Celiac Block Research Articles

Indications for endoscopic ultrasound and diagnosis on fine-needle aspiration and cytology.

To determine common indications for requesting Endoscopic Ultrasound (EUS) and to describe the diagnosis made after endoscopic ultrasound/Fine-Needle Aspiration and Cytology (FNAC) during two years at a tertiary gastrointestinal unit. Cross-sectional descriptive study. The study was carried out in Gastrointestinal Department of Military Hospital, Rawalpindi, from March 2006 to February 2008. One hundred and eighty nine patients who underwent EUS during study period at Military Hospital were included in the study. Patients too ill (hypoxemic/hypotensive) to undergo procedure safely and those with complete esophageal blockage at upper end by tumour not allowing scope/EUS probe to advance beyond were excluded. EUS was done with Olympus Exera EUS 160, linear or radial scope, as required. EUS findings were recorded against indications as enlarged lymph nodes, tumour, staging, normal or incomplete. Fine-Needle Aspiration (FNA) was done as per findings on EUS using 21-22 G needle. An on-site cytopathologist made the provisional cytopathological diagnosis. Final cytology/histopathology report was given after review of slides by consultant histopathologists at Armed Forces Institute of Pathology (AFIP), Rawalpindi, and were documented as tuberculosis, malignancy, chronic pancreatitis or reactive hyperplasia. Data was analyzed for documentation of patients' age, gender, common indications, findings on EUS/FNAC, using SPSS version 10. Percentages and frequencies were calculated for the presence of these above-mentioned variables. Of the 189 patients, 145 (77%) were male and 44 (23%) female. Age was 18-80 years (mean 49 years). Major indications for referral were lymphadenopathy in 92 (49%), suspected growth pancreas in 57 (28%), growth of stomach in 20 (11%) and a heterogeneous group included esophageal, liver, retroperitoneal masses, rectal and other pathologies. Findings on EUS included lymphadenopathy in 76, mostly in sub-carina and AP window. Mass in pancreas was seen in 36, followed by stomach tumour in 17 and esophagus in 9. FNAC was done in 142 out of 189 patients. Final diagnosis out of 67 FNAC/histopathology of lymph nodes were tuberculosis in 26 and malignant lesions in 23. These included metastatic adenocarcinoma in 8, lymphoproliferative disorder in 7, metastatic squamous cell carcinoma in 5, small cell carcinoma in 2 and anaplastic in 1. Pancreatic tumours were adenocarcinoma in 16, poorly differentiated in 3 and neuroendocrine in 2. Stomach tumours were found in 11, and included lymphomas 5, GIST 3, carcinoids 2, metastatic choriocarcinoma 1 and adenocarcinoma in 1. Therapeutically, 3 celiac blocks and one pancreatic pseudocyst drainage was done. The main indication of EUS and pathology of mediastinal and celiac nodes were metastatic malignancy and tuberculosis. Pancreatic adenocarcinoma was another common cause for asking EUS.

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

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. To compare the pain relief in chronic pancreatitis among patients undergoing CPB either by PCFG technique or by EUS guided technique. 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. 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). EUS-guided coeliac block appears to be better than PCFG-CPB for controlling abdominal pain in patients with chronic pancreatitis.

Cervical Esophageal Perforations at the Time of Endoscopic Ultrasound: A Prospective Evaluation of Frequency, Outcomes and Patient Management

With the exception of one retrospective survey, there are currently no prospectively published data about the frequency of cervical esophageal perforation at the time of endoscopic ultrasound (CEP-EUS). We prospectively investigated the frequency of CEP-EUS and the outcomes and management of patients sustaining CEP-EUS. All patients that underwent upper EUS by a single experienced endosonographer over a 7-year period were enrolled. All indications and immediate complications encountered, the baseline demographics, indication of the procedures, surgical interventions, length of hospital stay, and the final outcomes of the patients were prospectively recorded. A total of 5,225 EUS procedures were performed. Lower gastrointestinal tract EUS procedures (n=331) were excluded from the analysis, and thus 4,894 upper EUSs constitute this study. The mean age of the patients was 59.7 years (s.d. 14.3 years); 54% patients were men and 79% were white. Indications for EUS included pancreaticobiliary (58%), esophageal (14%), mediastinal (14%), gastric (9%), celiac blocks (1%), and other (4%). Of 4,894 patients, 3 (0.06%, exact 95% confidence interval: 0.01-0.18) suffered CEP-EUS. The curvilinear echoendoscope was used in all three patients. All patients were octogenarians and women. All perforations were suspected at the time of intubation. Esophagogram confirmed contained perforation in all patients. All patients were immediately admitted and underwent surgical repair with a neck incision and recovered completely. The length of hospital stay was 6, 11, and 23 days respectively. All patients resumed swallowing without complications. One patient died from progressive pancreatic cancer 6 months after Whipple's procedure. The two other patients remained alive and well 12 and 22 months after the procedure. CEP-EUS is rare but a potentially devastating event for the patient and the treating physician. Although rare, the incidence is 2- to 3-fold higher than what has been reported in the survey literature. Early recognition and treatment is crucial for prompt intervention and complete recovery from CEP-EUS. These data can be used by endosonographers to counsel their patients about frequency, management, and outcomes of CEP-EUS.

