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Abstract

We would like to thank Dr Larghi et al1Larghi A. Rimbas M. Crinò S.F. et al.EUS-guided radiofrequency ablation of the celiac axis in pancreatic cancer: Is money worth the pain?.Gastrointest Endosc. 2019; 89: 207Abstract Full Text Full Text PDF Scopus (2) Google Scholar for the comments on our article.2Bang J.Y. Sutton B. Hawes R.H. et al.EUS-guided celiac ganglion radiofrequency ablation versus celiac plexus neurolysis for palliation of pain in pancreatic cancer: a randomized controlled trial (with videos).Gastrointest Endosc. 2019; 89: 58-66Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar First, the technique adopted for EUS-guided radiofrequency ablation (EUS-RFA) of the celiac space was similar to that of EUS-guided celiac plexus neurolysis (EUS-CPN). The 1F RFA catheter was placed for energy administration in the same location where alcohol is injected at CPN. While maintaining the longitudinal view of the aorta, the echoendoscope was advanced toward the proximal part of the stomach until the takeoff of the celiac artery was identified. The echoendoscope was then slowly rotated clockwise or anticlockwise to identify an avascular window in the periaortic space, and RFA was conducted at 2 sites in this area that were at least a few centimeters apart. Second, as explained in the statistical analysis section, generalized estimating equations (GEE) were used for comparison of the change in pain and quality of life scores over the follow-up period, while accounting for any differences present at baseline and adjusting for potential confounders. Third, the advantage of the 1F probe is that it is conducive for targeting small areas and hence ideal for RFA of the ill-defined celiac space and small ganglia. By contrast, the currently available dedicated devices for EUS-RFA are of large caliber and are designed for solid tumor ablation rather than for ablation of the celiac plexus or ganglia. Using such devices for ablation of celiac plexus nerves is likely to induce severe tissue injury and possibly perforation. The present study included patients with metastatic or locally advanced cancer with short survival times. When patients elect not to pursue chemotherapy, the survival time is likely to be even less. Therefore, it will be difficult to assess treatment response over a 3-month to 6-month period, as suggested by these authors. Treatment options in pain management in patients with pancreatic cancer are currently limited. Therefore, although we agree that the cost effectiveness of EUS-RFA is an important consideration, if EUS-RFA is confirmed to be superior to EUS-CPN by other investigators, then the modality will serve as an important tool in the array of choices for improving patients’ quality of life (until death) in pancreatic cancer. Dr Varadarajulu is a consultant for Boston Scientific and Olympus America. The other author disclosed no financial relationships relevant to this publication. EUS-guided radiofrequency ablation of the celiac axis in pancreatic cancer: Is money worth the pain?Gastrointestinal EndoscopyVol. 89Issue 1PreviewWe read with interest the article by Bang et al1 reporting the results of a randomized trial comparing EUS neurolysis (EUS-CPN) (14 patients) versus EUS radiofrequency ablation (EUS-RFA) (12 patients) of the celiac plexus for palliation of pain in unresectable pancreatic cancer. As previously shown by a case report and in splanchnic nerves,2,3 RFA may offer a therapeutic alternative to the suboptimal pain control achieved with both narcotics and CPN in this patient population.1 EUS-RFA was performed with a 1F monopolar probe introduced through a 19-gauge FNA needle and used to target the area of the celiac plexus or directly the ganglia, when visualized (35% in the present study). Full-Text PDF