Celiac Plexus Block Research Articles

Management of Chronic Upper Abdominal Pain in Cancer

The use of celiac plexus block to relieve the intractable pain caused by upper abdominal malignancies is well established. However, its effects are inconsistent for many reasons, mainly because of structural anatomic distortion as a consequence for the malignancy. The splanchnic nerve blockade (SNB) seems to be a useful alternative to the celiac plexus block in upper abdominal pain relief. The pain of 109 patients with unresectable upper abdominal or lower esophageal neoplasms was managed by posterior transdiscal SNBs guided by computed tomography at the Instituto Nacional de Cancerología in Mexico City from January 2004 to June 2007. The study evaluated SNB efficacy with regard to pain relief, its adverse effects/complications, and patient satisfaction. Splanchnic nerve blockade efficacy with regard to pain relief was exhibited by a marked decrease in the visual analog score and in opioid consumption, with preprocedural mean values dropping from 6.1 ± 2.4 and 102.4 mg/d of morphine to 2.7 ± 2.4 and 53.3 mg/d at the first postprocedural visit, respectively. These results persisted during the 1-year follow-up period or until death. Minor adverse effects (moderate diarrhea and mild hypotension) were frequent (n = 64 and n = 47, respectively), and severe complications occurred in 1 patient with a transient paraparesis (n = 1). No procedure-related mortality was observed. Splanchnic nerve blockade via a transdiscal approach is a technique that provides analgesia and the alleviation of the secondary undesirable effects of analgesic drugs resulting from the decrease of morphine consumption in patients with upper abdominal malignancies. In experienced teams, the reliability of its analgesic effect is high, with a low rate of severe complications.

Use and perceived effectiveness of non‐analgesic medical therapies for chronic pancreatitis in the United States

Effectiveness of medical therapies in chronic pancreatitis has been described in small studies of selected patients. To describe frequency and perceived effectiveness of non-analgesic medical therapies in chronic pancreatitis patients evaluated at US referral centres. Using data on 516 chronic pancreatitis patients enrolled prospectively in the NAPS2 Study, we evaluated how often medical therapies [pancreatic enzyme replacement therapy (PERT), vitamins/antioxidants (AO), octreotide, coeliac plexus block (CPB)] were utilized and considered useful by physicians. Oral PERT was commonly used (70%), more frequently in the presence of exocrine insufficiency (EI) (88% vs. 61%, P < 0.001) and pain (74% vs. 59%, P < 0.002). On multivariable analyses, predictors of PERT usage were EI (OR 5.14, 95% CI 2.87-9.18), constant (OR 3.42, 95% CI 1.93-6.04) or intermittent pain (OR 1.98, 95% CI 1.14-3.45). Efficacy of PERT was predicted only by EI (OR 2.16, 95% CI 1.36-3.42). AO were tried less often (14%) and were more effective in idiopathic and obstructive vs. alcoholic chronic pancreatitis (25% vs. 4%, P = 0.03). Other therapies were infrequently used (CPB - 5%, octreotide - 7%) with efficacy generally <50%. Pancreatic enzyme replacement therapy is commonly utilized, but is considered useful in only subsets of chronic pancreatitis patients. Other medical therapies are used infrequently and have limited efficacy.

Prospective Evaluation of Laparoscopic Celiac Plexus Block in Patients with Unresectable Pancreatic Adenocarcinoma

The efficacy of laparoscopic celiac plexus block (CPB) in patients with unresectable pancreatic cancer has not been reported. Patients with elevated pain scores scheduled for laparoscopy for diagnosis/staging of unresectable pancreatic adenocarcinoma were eligible. The study was designed to evaluate 20 consecutive patients with validated quality of life (EORTC QLQ-C30, QLQ-PAN26) and validated pain assessment tools [Brief Pain Inventory (BPI)]. Questionnaires were obtained preoperatively, and postoperatively at 1, 4, and 8weeks. Laparoscopic CPB was performed by bilateral injection of 20cc 50% alcohol utilizing a recently described laparoscopic technique. Functional and symptom scoring was performed by EORTC scoring manual. Median age was 61years (range 42-80years), and mean preoperative pain score [worst in 24h on 0-10 visual analogue scale (VAS)] was 7.8 [standard deviation (SD) 1.6]. Median total operative time (laparoscopy+biopsy+CBP) was 57min (range 29-92min), and all patients except one were discharged on day of surgery. No major complications occurred. EORTC functional scales did not change significantly during the postoperative period. EORTC symptomatic pain scores decreased significantly. These findings were also observed in the BPI, with significant decreases in visual analogue score for reported mean (preoperative versus week 4, mean: 5.7 versus 2.7; p<0.01) and worst (preoperative versus week 4, mean: 7.8 versus 5.1; p<0.01) pain during a 24-h period. This study documents the efficacy of laparoscopic CPB. The procedure was associated with minimal morbidity, brief operative times, outpatient management, and reduction in pain scores similar to that reported with other approaches to celiac neurolysis.

What is the role of endotherapy in chronic pancreatitis?