Pancreatic Pain: A Mini Review

Pain management is one of the corner stones in the treatment of pancreatitis. There are a variety of pharmacological and non-pharmacological strategies to manage the symptoms. Recognizing the type of pain, nociceptive or neuropathic, is essential for appropriate treatment. The pharmacological armamentarium currently available is substantial and includes adjuvant analgesics, non-steroidal anti-inflammatories, and opioids that are customized to the etiology of the pain. When pain relief is suboptimal with pharmacological interventions, celiac block and other interventions should be considered. In acute pancreatitis the use of opioids is widely accepted while its use in chronic states is more controversial. When opioids are utilized, special care has to be taken for the assessment of indicators of misuse or abuse. A multidisciplinary approach to manage these complex patients will result in a high yield of success in controlling this and Other Symptoms.

Celiac plexus block with the long stylet needle technique

Neurolytic celiac plexus block has been used successfully in the treatment of patients with intractable intra-abdominal pain due to malignancy or to benign pain syndromes. A new technique is described here for blocking the celiac plexus through the retrocrural approach with a special long stylet needle inserted under fluoroscopic guidance. Celiac blocks were performed in 2 groups of patients. In the first group (n=7), the classic technique was performed with the use of 2 needles; in the second group (n=5), 1 needle and 2 stylets were used to complete the block through the long guided needle approach. Parameters evaluated in each group consisted of the number of attempts, defined as the number of skin punctures, and fluoroscopy injection time, defined as time from the beginning of fluoroscopy to completion of successful needle insertion into the celiac area. Patients who had abdominal pain resulting from pancreatic cancer underwent celiac plexus block performed by the long guided needle technique. In the classic technique group, fluoroscopy injection time was 13+/-3 min and the number of attempts was 5.3+/-3; values in the long guided needle group were 8.9+/-3 min and 4.9+/-2, respectively. The difference in fluoroscopy injection times was significant (P<.05). The long guided needle technique for celiac plexus block may be an effective and appropriate method for beginners or for practitioners who are not knowledgeable about imaging techniques used in various medical specialties.

Endoscopic ultrasound-guided fine-needle aspiration of left adrenal gland masses

Although the left adrenal gland is readily visible by endoscopic ultrasound (EUS), there are few published data on the utility of EUS-guided fine-needle aspiration (EUS-FNA) of this site. The aim of this study was to report our experience of EUS-FNA of left adrenal gland masses. In this retrospective case series, we reviewed our EUS and cytology databases to identify consecutive patients who underwent EUS-FNA of the left adrenal gland between January 1997 and January 2004. Medical records were reviewed and the results of EUS examinations and cytological investigations were abstracted. Our searches resulted in the identification of a series of 38 consecutive patients who underwent EUS for the evaluation of a lung mass (n = 14), a pancreatic mass (n = 14), obstructive jaundice (n = 1), dysphagia (n = 2), an ampullary adenoma (n = 1), celiac block (n = 1), or a left adrenal gland mass (n = 5). The mean maximal left adrenal mass diameter was 24 mm (range 7-66 mm). Diagnoses after EUS-FNA (the mean number of passes was 3.6) were: metastatic lung cancer (n = 2), esophageal adenocarcinoma (n = 1), melanoma (n = 1), renal cell carcinoma (n = 1), and pancreatic neuroendocrine tumor (n = 1); primary pheochromocytoma (n = 1); benign adrenal tissue (n = 21); and granulomatous inflammation (n = 1). Nine aspirations (24 %) were nondiagnostic. The absence of a discrete adrenal mass on EUS occurred more frequently in patients with nondiagnostic biopsies than in those with diagnostic biopsies (56 % vs. 7 %; odds ratio 23.4, 95 %CI 3.5 - 157.0; P = 0.004). No complications were noted. EUS-FNA of the left adrenal gland is safe and can be useful for the evaluation and staging of suspected malignancy. Nondiagnostic biopsies are more common when sampling diffusely enlarged glands, compared with glands with a focal mass.

