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Background: Pain remains a significant challenge for cancer patients. Upper abdominal cancer patients often experience severe visceral pain, profoundly impacting their quality of life. In such cases, minimally invasive pain interventions like celiac plexus neurolysis may be necessary to alleviate the debilitating pain and improve overall wellbeing. Objective: Our study aimed to evaluate the effectiveness of various volumes of 70% alcohol (40 ml, 30 ml, 20 ml) for neurolytic celiac plexus block in alleviating pain associated with upper abdominal tumors. Patients and Methods: at the Anesthesia, ICU and Pain Management Department of Al Menoufia University Hospital, and the Pain Therapy Unit at Tanta Cancer Center, spanning one year. Ninety patients of both sexes who were suffering from non-resectable upper abdominal tumors were enrolled in the study. Results: Visual Analog Scale (VAS) scores exhibited a significant decrease for 12 months in all groups with the degree of relief being directly proportional to the volume of the neurolytic agent. Additionally, there was a noteworthy reduction in tramadol requirements observed up to 12 months in both Group I and group II, and up to 5 months only for Group III. Furthermore, Quality of Life Questionnaire-Core 30 (QLQ-C30) scores were markedly decreased in Group III compared to other two groups, but it was better in group I than in group II from 4th month onward. Conclusion: Administration of 40 ml and 30 ml of 70% alcohol yielded significant outcomes compared to the use of 20 ml of 70% alcohol. Furthermore, the use of 40 ml of 70% alcohol demonstrated superior results when compared to 30 ml in terms of the duration of pain relief, opioid consumption, and overall QOL improvement. [ABSTRACT FROM AUTHOR]

The emergence of endoscopic ultrasound (EUS) has significantly impacted the diagnosis and management of pancreatic cancer and its associated sequelae. While the definitive role of EUS for pancreatic cancer remains incompletely characterized by currently available guidelines, EUS undoubtedly offers high diagnostic accuracy, the precise staging of pancreatic neoplasms, and the ability to perform therapeutic and palliative interventions. However, current challenges to EUS include limited specialized expertise and variability in operator proficiency. As the technology and techniques continue to evolve and become more refined, EUS is poised to play an increasingly integral role in shaping pancreatic cancer care. [ABSTRACT FROM AUTHOR]

Background and Objectives: Endoscopic ultrasound (EUS)-guided celiac plexus block (CPB) for pain relief in chronic pancreatitis (CP) has wide variation in results as reported in the literature. The objective was to find out the efficacy of EUS-CPB in painful CP from our region where phenotype of CP is different from West and to find out factors favoring response to EUS-CPB.

Endoscopic ultrasound (EUS) is an integrated diagnostic technique merging endoscope and ultrasound to examine the digestive system. EUS has emerged as a primary diagnostic method for pancreatic diseases due to its distinctive benefits. Over the past four decades, EUS has undergone a transformation, shifting its role from primarily diagnostic to increasingly therapeutic. Additionally, in recent years, EUS has emerged as an increasingly prominent adjunctive or alternative approach to conventional surgical interventions. This review provides a comprehensive analysis of current technological approaches in the treatment of pancreatic diseases. The dynamic interplay with diverse therapeutic approaches has reinvigorated EUS and shaped its trajectory in the management of pancreatic diseases.

Background and Objectives : Endoscopic ultrasound (EUS)-guided celiac plexus block (CPB) for pain relief in chronic pancreatitis (CP) has wide variation in results as reported in the literature. The objective was to find out the efficacy of EUS-CPB in painful CP from our region where phenotype of CP is different from West and to find out factors favoring response to EUS-CPB. Methods and Results : Patients with known CP who underwent EUS-CPB were assessed for response to CPB. Response to EUS-CPB was recorded as more than 50% reduction in visual analogue scale (VAS) score for pain severity at 1 week, 4 weeks, 12 weeks and 24 weeks after procedure. Factors between responders and nonresponders were analyzed. Among 29 patients who underwent EUS-CPB during the study period, response was seen in 72.4% patients after the procedure. The mean time to response to EUS-CPB was 1.22 (± 0.43) days. Mean duration of response was 8 months (± 4.73). Short duration of painful CP (≤2 years) was seen in 15 patients (51.72%) and long duration (>2 years) was seen in 14 (48.27%). Among responders (21/29), those patients who had short duration of disease had significantly lower median VAS score at 12 weeks, (1 versus 3, p- value= 0.026) and at 24 weeks, (1.5 versus 2.5, p -value= 0.049), as compared to those with longer duration of disease. Overall, 83.3% males responded as compared to 54.54% females (p = 0.04). Significant proportion of subjects who responded either stopped or used analgesics occasionally (p < 0.0001). There was no statistically significant difference in response to EUS-CPB with respect to age, prior history of endoscopic retrograde cholangiopancreatography (ERCP), etiology of CP, prior history of surgery, or whether only EUS-CBP was done (p > 0.05 for all). Conclusion : EUS-CPB can be effective when used in select group of painful CP patient who are not immediate candidates for surgery especially in early course of disease. It can be offered to patients with persistent pain despite optimum medical therapy. When effective, it can reduce need for analgesic medication at least in short to medium term. [ABSTRACT FROM AUTHOR]

