoneal anatomy avoids injury to adjacent viscera and vascular structures. Para-aortic needle tip position between the origins of celiac and superior mesenteric arteries is an accepted position to inject neurolytic agent. We report a case of successful celiac plexus neurolysis in a patient with a celiacomesenteric trunk. Till date no such case has been reported, primarily due to the Low incidence of celiacomesenteric trunk. Case presentation: A 63-year-old man developed progressive icterus and severe abdominal pain over 3 months. The pain severity was 6/10. An Ultrasonography and contrast enhanced CT of the abdomen revealed inoperable carcinoma of head of pancreas and a celiacomesenteric trunk. The pancreatic mass extended along the right lateral border of the celiacomesenteric trunk, not extending upto the aorta. Considering the severity of pain, poor compliance to opioid pain medication, and a possibility of early tumour extension upto the aortic margin, celiac plexus neurolysis was considered. The procedure was performed under CT guidance and local anaesthesia, using a mixture of absolute alcohol, Bupivacaine and diluted iodinated contrast. Bilateral paravertebral antecrural access was performed, using 22 gauge Chiba needles, after localisation on preprocedural CT-scan. On the left, hydrodissection was performed using normal saline, to displace the left renal parenchyma from the trajectory of the needle to be used for neurolysis. The patient's pain visual analogue scale score reduced to 0/10, immediately after the procedure. He had a post procedural hypotension, managed conservatively by complete bed rest for 1 day and intravenous fluid administration. Conclusions: Celiac plexus neurolysis can safely be done in aberrant upper abdominal vascular anatomy, under CT guidance and local anaesthesia. To avoid periprocedural complications, hydrodissection may be effectively used to displace normal anatomical structures from the trajectory of the access needle, through which a mixture of absolute alcohol and local anaesthetic may be delivered. [ABSTRACT FROM AUTHOR]

Over the last decade, endoscopic ultrasound-guided celiac plexus block and celiac plexus neurolysis (CPN) have been established as effective and safe interventions to palliate visceral abdominal pain resulting from chronic pancreatitis and pancreatic cancer, respectively. Endoscopic ultrasound-guided approach has advantages over the percutaneous methods because it facilitates precise injection into the region owing to its more direct access. More recently, celiac ganglion neurolysis has been promoted as a safe alternative to CPN and it may be a more efficacious technique than CPN. Although large, adequately powered randomized trials are lacking, observational studies and small randomized trials support the use of celiac plexus block and CPN in palliation of pain in patients with chronic pancreatitis or pancreatic cancer, respectively. However, these interventions’ affect on quality of life and survival is unclear and further large randomized studies are needed. [ABSTRACT FROM AUTHOR]

Abstract: Endoscopic ultrasound (EUS) has become the most accurate imaging modality for the gallbladder/bileduct/liver and locoregional cancer staging of the gastrointestinal tract. Fine-needle aspiration (FNA) has added a new level of accuracy for EUS in nodal staging, with reported numbers in the 90% range for luminal and pancreaticobiliary disease. In addition, new non-gastrointestinal applications are being evaluated, such as the role of EUS-FNA for the staging of non-small-cell lung cancer and exploration of the posteriormediastinum. Furthermore, the same techniques that makes safe tissue sampling possible are being explored for their use as interventional applications, such as EUS-guided celiac plexus neurolysis, fine-needle injection, EUSguided pseudocyst drainage, and EUS-guided cholangiography and pancreatography. This review describes the current clinical status of EUS in gastrointestinal and pancreatobiliary diseases as well as future and novel indications and therapeutic strategies for this technology. [Copyright &y& Elsevier]

EUS-guided celiac plexus neurolysis (CPN) and celiac plexus block (CPB) are safe and at least as effective as percutaneous approaches. EUS-guided CPN is particularly effective for pain related to malignant involvement of the celiac ganglia. For patients without cancer, CPB is generally used instead but appears to be less effective. Given the different injectates, needles, and techniques that are available, there are many possible ways to perform the procedure. Further studies are needed to clarify the most effective way to perform the technique and to determine the optimal place for it in the therapeutic algorithms. [Copyright &y& Elsevier]

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. [ABSTRACT FROM AUTHOR]