Endoscopic treatment of chronic pancreatitis

Treatment of chronic pancreatitis has been exclusively surgical for a long time. Recently, endoscopic therapy has become widely used as a primary therapeutic option. Initially performed for drainage of pancreatic cysts and pseudocysts, endoscopic treatments were adapted to biliary and pancreatic ducts stenosis. Pancreatic sphincterotomy which allows access to pancreatic ducts was firstly reported. Secondly, endoscopic methods of stenting, dilatation, and stones extraction of the bile ducts were applied to pancreatic ducts. Nevertheless, new improvements were necessary: failures of pancreatic stone extraction justified the development of extra-corporeal shock wave lithotripsy; dilatation of pancreatic stenosis was improved by forage with a new device; moreover endosonography allowed guidance for celiac block, gastro-cystostomy, duodeno-cystostomy and pancreatico-gastrostomy. Although endoscopic treatments are more and more frequently accepted, indications are still debated.

Techniques and results of neurolysis for chronic pancreatitis and pancreatic cancer pain

Chronic abdominal pain can be associated with benign and malignant disease. Pain associated with pancreatic cancer and chronic pancreatitis can be severely debilitating, with significant impairment in quality of life. Frequently, chronic abdominal pain is not adequately responsive to conventional medical therapies, including nonsteroidal anti-inflammatory drugs and opioids. For this reason, alternative methods to alleviate pain have been developed. Celiac plexus neurolysis and celiac block involve injecting an agent at the celiac axis, with the goal of either selectively destroying the celiac plexus or temporarily blocking visceral afferent nociceptors to alleviate chronic abdominal pain. Agents most commonly used for this purpose include alcohol or phenol for neurolysis and bupivacaine and triamcinolone for temporary block. Methods to administer such agents to the celiac ganglion include CT imaging, percutaneous ultrasound, fluoroscopy, endoscopic ultrasound, or surgery (ganglionectomy). Response rates and complications vary depending on technique but are relatively low. This review highlights the techniques of celiac plexus neurolysis and celiac block and their status in the treatment of chronic pancreatitis and pancreatic cancer pain.

A Modified Approach to Transcrural Celiac Plexus Block

Transcrural celiac block using the needle "walking off" the L1 vertebra technique may cause complications. We used patient-specific computed tomography (CT) images as a roadmap to perform the block under fluoroscopy. We present 1 case to describe the technique. The patient is a 63-year-old woman with refractory pain from pancreatic cancer. Her CT showed the celiac trunk at the upper L1 vertebra and 2 cm left to the midline. Needle trajectories were drawn on that film. The line representing the classic "walking off" the bone technique on the left side crossed the aorta. Two lines targeting the base of the celiac trunk were modified, thereby avoiding both the L1 vertebra and the surrounding organs. The following were measured: the distance from the midline to the left needle entry (2.5 cm), the angle for the left needle insertion (90 degrees), the distance (6 cm) and the angle (65 degrees) for the right needle entry, and the distance from the anterior margin of the L1 to the celiac trunk (2.6 cm). During the procedure, 2 needles were placed according to these measurements in a plane superior to the transverse process of the L1. No bony contact or needle redirection was made. Both needles reached 3 cm anterior to the anterior margin of the L1. X-ray contrast crossed the midline and silhouetted the target vasculature. Five milliliters of 0.2% ropivacaine followed by 10 mL of 6% phenol were injected on each side. The patient's pain level improved to 0 to 1/10 on a visual analog scale. The modified technique avoided painful needle contact on the bone, reduced needle redirections, and decreased the possibility of vital organ puncture.