Objectives: The management of chronic pain among patients with abdominal cancer is complex; against that, the neurolysis of the celiac plexus (CPN) is the best technique at the moment to determine the efficacy and safety in the treatment of chronic pain secondary to oncological pathology of the upper abdomen. Material and Methods: This was a systematic review of controlled clinical trials between 2000 and 2021, in the sources MEDLINE/PubMed, Cochrane, Scopus, Web of Science, and Google Scholar. Three independent evaluators analysed the results of the bibliographical research. The quality of the studies was assessed with the Jadad scale and the mean difference (95% confidence interval) and heterogeneity of the studies (I2) were calculated with Review Manager 5.3. Results: Seven hundred and forty-four publications were identified, including 13 studies in the qualitative synthesis and three studies in the quantitative synthesis. No difference was found in the decrease in pain intensity between 1 and 12 weeks after the intervention, comparing the experimental group with the control (P > 0.05). The adverse effects related to neurolysis were not serious and transitory, mentioning the most frequent adverse effects and reporting a percentage between 21% and 67% (with 17% for echoendoscopic neurolysis and 49% for percutaneous neurolysis). Conclusion: Celiac plexus neurolysis for the treatment of severe chronic pain secondary to oncological pathology in the upper hemiabdomen produces similar pain relief as conventional pharmacological analgesic treatment. It is a safe analgesic technique since the complications are mild and transitory. [ABSTRACT FROM AUTHOR]

Abstract 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.

The emergence of endoscopic ultrasound (EUS) has significantly impacted the diagnosis and management of pancreatic cancer and its associated sequelae. While the definitive role of EUS for pancreatic cancer remains incompletely characterized by currently available guidelines, EUS undoubtedly offers high diagnostic accuracy, the precise staging of pancreatic neoplasms, and the ability to perform therapeutic and palliative interventions. However, current challenges to EUS include limited specialized expertise and variability in operator proficiency. As the technology and techniques continue to evolve and become more refined, EUS is poised to play an increasingly integral role in shaping pancreatic cancer care.

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]

Purpose: To perform a systematic review and meta-analysis of published studies to evaluate the analgesic efficacy and safety of computed tomography (CT)-guided single celiac plexus neurolysis (CPN) with the injection of a neurolytic agent into the celiac plexus in one session (CT-guided single CPN). Methods: PubMed, the Cochrane Library, and Ichushi-Web were searched for English or Japanese articles published up to February 2022, which reported findings about patients who underwent CT-guided single CPN. The outcome measures assessed in the systematic review and meta-analysis were the pain measurement scales from 0 to 10 before and after the intervention and the rate of minor and major complications. Results: The pooled pain measurement scales at pre-intervention and 1- or 2-, 7-, 30-, 60-, 90-, and 180-day post-intervention was 6.72 (95% confidence interval [CI], 4.77–9.46, I2 = 98%), 2.31 (95% CI 2.31–4.44, I2 = 92%), 2.84 (95% CI 1.39–5.79, I2 = 95%), 3.36 (95% CI 1.66–6.77, I2 = 98%), 3.19 (95% CI 1.44–7.08, I2 = 59%), 3.87 (95% CI 1.88–7.97, I2 = 0%), and 3.40 (95% CI 3.02–3.83, I2 = not applicable), respectively. The pooled minor complication rates of diarrhea, hypotension, nausea or vomiting, and pain associated with the procedure were 18% (95% CI 8–37%, I2 = 45%), 16% (95% CI 2–58%, I2 = 76%), 6% (95% CI 2–16%, I2 = 1%), and 7% (95% CI 2–21%, I2 = 17%), respectively. There was no major complication in the included studies. Conclusion: CT-guided single CPN can be performed safely and provides immediate analgesic efficacy although the amount of heterogeneity is characterized as large. Further investigation of its long-term analgesic efficacy is required. [ABSTRACT FROM AUTHOR]

Context: Currently, short-term recurrence of pain is the biggest clinical challenge of celiac plexus neurolysis for patients with refractory abdominal cancer pain.Aim: To evaluate the analgesic effect and safety of celiac plexus neurolysis using ethanol injection combined with iodine-125 (125I) radioactive seed implantation for refractory abdominal cancer pain.Settings and Design: The study was a randomized controlled trial.Methods and Materials: About 10 patients with severe refractory abdominal cancer pain were enrolled in this study. The patients were randomly divided into group A (ethanol injection combined with 125I radioactive seed implantation, n = 5) and group B (ethanol injection alone, n = 5). The primary end point was pain relief measured by means of numerical rating scale (NRS). And the secondary end point was mean administration of analgesic drugs and the safety of the procedure.Statistical Analysis Used: Repeated measures of analysis of variance were used for statistical analysis.Results: The NRS scores were significantly reduced by 24 h postprocedure in both groups (group A: P = 0.001 and group B: P = 0.001). Group A did not show significant recurrence based on NRS scores during the follow-up period. In contrast, the NRS scores recurred significantly in group B by 1 month postprocedure (P = 0.026). The intake of analgesic drugs was significantly reduced in both the groups postprocedure (group A: P = 0.013 and group B: P = 0.013). Overall, it was significantly lower in group A than in group B (P = 0.041). No treatment-related deaths or major complications were observed.Conclusions: Celiac plexus neurolysis using ethanol injection in combination with 125I radioactive seed implantation has a longer analgesic duration than using ethanol injection alone. It could be a safe and long-lasting analgesic approach for managing refractory abdominal cancer pain. [ABSTRACT FROM AUTHOR]