Traitement endoscopique de la pancréatite chronique

The treatment of chronic pancreatitis has been exclusively surgical for a long time. Recently, endoscopic therapy has become widely used as primary therapeutic option. Initially performed for the drainage of pancreatic cysts and pseudocysts, endoscopy was extended to stenosis of biliary and pancreatic ducts. Pancreatic sphincterotomy which allows access to the pancreatic ducts was first developed, rapidly followed by endoscopic biliary stenting, dilatation of stenosis, and stone extraction. Nevertheless, new improvements were necessary: failures in pancreatic stone extraction justified the development of extra-corporeal shock wave lithotripsy; dilatation of pancreatic strictures was improved by forage with new devices; endosonography allowed guidance for coeliac block, cyst-gastrostomy, cyst-duodenostomy and pancreatico-gastrostomy. Although endoscopic management is increasingly accepted, its indications are still debated.

EUS in the evaluation and management of chronic pancreatitis

Endoscopic ultrasound (EUS) has become a valuable tool in the diagnosis and treatment of chronic pancreatitis. The high resolution images provided can identify the parenchyma and ductal abnormalities that characterize the disease. In appropriate cases EUS can effectively establish or exclude the diagnosis of chronic pancreatitis. Like all other diagnostic tests, EUS can be impacted by the pretest probability of each individual case. The role of EUS in chronic pancreatitis is changing as this modality progresses from a primarily diagnostic role to one of therapeutic intervention. Established interventional EUS techniques include celiac block and transmural pseudocyst drainage. The techniques used to achieve pseudocyst drainage are being modified to allow EUS guided treatment of panreaticobiliary or gastric outlet obstruction.

Interventional endoscopic ultrasound in pancreatic disease.

The use of endoscopic ultrasound (EUS) in pancreatic disease is rapidly evolving as the field moves from a primarily diagnostic role to one of therapeutic intervention. Therapeutic EUS includes techniques such as the celiac block and transmural pseudocyst drainage. Newer techniques include EUS-guided fine-needle injection therapy in which a variety of agents are being investigated for the treatment of pancreatic cancer. Novel EUS-guided techniques are being devised to drain and alleviate pancreaticobiliary and gastroduodenal obstruction.

Endoscopic Ultrasound-Guided Fine Needle Aspiration of Left Adrenal Gland Masses

Introduction: CT-guided percutaneous FNA is traditionally used for cytologic sampling of adrenal masses. Although the left adrenal gland is readily visible by EUS imaging from the proximal stomach, there are limited published data on the utility of EUS-FNA of this site. Aim: To report our experience of EUS-FNA of left adrenal gland masses. Methods: A review of our EUS and cytology databases was conducted to determine all patients who underwent EUS-FNA of the left adrenal gland between from 1/97 to 10/03. Medical records of all subjects were reviewed and results of EUS examinations and cytology were abstracted. On-site cytopathology was present for all procedures. Results: 35 patients (20 male; mean age 64) were identified. Indications for EUS included: evaluation or staging of a lung or mediastinal mass (14), pancreatic mass (14), esophageal cancer (2), renal cell carcinoma (1), ampullary adenoma (1), chronic pancreatitis (1), left adrenal gland mass (1) or planned celiac block (1). Mean maximal adrenal mass diameter was 27 mm (range: 7-66 mm). Results of EUS-FNA: mean passes 3.6 (range: 1-7), diagnoses: metastatic small cell (1), non-small cell (1) or esophageal cancer (1), pheochromocytoma (1), adrenal adenoma or hyperplasia (7), benign adrenal tissue (14), granulomatous inflammation (1) or nondiagnostic material (9). The three patients who had metastases to the left adrenal gland were also found to have metastatic mediastinal or celiac lymph nodes confirmed by EUS-FNA. Findings of EUS-FNA could not differentiate a benign adrenal adenoma from hyperplasia. No complications from EUS-FNA were encountered. Conclusion: EUS-FNA of the left adrenal gland is useful for the evaluation of left adrenal gland masses. A thorough examination of the left adrenal gland during EUS is indicated during evaluation and staging of suspected malignancy, particulary lung cancer. A prospective study comparing EUS-FNA to CT-guided FNA of left adrenal masses is indicated.

The future of simulators in GI endoscopy: An unlikely possibility or a virtual reality?

The future of simulators in GI endoscopy: An unlikely possibility or a virtual reality?