Introduction: Celiac plexus neurolysis (CPN) has been developed as adjunctive therapy to medical management (MM) of abdominal pain associated with unresectable pancreatic cancer. We aimed to conduct a systematic review and meta‐analysis to obtain updated and more accurate evidence on the efficacy of additional types of CPN, including endoscopic ultrasound‐guided CPN (EUS‐CPN). Methods: On March 16, 2021, we performed searches of PubMed, Web of Science, and CENTRAL for original randomized controlled trials (RCTs). We defined the primary outcome as a standardized pain intensity score with a range of 0–10, and evaluated the mean difference between the CPN + MM and MM groups at 4, 8, and 12 weeks after the initiation of treatment. We used a random‐effects model to synthesize the mean differences across RCTs. Results: We selected 10 RCTs involving 646 individuals. The synthesized mean difference in the pain intensity score between the CPN + MM and MM groups was −0.58 (95% confidence interval [CI]: −1.09 to −0.07) (p = 0.034) in favor of CPN + MM at 4 weeks, −0.46 (95%CI: −1.00 to 0.08) (p = 0.081) at 8 weeks, and − 1.35 (95%CI: −3.61 to 0.92) (p = 0.17) at 12 weeks. Conclusions: This updated meta‐analysis of CPN demonstrates its efficacy for managing abdominal pain at 4 weeks. Although there are various limitations, when abdominal pain in patients with unresectable pancreatic cancer is poorly controlled with MM alone, CPN should be an option even if the duration of effect is short‐lived, taking into account the absence of serious adverse events. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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.

Celiac plexus neurolysis (CPN) is an effective intervention of upper abdominal malignant pain. Multiple approaches have been described for performing CPN. This narrative review has been done to evaluate current literature on CPN by different approaches and to determine whether anyone approaches is better. The literature search of PubMed and Google Scholar was done and relevant literature was compiled for the review. The literature was reviewed to find the preferred technique of CPN by different investigators and differences in the outcome and/or complications and side effects. Multiple techniques of CPN such as classic retrocrural approach, antecrural approach, transaortic approach, anterior approach, and transdiscal approach have been used by different researchers. Effective pain relief and improved quality of life (QOL) have been reported to be achieved by all the approaches. Unilateral transaortic approach has been found to be associated with less morbidity owing to single needle and with a lesser volume of neurolytic agent used. The most common imaging method used by a large number of researchers is c-arm fluoroscope, though few authors have recommended computed tomography scan-guided CPN, especially in cases with distorted anatomy due to disease spread or metastasis. This review has focused only on CPN by the pain physicians. Other techniques such as endoscopic ultrasound technique by gastroenterologists and splanchnic radio-frequency ablation have not been compared. CPN is an effective technique for pain control and improved QOL in upper abdominal malignant pain. The selection of approach is largely dependent on the pain physician's choice and does not show the difference in the outcomes.

Endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to an advanced therapeutic modality. With the advent of better technologies and accessories, EUS has found ground in the management of gastrointestinal (GI) malignancies, not only for diagnosis but also for therapeutic purposes. EUS can tackle a host of conditions, including hepato-pancreatico-biliary malignancies. Advances and experience in various EUS-guided biliary drainage techniques have enabled the endosonologist to tackle biliary obstruction when conventional techniques of endoscopic retrograde cholangiopancreatography (ERCP) and/or percutaneous transhepatic biliary drainage (PTBD) fails. More and more emerging data not only establishes the safety of EUS-BD but also demonstrates superior efficacy over PTBD and sometimes even ERCP. Malignant gastric outlet obstruction can now be safely managed with EUS-guided gastroenterostomy. Starting from pain management in malignant tumors through celiac plexus neurolysis to various tumor ablative therapies, EUS has forged ahead over percutaneous treatment or surgical options in the management of GI malignancies. Additional data is now coming up on the prospects of EUS-guided immunotherapy and biological therapy for tumor management. The future of EUS therapeutics in the field of GI malignancies is bright. With increasing evidence, this modality becoming a key player in management of a host of complex clinical conditions arising out of GI malignancies is in the offing. This review focuses on elucidating the role of therapeutic EUS in the management of GI malignancies, a synopsis of various techniques, data on its safety and efficacy as well as future advancements in this domain. [ABSTRACT FROM AUTHOR]

Rong Shi, Danxu Ma, Yinan Yang, Yun Wang Department of Anesthesia and Pain Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, People’s Republic of ChinaCorrespondence: Yun WangDepartment of Anesthesia and Pain Medicine, Beijing Chaoyang Hospital, Capital Medical University, No. 8, Gongtinan Road, Chaoyang District, Beijing 100020, People’s Republic of ChinaEmail wangyun129@ccmu.edu.cnBackground: Imaging-guided celiac plexus neurolysis using ultrasound (US) guidance via a transabdominal approach and endoscopic-ultrasound (EUS) has been increasingly applied for the treatment of pancreatic cancer-associated abdominal pain.Objective: To investigate the application of ultrasound-guided and fluoroscopy-assisted celiac plexus neurolysis in a patient with advanced pancreatic cancer suffering from refractory abdominal pain for which oral opioid treatment was ineffective.Case Report: We report a case of ultrasound-guided and fluoroscopy-assisted celiac plexus neurolysis in a patient with advanced pancreatic cancer with refractory abdominal pain. With the patient in the prone position, celiac plexus neurolysis was performed under real-time US guidance. The transducer was placed below the costal margin and a puncture needle with an ultrasound enhancement tip was inserted in-plane aiming for the lateral anterior end of the vertebral body. The correct needle tip position was confirmed by the C-arm with contrast material located anterior to the vertebral body and posterior to the diaphragm.Conclusion: We highlight the use of an US-guided and fluoroscopy-assisted posterior approach for use in celiac plexus neurolysis procedures, particularly in patients suffering from contraindications from the US or EUS-guided anterior approaches.Keywords: ultrasound, image-guidance, posterior approach, celiac plexus neurolysis, pancreatic cancer, abdominal pain

Savas Comlek Gayrettepe Florence Nightingale Hospital, Department of Anesthesiology and Reanimation, Istanbul, Besiktas 34349, TurkeyCorrespondence: Savas ComlekGayrettepe Florence Nightingale Hospital, Department of Anesthesiology and Reanimation, Istanbul, Besiktas 34349, TurkeyTel +90 532 4273310Email savatc@gmail.comBackground/Aims: In most instances of abdominal pain associated with pancreatic cancer, pain may become refractory to increasing doses of narcotics. Celiac plexus neurolysis represents an option; however, altered celiac plexus anatomy may render this treatment infeasible or ineffective, where splanchnic nerve neurolysis may represent another option. This study aimed to investigate the outcomes of splanchnic neurolysis in pancreatic cancer patients not responsive to celiac plexus neurolysis.Patients and Methods: Among all 84 patients who underwent celiac plexus neurolysis for pancreatic cancer pain during the study period, 34 patients did not respond and underwent splanchnic nerve neurolysis under fluoroscopic guidance and thus included in this retrospective study. Stage IV, III, and II disease was present in 38.2%, 47.1%, and 14.7% of the patients. During the study, 88.2% were receiving chemotherapy, whereas none were on radiotherapy. Data for daily narcotic dose equivalents and Visual Analogue Scale (VAS) scores during outpatient visits at baseline, 2 weeks, 2 months, and 3 months were extracted.Results: Pain response rates were 76.5%, 84.4%, and 71.0%, at 2 weeks, 2 months, and 3 months, respectively. A significant and dramatic reduction was seen in VAS scores at 2 weeks (2.8± 1.2 versus 6.3± 1.1, p< 0.001), and this significant decline was maintained for 3 months. Similarly, a significant and dramatic reduction was seen in daily narcotic need at 2 weeks (20.8± 32.9 versus 93.4± 86.2 mg, p< 0.001), which was also maintained during the 3-month follow-up. The procedure was generally well tolerated.Conclusion: Findings of this study suggest that splanchnic neurolysis represents a durable and effective option for pain control in pancreatic cancer patients in whom the neurolysis of the celiac plexus is ineffective. However, these conclusions refer to only preliminary single-center results in a selected patient group; thus, further large studies are warranted.Keywords: pancreatic cancer, pain control, splanchnic neurolysis, celiac plexus neurolysis

Abdominal pain related to pancreatic disease is often extremely disabling. Endoscopic ultrasound (EUS)-guided celiac plexus block (CPB) is used to control pain associated with chronic pancreatitis. EUS-guided celiac plexus neurolysis (CPN) is typically used to reduce pain associated with pancreatic cancer and can be considered early at the time of diagnosis of inoperable disease. EUS-guided celiac plexus interventions have been shown to be significantly effective in pancreatic pain relief, which is achieved in approximately 70–80% of patients with pancreatic cancer and in 50–60% of those with chronic pancreatitis. Serious complications from CPB and CPN are rare. Most frequent adverse events are diarrhoea, orthostatic hypotension, and a transient increase in abdominal pain. In this article, the Portuguese Group for Ultrasound in Gastroenterology (GRUPUGE) presents an updated perspective of the potential role of EUS-guided celiac plexus interventions, addressing the selection criteria and technical issues of different techniques and analysing recent data on their safety and efficacy.

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. [ABSTRACT FROM AUTHOR]

The Indian Society for Study of Pain (ISSP), Cancer Pain Special Interest Group guidelines on interventional management for cancer pain in adults provide a structured, stepwise approach which will help to improve the management of cancer pain and to provide the patients with minimally acceptable quality of life. The guidelines have been developed based on the available literature and evidence, to suit the needs, patient population, and situations in India. A questionnaire based on the key elements of each sub draft addressing certain inconclusive areas where evidence was lacking was made available on the ISSP website and circulated by e-mail to all the ISSP and Indian Association of Palliative Care members. We recommend using interventional management when conventional therapy fails to offer adequate benefits or causes undesirable side effects. Vertebroplasty should be offered to patients with uncontrolled bone pain when expertise is available.

Background: Abdominal and back pain is present in up to 80% of patients with pancreatic cancer and represents a significant cause of morbidity. Celiac plexus neurolysis (CPN) demonstrated good results in relief of pain of upper abdominal malignancy. Dexmedetomidine is alpha-2 adrenoceptor highly selective agonist approved for procedural sedation use. Patients and Methods: Fifty patients divided in two groups with locally advanced pancreatic cancer-associated abdominal pain underwent endoscopic ultrasound (EUS)-guided CPN using bupivacaine 0.5% alone with alcohol for the first group and bupivacaine 0.5% plus dexmedetomidine in the second. Patients scored their pain according to the Numeric Rating Scale (NRS-11) before, 2, 4, 6, 8, 12, 16, and 24 week after the procedure. Results: The study has included 50 patient in two groups. There was no significant difference between the two groups as regards medical, laboratory, or tumor characters. The median pain score decreases from 8.32 ± 0.75 before the procedure to 3.75 ± 3.72 24 week after the procedure in group 1 and from 8.08 ± 0.86 before to 1.67 ± 2.3 24 week after the procedure in group 2. However, there was no significant difference between the two groups in the median pain score during the first 4 weeks. There was no statistically significant difference between the two groups as regards the median survival time. Conclusion: The addition of dexmedetomidine to bupivacaine 0.5% in EUS-CPN demonstrated beneficial effects as regards the degree and duration of pain relieve with negligible effect on the patient survival. [ABSTRACT FROM AUTHOR]