Coeliac plexus block: utility of the anterior approach and the real time colour ultrasound guidance in cancer patient

Aims: The aim of our study was to demonstrate the efficacy of ultrasound-guidance compared with computed tomography (CT) guidance for coeliac plexus block in cancer patients. Methods: Coeliac plexus block (30 ml ethanol) was performed in 34 cancer patients (sex ratio: 10F, 24M), mean age: 54.8 years (range 26–67) under CT (n=21) and ultrasound-guidance (n=13). All patients had excruciating epigastric and generalized abdominal pain caused by cancer of the pancreas (n=13) or upper abdominal viscera (n=9) or a malignancy of extra-digestive origin (n=12). Feasibility and complication rates were analysed. Results: Notable pain relief was obtained in 27 (79%) of the patients. The technical success rate was 100% for CT-guidance and 93% (13/14) for ultrasound guidance. There were six minor complications (17%): chemical peritonitis (n=2), orthostatic arterial hypotension (n=2) and transient left shoulder pain (n=2), no major complications occurred. The target route was transhepatic in 6/13 of the ultrasound cases and mean length was 6 cm (range 3–12 cm). Colour Doppler sonography improved visualization of the 21 Gauge Chiba needle when the needle shaft was vibrated. Echogenic foci were observed around the origin of the coeliac trunk and superior mesenteric artery in all cases. CT coeliac block was successfully performed after failure of ultrasound guidance in one patient. Conclusion: Ultrasound guidance is safe and effective and should be attempted for coeliac plexus block whenever possible.

Endoscopic Ultrasound-Guided Celiac Plexus Block for Managing Abdominal Pain Associated With Chronic Pancreatitis: A Prospective Single Center Experience

In our previous randomized trial, we suggested a possible role for endoscopic ultrasound (EUS) guided celiac plexus block in the treatment of abdominal pain associated with chronic pancreatitis. The purpose of this study was to evaluate our prospective experience with EUS-guided celiac plexus block for controlling pain attributed to chronic pancreatitis, including follow-up on response rates and complications. All subjects enrolled had documented chronic pancreatitis by ERCP and EUS criteria and presented with chronic abdominal pain unresponsive to current treatment options. All were treated with EUS-guided celiac plexus block under the guidance of linear array endosonography using a 22-gauge FNA needle (GIP, Mediglobe Inc., Tempe, AZ) inserted on each side of the celiac area, followed by injection of 10 cc bupivacaine (0.25%) and 3 cc (40 mg) triamcinolone on each side of the celiac plexus. Individual pain scores, based on a visual analog scale (0-10), were determined preblock and postblock by a nurse at 2, 7, 14 days and monthly thereafter. Subjects also rated their overall comfort level during the EUS procedure. EUS-guided celiac plexus block was performed in 90 subjects (40 males, 50 females) having a mean age of 45 yr (range 17-76 yr) between July 1, 1995 and December 30, 1996. A significant improvement in overall pain scores occurred in 55% (50/90) of patients. The mean pain score decreased from 8 to 2 post EUS celiac block at both 4 and 8 wk follow-up (p < 0.05). In 26% of patients there was persistent benefit beyond 12 wk, and 10% still had persistent benefit at 24 wk, including three patients who were pain-free between 35 and 48 wk. Younger patients (<45 yr of age) and those having previous pancreatic surgery for chronic pancreatitis were unlikely to respond to the EUS-guided celiac block. Three patients experienced diarrhea post EUS celiac block, which resolved in 7-10 days; however, it is unclear whether this diarrhea was due to the block or to refractory disease. A cost comparison between the EUS ($1200) and CT ($1400) techniques shows the EUS celiac block to be less costly and perhaps more cost efficient in a subset of subjects. EUS-guided celiac plexus block appears to be safe, effective, and economical for controlling pain in some patients with chronic pancreatitis. Younger patients (<45 yr) and those having prior pancreatic surgery for chronic pancreatitis do not appear to benefit from this technique. Prophylactic antibiotics should be considered if acid suppressing agents are being taken.

Endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience

OBJECTIVE: In our previous randomized trial, we suggested a possible role for endoscopic ultrasound (EUS) guided celiac plexus block in the treatment of abdominal pain associated with chronic pancreatitis. The purpose of this study was to evaluate our prospective experience with EUS-guided celiac plexus block for controlling pain attributed to chronic pancreatitis, including follow-up on response rates and complications. METHODS: All subjects enrolled had documented chronic pancreatitis by ERCP and EUS criteria and presented with chronic abdominal pain unresponsive to current treatment options. All were treated with EUS-guided celiac plexus block under the guidance of linear array endosonography using a 22-gauge FNA needle (GIP, Mediglobe Inc., Tempe, AZ) inserted on each side of the celiac area, followed by injection of 10 cc bupivacaine (0.25%) and 3 cc (40 mg) triamcinolone on each side of the celiac plexus. Individual pain scores, based on a visual analog scale (0–10), were determined preblock and postblock by a nurse at 2, 7, 14 days and monthly thereafter. Subjects also rated their overall comfort level during the EUS procedure. RESULTS: EUS-guided celiac plexus block was performed in 90 subjects (40 males, 50 females) having a mean age of 45 yr (range 17–76 yr) between July 1, 1995 and December 30, 1996. A significant improvement in overall pain scores occurred in 55% (50/90) of patients. The mean pain score decreased from 8 to 2 post EUS celiac block at both 4 and 8 wk follow-up ( p < 0.05). In 26% of patients there was persistent benefit beyond 12 wk, and 10% still had persistent benefit at 24 wk, including three patients who were pain-free between 35 and 48 wk. Younger patients (<45 yr of age) and those having previous pancreatic surgery for chronic pancreatitis were unlikely to respond to the EUS-guided celiac block. Three patients experienced diarrhea post EUS celiac block, which resolved in 7–10 days; however, it is unclear whether this diarrhea was due to the block or to refractory disease. A cost comparison between the EUS ($1200) and CT ($1400) techniques shows the EUS celiac block to be less costly and perhaps more cost efficient in a subset of subjects. CONCLUSIONS: EUS-guided celiac plexus block appears to be safe, effective, and economical for controlling pain in some patients with chronic pancreatitis. Younger patients (<45 yr) and those having prior pancreatic surgery for chronic pancreatitis do not appear to benefit from this technique. Prophylactic antibiotics should be considered if acid suppressing agents are being taken.

MRI‐guided celiac plexus block

Celiac plexus block is used as a palliative procedure in cases of severe upper abdominal pain caused by pancreatitis or tumors of the pancreas. It can be guided by bony landmarks, fluoroscopy, ultrasound (US), or computed tomography (CT). To avoid severe complications, methods visualizing soft tissue, like CT and magnetic resonance (MR) imaging, are preferable. We describe celiac plexus blocks carried out in an open MR scanner, offering needle guidance with an optical tracking system and near real-time image acquisition. Eight patients with severe chronic abdominal pain were included. In these, 14 celiac blocks were carried out. Good or total pain relief was achieved in 8 of the 14 blocks (57%), a moderate effect in 5 blocks (36%), and no effect in 1 block (7%). The placement of the needle was easily guided with MR in all cases. The MR technique ensures good visualization of soft tissue, direct monitoring of needle movement and avoids exposure to ionizing radiation. Celiac plexus block can safely be carried out in an open MR scanner. J. Magn. Reson. Imaging 2000;12:562–564. © 2000 Wiley-Liss, Inc.

Improved model for teaching interventional EUS

Background: A swine model was previously developed for teaching endoscopic ultrasound (EUS). The purpose of this study was to improve this model and develop a method for creating focal lesions for EUS imaging and intervention. Methods: Experiments were performed in farm pigs (Sus scrofa) under general anesthesia. Under real-time EUS guidance attempts were made to create a submucosal lesion and a focal mediastinal lesion, to perform EUS-guided fine-needle aspiration of the pancreas, and to confirm the site of injection during “sham” EUS-guided celiac block. Results: A hypoechoic, submucosal mass was created in the stomach, which was then imaged by EUS and punctured trans-gastrically. Injection of saline solution in the mediastinum created a pseudo-mediastinal lymph node. A needle was then advanced trans-esophageally into the mediastinum to mimic EUS-guided fine-needle aspiration of a mediastinal lymph node. Abdominal exploration of the pigs after euthanasia confirmed injection of the sham celiac block around the celiac ganglion. Conclusion: The swine model is not only useful for teaching normal EUS anatomy, but it may be a useful model for teaching EUS-guided intervention.

Prise en charge de la douleur du cancer du pancréas

Pain management in cancer of the pancreas. Pain remains an indicator of progression of cancer of the pancreas. Regular pain evaluation combined with early analgesic treatment improves the duration and quality of life. New modes of morphine administration and specific chemotherapy can improve this management. Neurolysis is more effective in the case of recent pain, previously controlled by anti -inflammatory drugs. The endoscopic ultrasound (EUS)-guided technique allows celiac block during EUS examination for local staging. Early introduction of palliative surgery and analgesic procedures can reduce the morbidity and mortality of these procedures. A graduated multidisciplinary pain management program allows optimal pain control.