Background: Abdominal pain from primary cancer or metastatic disease is a significant cause of pain for patients undergoing treatment for the disease. Patient's pain may be resistant or non-responsive to the pharmacological management, hence minimal invasive pain intervention like celiac plexus neurolysis or splanchnic nerve rhizolysis may be required to relieve pain of such patients. Objective: The aim of this retrospective study is to assess the effect of celiac plexus neurolysis for pain relief in patients with upper gastro-intestinal malignancies. Study Design: This is a retrospective, observational study with short review. Methods: This retrospective observational study was done in the Pain Medicine unit from 2016 and November 2018. Ninety-four patients with upper abdominal malignancy and unrelenting pain, non-responsive or poorly responsive to pharmacological treatment as per WHO ladder of analgesics, received fluoroscopy-guided celiac plexus neurolysis (CPN). All the patients underwent celiac plexus neurolysis through Trans-Aortic approach and the primary outcome measure was pain as assessed with Visual Analogue Scale (VAS) ranging from 0 to 10; the secondary outcome measures were morphine consumption per day (M), quality of life (QOL) as assessed by comparing the percent of positive responses and complications, if any. These were noted and analyzed prior to intervention and then on day 1, and months 1, 2, 3, 4, 5, 6 following CPN. Results: Follow up was completed 6 months after the procedure. VAS score, daily morphine consumption, and the quality of life showed improvement for the duration of the study. There was some relapse in pain and deterioration in QOL during the fourth to sixth month of pain intervention due to disease progression. Some transient known side effects also occurred. Conclusion: Trans-Aortic celiac plexus neurolysis with low volume of alcohol is a safe procedure providing up to 6 months of pain relief and is an effective, well established, minimally invasive procedure for abdominal pain due to primary malignancy or metastatic spread. [ABSTRACT FROM AUTHOR]

Introduction: In gallbladder cancer (GBC), nearly 80% of patients present with pain in the upper abdomen. Narcotic analgesics are usually effective in relieving cancer pain, but induce adverse effects. Celiac plexus neurolysis (CPN) is an effective alternative to reduce pain caused by upper abdominal cancer; however, no published data is available on endoscopic ultrasound–guided celiac plexus neurolysis (EUS-CPN) for pain relief in GBC. Methods: Patient with unresectable GBC with upper abdominal pain of severity ≥ 3 on visual analogue scale (VAS), not responding to non-steroidal anti-inflammatory drugs (NSAIDs) and tramadol were recruited prospectively over a 2-year period. EUS-CPN was done using the central approach in all the patients. Pain severity was assessed using a VAS, prior to EUS-CPN and at 2, 4, and 8 weeks after CPN. Results: The technical success was achieved in 19 of 21 patients in whom the procedure was attempted. There was a significant improvement in pain severity as measured by VAS compared with the baseline at 2 and 4 weeks after treatment (p <.001); at 8 weeks, pain severity was less but was not statistically significant. At week 2, nearly 95% of patients had either complete or partial relief of pain. This response declined to 63% and 61% at 4 and 8 weeks, respectively. There was a significant reduction in daily requirement of analgesics in all the patients at 2 and 4 weeks compared with baseline (p <.001); at week 8, there was no significant reduction in analgesic dose. Conclusion: EUS-CPN has a high technically success in most patients with GBC. It improved pain in about 60% to 70% patients and lowered daily analgesic dose requirement for up to 4 weeks. There was no procedure-related complication. [ABSTRACT FROM AUTHOR]

The Indian Society for Study of Pain (ISSP), Cancer Pain Special Interest Group guidelines on interventional management for cancer pain in adults provide a structured, stepwise approach which will help to improve the management of cancer pain and to provide the patients with minimally acceptable quality of life. The guidelines have been developed based on the available literature and evidence, to suit the needs, patient population, and situations in India. A questionnaire based on the key elements of each sub draft addressing certain inconclusive areas where evidence was lacking was made available on the ISSP website and circulated by e-mail to all the ISSP and Indian Association of Palliative Care members. We recommend using interventional management when conventional therapy fails to offer adequate benefits or causes undesirable side effects. Vertebroplasty should be offered to patients with uncontrolled bone pain when expertise is available. [ABSTRACT FROM AUTHOR]

Celiac plexus neurolysis (CPN) is an established modality of choice for the management of pain due to advanced upper abdominal malignancies. The procedure is usually performed under imaging guidance, traditionally, using fluoroscopy. Numerous techniques and approaches have been described in literature for conducting CPN with fluoroscopy and computed tomography guidance. Ultrasound (USG) has gained popularity recently for performing the procedure with added advantage of being radiation free, enabling real-time visualization of the needle tract, and possibility of performing CPN in bedside setting. This article describes the technique of USG-guided CPN using percutaneous anterior approach and discusses the dos and don'ts associated with it.

Aims: The study aimed to evaluate the safety and efficacy of navigated magnetic resonance imaging (MRI)-guided celiac plexus neurolysis (CPN) using a 0.4 T open magnetic resonance system.Materials and Methods: A retrospective analysis was performed on 23 patients with unresectable pancreatic cancer who underwent MRI-guided CPN between January 2013 and October 2017. Clinical outcomes were evaluated by recording the complications, the opioid intake, and questionnaire before the intervention and at the time point of 1 day, 1 month, and 3 months postprocedure using a numerical visual analog scale (VAS).Results: Navigated MRI guidance allowed the precise placement of needle in the targeted area and the visualization of the injected neurolysis agents for all cases. The VAS scores decreased from 8.8 ± 1.0 to 2.9 ± 0.9, 4.2 ± 1.7, and 4.7 ± 1.8 at 1 day, 1 month, and 3 months postprocedure (P < 0.05). This intervention reduced the dosage of opioid consumption 1 month after the procedure (52.3 ± 10.4 mg before the treatment vs. 28.2 ± 4.9 mg after the treatment; P < 0.001). Treatment-related side effects included hematoma in one patient, short episodes of diarrhea in three patients, and hypotension in four patients.Conclusions: With the assistance of the navigation system, MRI-guided CPN is a safe and effective treatment approach for managing the upper abdominal pain in patients with unresectable pancreatic cancer. [ABSTRACT FROM AUTHOR]

Chronic upper abdominal pain occurs as a complication of various malignant and benign diseases including pancreatic cancer and chronic pancreatitis, and when present may contribute to lower quality of life and higher mortality. Though various pain management strategies are available as part of a multimodal approach, they are often incompletely effective and accompanied by side effects. Pain originating in upper abdominal viscera is transmitted through the celiac plexus, which is an autonomic plexus located in the retroperitoneum at the root of the celiac trunk. Direct intervention at the level of the plexus, referred to as celiac plexus block or neurolysis depending on the injectate, is a minimally invasive therapeutic strategy which has been demonstrated to decrease pain, improve function, and reduce opiate dependence. Various percutaneous techniques have been reported, but, with appropriate preprocedural planning, use of image guidance (usually computed tomography), and postprocedural care, the frequency and severity of complications is low and the success rate high regardless of approach. The main benefit of the intervention may be in reduced opiate dependence and opiate-associated side effects, which in turn improves quality of life. Celiac plexus block and neurolysis are safe and effective treatments for chronic upper abdominal pain and should be considered early in patients experiencing such symptoms. [ABSTRACT FROM AUTHOR]

Introduction:Endosonography guided celiac plexus neurolysis is efficacious in the management of severe pain due to advanced pancreatic cancer. Although endoscopic ultrasound (EUS) guided celiac neurolysis (CN) is mostly a safer procedure than the percutaneous posterior approach, severe complications such as paraplegia have been reported. Case report:We describe a patient with advanced adenocarcinoma of the pancreas and severe pain who developed irreversible paraplegia after EUS guided CN. Conclusions:Endosonography guided celiac plexus neurolysis also might be complicated with paraplegia as already observed with percutaneous approach. The underlying mechanism could not be explained clearly until now. We detected concomitant embolic occlusion of Adamkiewicz and anterior radicularis magna arteries in magnetic resonance angiography. So, this procedure must be considered only for malignancy patients. [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]

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. [ABSTRACT FROM AUTHOR]

Background: An interventional procedure like celiac plexus neurolysis (CPN) has a significant role in relieving intractable pain in patients with locally advanced abdominal malignancies. Ultrasound (USG) guidance enables performance of bedside CPN by real-time visualization of the needle trajectory. The objective of the study was to perform percutaneous USG-guided CPN and to verify technical outcomes of the procedure using a post-procedure CT scan. Methods: Eleven eligible patients of advanced upper abdominal malignancies having a pain score of >3/10 on visual analog scale (VAS) were recruited to undergo CPN. A post-procedure CT scan was performed to evaluate technical outcomes of the procedure. Patients were evaluated for pain relief. They were followed up at the 1st, 4th, and 6th weeks after CPN. Results: Eleven patients underwent USG-guided CPN. The injected drug was visualized as an echogenic cloud in ultrasound in 7 out of 11 (64%) patients. In the remaining 4 patients, the echogenic cloud was not well formed. In the post-procedure CT scan, the spread of the drug was seen in all 11 patients. This spread was bilaterally symmetrical in 7 (64%) patients and asymmetrical or unilateral in 4 (36%) patients. All patients in the immediate post-procedure period and 91% of the patients during the 1st-, 4th-, and 6th-week follow up had improvement in their pain scores. Conclusion: A post-procedure CT scan was useful in verifying the technical outcome of USG-guided CPN in patients with advanced upper abdominal malignancies. [ABSTRACT FROM AUTHOR]

Endoscopic ultrasound-guided celiac plexus neurolysis (EUSCPN) 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. [ABSTRACT FROM AUTHOR]

Managing pancreatic adenocarcinoma pain is challenging particularly because of the multifactorial etiology of the pain. Too often, the treatment relies only on the WHO analgesics ladder. According to this approach, analgesics should only be prescribed depending on the pain intensity. As far as possible, treatment should also take into account the mechanisms of the nociceptive process as well as the comorbidity. Perineural invasion which is encountered in nearly 100% of pancreatic adenocarcinoma, generates a neuropathic pain. Neuropathic analgesic regimens should be introduced in advanced pancreatic adenocarcinoma, regardless of the pain intensity. The concept of multi-drugs regimen acting on different nociceptive targets should be promoted in order to improve analgesia and to reduce side-effects. If the medical treatment fails to relieve pain, interventional techniques should be considered. [ABSTRACT FROM AUTHOR]

The purpose of this study was to assess outcomes in patients who have undergone celiac plexus neurolysis (CPN) as treatment for refractory abdominal visceral pain at a tertiary care medical center. This study involved retrospective analysis of all patients who had undergone computed tomography (CT)-guided CPN over a 7-year period, as identified in the medical record. Cases were categorized into 1 of 3 groups--group 1: patients getting at least moderate improvement in pain but with improvements subsiding within 2 days; group 2: patients with some sustained pain relief but still requiring heavy doses of narcotics; group 3: patients with major or complete sustained reduction in pain where the narcotic dose was able to be reduced. One hundred thirty-eight cases were identified, 51 of which had no or insufficient follow-up, leaving 87 cases for analysis. Of the 87 cases, 31 (36%) were categorized as group 1, 21 (24%) as group 2, and 35 (40%) as group 3. There were no statistical differences in outcomes based on patient age, gender, time since diagnosis, or type of cancer. Documented postoperative complications were diarrhea (11 cases) and 1 case each of obtundation, hypotension, and presyncopal event. We conclude that patients undergoing CT-guided CPN for abdominal visceral pain achieve moderate or major short-term pain relief in a majority of cases. The procedure is safe with minimal complications. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: A number of patients with inoperable pancreatic cancer may concurrently complain of pain, biliary obstruction, and duodenal stenosis. Endoscopic palliative treatments and opioid therapy are generally performed in these patients. The study aimed to assess the efficacy and safety of a multimodal 'one-Session Three Endoscopic Procedures' (one-STEP) to simultaneously treat cholestasis, restore duodenal transit, and achieve pain relief in selected patients with advanced pancreatic cancer.Methods: Selected patients diagnosed with an advanced pancreatic cancer presenting with biliary obstruction, duodenal stenosis, and severe pain treated with the one-STEP were considered. The one-STEP endoscopic approach included biliary and duodenal stenting, and EUS-guided celiac plexus neurolysis. The technical success rate, complications, pain relief, and opioid use at follow-up were assessed.Results: A total of 15 patients were treated. The one-STEP was successful in 13 (87 %) cases, while it failed in two patients due to the impossibility of dilating the neoplastic mass for creating a fistula. No endoscopy-related complications occurred. The median of pain intensity was 8 (range 7-10) at entry and significantly decreased to 2 (range 2-4) 72 h following celiac plexus neurolysis. At follow-up (median survival 4 months; range 3-8), only 3 (20 %) needed of narcotic treatment in the last period.Conclusions: The multimodal one-STEP is an effective and safe endoscopic approach for palliative treatment of biliary and duodenal stenosis, and for relieving chronic pain in patients with advanced pancreatic cancer. [ABSTRACT FROM AUTHOR]

Radiotherapy is an established treatment modality for patients with pancreatic cancer. Image-guided radiation therapy (IGRT) allows the delivery of high doses to the tumour, while sparing the sensitive tissues around it, thus reducing side effects. However, the need of precisely contouring and identifying the target lesion is mandatory to be able to perform IGRT. Endoscopic ultrasound has been progressively implemented in the field of radiotherapy as a tool for intra-lesional placement of fiducial markers to perform IGRT and for direct placing of sealed radioactive sources in contact with the target lesions. In the current paper we provide an updated review on the role of endoscopic ultrasound in the radiation treatment of pancreatic cancer, highlighting areas of future research. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Celiac plexus neurolysis (CPN) is an established treatment for upper abdominal cancer pain. Recently, endoscopic ultrasound-guided CPN (EUS-CPN) was introduced and has enabled the performance of CPN under real-time imaging guidance, thereby making this technique much safer and easier. However, this procedure is not always efficacious, and a limited number of patients benefit from it. It should not be recommended for patients suspected of having unfavorable outcomes. We determined the predictive factors for response to EUS-CPN in order to enable rational selection of the therapeutic strategy. Forty-seven consecutive patients who underwent EUS-CPN at our institutions were eligible for this study. Absolute ethanol containing a contrast medium was injected just above the origin of the celiac trunk from the aorta under real-time EUS guidance, and abdominal computed tomography was performed immediately after the procedure to evaluate the distribution of the injected ethanol. The efficacy in pain relief was evaluated based on the pain score at day 7 after EUS-CPN. Pain relief was obtained in 32 patients (68.1%). Multivariate analysis using a multiple logistic regression model revealed that direct invasion of the celiac plexus and distribution of ethanol only on the left side of the celiac artery were significant factors for a negative response to EUS-CPN (odds ratio = 4.82 and 8.67, P = 0.0387 and 0.0224, respectively). EUS-CPN seems to be less effective in patients with direct invasion of the celiac plexus. Ethanol should be injected on both sides of the celiac axis to obtain greater pain relief. [ABSTRACT FROM AUTHOR]

A forward-viewing echoendoscope (FV-CLA) has been recently developed for performing interventional endoscopic ultrasound (EUS). The role of FV-CLA in performing standard EUS-guided fine-needle aspiration (FNA), Tru-cut biopsy (TCB), and celiac plexus neurolysis (CPN) is unknown. Our aims were to evaluate the feasibility of the FV-CLA for performing EUS-guided FNA/TCB and CPN. In this prospective study conducted over a 3-month period, 30 patients were evaluated with the FV-CLA. Procedures performed were FNA in 28 lesions, TCB in one, and CPN in five patients. EUS-guided FNA was undertaken at the following sites: mediastinum ( n = 3), liver ( n = 2), retroperitoneal mass ( n = 2), pancreas head/uncinate ( n = 9), pancreas body ( n = 6), pancreas tail ( n = 4), and perigastric lymph node ( n = 2). The median size of the lesions was 37 × 34 mm. A median of two passes was performed (range: 1-7). Final cytopathology diagnosed malignancies in 21 patients, with adenocarcinoma suspected for one.TCB of a mediastinal lymph node revealed lymphoma. FNA was benign in six patients. The sensitivity, specificity, positive predictive value, and negative predictive value for a malignancy diagnosis was 96% (95% confidence interval [CI], 87-96%), 100% (95% CI, 70-100%), 100% (92-100), and 86% (60-86%), respectively. CPN was successful in all five patients. It was easier to deploy the needle from the echoendoscope at all locations, including the duodenum, and irrespective of the site of the lesion. The initial evaluation and safety profile of the FV-CLA echoendoscope for performing standard FNA/TCB and CPN appear to be favorable. The narrow image does not preclude basic therapeutic maneuvers. A major advantage appears to be easy needle deployment at any site within reach of the echoendoscope. [ABSTRACT FROM AUTHOR]

The objective of this study was to evaluate the efficacy of EUS-guided CPN for pain relief in patients with chronic pancreatitis and pancreatic cancer. An initial search identified 1,439 reference articles, of which 130 relevant articles were selected and reviewed. Data was extracted from 8 studies ( N = 283) for EUS-guided CPN for pain due to pancreatic cancer and nine studies for chronic pancreatitis ( N = 376) which met the inclusion criteria. With EUS-guided CPN, the pooled proportion of patients with pancreatic cancer that showed pain relief was 80.12% (95% CI = 74.47–85.22). In patients with pain due to chronic pancreatitis, EUS-guided CPN provided pain relief in 59.45% (95% CI = 54.51–64.30). In conclusion, EUS-guided CPN offers a safe alternative technique for pain relief in patients with chronic pancreatitis or pancreatic cancer. In patients with pain due to chronic pancreatitis, better techniques or injected materials are needed to improve the response. [ABSTRACT FROM AUTHOR]

Endoscopic ultrasonography (EUS), since its development in the 1980s, has undergone a great deal of technological advancement in imaging, scopes with larger channels and accessories. This has given the endosonographer an immense reach in terms of accessing difficult areas with fewer complications. Currently, it is possible not only to obtain tissue for histological diagnosis but also to perform therapeutic procedures that hitherto would have needed surgery with its attendant morbidity. EUS has evolved over the years and EUS-guided fine needle aspiration for histological diagnosis has become standard practice. A wide array of interventional procedures are performed under EUS guidance including, celiac plexus neurolysis, drainage of pancreatic and pelvic fluid collections, drainage of obstructive biliary/pancreatic ducts, and implantation of fiducial markers/radioactive seeds into gastrointestinal tumors. Also, various experimental procedures are underway evaluating the role of EUS in radiofrequency ablation, vascular therapy, and natural orifice transluminal endoscopic surgery. In this review, we examine the various EUS-guided interventions currently undertaken and explore the potential of other emerging experimental techniques. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Endoscopic ultrasound (EUS) has emerged as an excellent tool for the imaging of the gastrointestinal wall and surrounding structures. EUS-guided fine needle aspiration has broadened the applicability of this tool by allowing tissue sampling of a variety of lesions within or accessible from the gastrointestinal (GI) tract. In particular, EUS became the test of choice for evaluating pancreatic cysts and mass lesions, biliary strictures and masses, abnormal adenopathy accessible from the GI tract, and GI submucosal lesions. There appears to be an increasing role for EUS in the staging of lung cancer, evaluating adrenal lesions and GI mesenchymal tumors. More recently, EUS has acquired a new dimension in interventional applications. This includes, but is not limited to, celiac plexus block and celiac neurolysis for the management of pain associated with chronic pancreatitis and locally advanced pancreaticobiliary malignancies, respectively. Copyright © 2009 S. Karger AG, Basel [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]

Endosonography-guided celiac plexus neurolysis (EUS-CPN) safely and effectively relieves pain associated with intra-abdominal malignancies when the neurolytic is accurately injected. We applied contrast medium to evaluate the ethanol injection sites in patients who received EUS-CPN due to abdominal pain caused by malignancies. We injected, under the guidance of endoscopic ultrasonography (EUS), ethanol containing 10% contrast medium into the celiac plexus of patients with intra-abdominal pain due to malignancies. Immediately after the endoscopic therapy, patients underwent computed tomography (CT) to confirm the injection site. Images of distribution of injected solutions were classified into three groups. Injected solution dispersed in unilateral and bilateral anterocrural space was defined as ‘unilateral injection’ or ‘bilateral injection’, respectively. Injected solution located out of the anterocrural space was defined as ‘inappropriate injection’. Pre- and postprocedure pain was assessed using a standard analog scale. Before and 2, 4, 8, 12, and 16 weeks after the procedure, pain scores were evaluated. From April 2003 to May 2005, 13 patients were enrolled in this study. Improvement of pain score in the ‘bilateral injection’ and ‘unilateral injection’ groups was significantly superior to the change in the ‘inappropriate injection’ group. Although EUS-CPN was effective in eight of 13 patients (61.5%), additional EUS-CPN to the ‘inappropriate injection group’ increased the response rate to 84.6%. Injection of ethanol to the anterocrural space by EUS-CPN produced adequate pain relief. Immediate examination by CT for confirmation of injection sites after EUS-CPN would increase the likelihood of induction of pain relief. [ABSTRACT FROM AUTHOR]

During the last 15 years, endoscopic ultrasound (EUS) has become an important imaging procedure for diagnosis and management of pancreatic diseases. The clinical interest of EUS is now enhanced by interventional procedures. Noteworthy, fine-needle aspiration biopsy is one of the most important contributions of EUS, in particular for the investigation of patients with pancreatic cancer and cystic tumors. EUS-guided fine-needle aspiration appears to be a safe and reliable technique to obtain tissue from pancreatic masses with a low risk of complications. EUS became also a therapeutic procedure, especially applied for celiac plexus neurolysis, pseudocyst drainage, and pancreaticogastrostomy. Further developments are expected by improvement of needle devices such as pancreatic pseudocyst drainage kits. In the future, EUS might be also a support for local application of new treatments of pancreatic tumors, such as gene or cellular therapy products. In this review, we discuss the current clinical applications of interventional EUS and the future development for diagnosis and management of pancreatic diseases. Copyright © 2006 S. Karger AG, Basel and IAP [ABSTRACT FROM AUTHOR]

Endoscopic ultrasound (EUS) is a useful imaging modality in patients with certain gastrointestinal malignancies as well as lung cancer. In many cases, EUS has been shown to have superior staging accuracy compared with other imaging techniques such as computed tomography, magnetic resonance imaging and positron emission tomography. This article will review the role of EUS in diagnosing and staging esophageal, rectal, pancreatic and lung cancers as well as subepithelial lesions. Newer therapeutic applications of EUS, namely endoscopic mucosal resection for removal of localized lesions as well as celiac plexus neurolysis for pain control, will also be discussed. Copyright © 2005 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]