Chronic pancreatitis (CP) can have debilitating clinical course due to chronic abdominal pain, malnutrition and related complications. Medical, endoscopic and surgical treatment of CP should aim at control of symptoms, prevention of progression of the disease and correction of complications. Endoscopic management plays a specific role in carefully selected patients as primary interventional therapy when medical measures fail or in high-risk surgical candidates. Endotherapy for CP is utilized also as a bridge to surgery or to assess potential response to pancreatic surgery. In this review we address the role of endotherapy for the relief of obstruction of the pancreatic duct (PD) and bile duct, closure of PD leaks and drainage of pseudocysts in the setting of CP. In addition, endotherapy for relief of pancreatic pain by endoscopic ultrasound-guided celiac plexus block for CP is discussed.

Pain management in chronic pancreatitis: A treatment algorithm

Abdominal pain is common and frequently debilitating in patients with chronic pancreatitis. Medical therapy includes abstinence from tobacco and alcohol and the use of analgesics and adjunctive agents. In many patients, a trial of non-enteric-coated pancreatic enzymes and/or antioxidants may be tried. Endoscopic or surgical therapy requires careful patient selection based on a detailed analysis of pancreatic ductal anatomy. Those with a non-dilated main pancreatic duct have limited endoscopic and surgical alternatives. The presence of a dilated main pancreatic duct makes endoscopic or surgical therapy possible, which may include ductal decompression or pancreatic resection, or both. Randomised trials suggest surgical therapy is more durable and effective than endoscopic therapy. Less commonly employed options include EUS-guided coeliac plexus block, thoracoscopic splanchnicectomy, or total pancreatectomy with auto islet cell transplantation. These are used rarely when all other options have failed and only in very carefully selected patients.

An Open Randomized Comparison of Clinical Effectiveness of Protocol-Driven Opioid Analgesia, Celiac Plexus Block or Thoracoscopic Splanchnicectomy for Pain Management in Patients with Pancreatic and Other Abdominal Malignancies

In inoperable malignancy, pain relief with opioids is often inadequate. Nerve block procedures may improve symptom control. Our aim was to assess celiac plexus block (CPB) and thoracoscopic splanchnicectomy (TS) in patients receiving appropriate medical management (MM). Methods: Patients with confirmed irresectable malignancy of the pancreas or upper abdominal viscera who required opioid analgesia were randomized to MM alone, MM+CPB, or MM+TS. Randomization was stratified by treatment centre, tumour type and previous opioid medication. The primary end point was pain relief at 2 months. Results: 65 patients (58 pancreas cancer) were randomized, 18 withdrew or died within 2 months. Effective pain relief was achieved in only one third of subjects at 2 weeks, and just under half at 2 months (MM: 6/19 and 5/12 evaluable patients; CPB: 5/14 and 5/9; TS 4/14 and 4/11). There were no significant differences between the groups in pain scores or opioid consumption, and there was no correlation between continued use of opioids and effective pain relief. Discussion: Previous randomized studies have shown small differences in pain scores, but no difference in opioid consumption and quality of life. The absence of any benefit from interventions in the present study questions their Value.

Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine.

Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine.

A review of the thoracic splanchnic nerves and celiac ganglia

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

Efficacy of Endoscopic Ultrasound-guided Celiac Plexus Block and Celiac Plexus Neurolysis for Managing Abdominal Pain Associated With Chronic Pancreatitis and Pancreatic Cancer

Endoscopic ultrasound (EUS)-guided celiac plexus block (CPB) and celiac plexus neurolysis (CPN) have become important interventions in the management of pain due to chronic pancreatitis and pancreatic cancer. However, only a few well-structured studies have been performed to evaluate their efficacy. Given limited data, their use remains controversial. Herein, we evaluate the efficacy of EUS-guided CPB and CPN in alleviating chronic abdominal pain due to chronic pancreatitis and pancreatic cancer respectively. Using Medline, Pubmed, and Embase databases from January 1966 through December 2007, a thorough search of the English literature for studies evaluating the efficacy of EUS-guided CPB and CPN for the management of chronic abdominal pain due to chronic pancreatitis and pancreatic cancer was conducted, along with a hand search of reference lists. Studies that involved less than 10 patients were excluded. Data on pain relief was extracted, pooled, and analyzed. A total of 9 studies were included in the final analysis. For chronic pancreatitis, 6 relevant studies were identified, comprising a total of 221 patients. EUS-guided CPB was effective in alleviating abdominal pain in 51.46% of patients. For pancreatic cancer, 5 relevant studies were identified with a total of 119 patients. EUS-guided CPN was effective in alleviating abdominal pain in 72.54% of patients. EUS-guided CPB was 51.46% effective in managing chronic abdominal pain in patients with chronic pancreatitis, but warrants improvement in patient selection and refinement of technique, whereas EUS-guided CPN was 72.54% effective in managing pain due to pancreatic cancer and is a reasonable option for patients with tolerance to narcotic analgesics.

The Effect of Celiac Plexus Block in Critically Ill Patients Intolerant of Enteral Nutrition

In this study, we evaluated the efficacy of celiac plexus block for the treatment of feeding intolerance in critically ill patients. Nineteen mechanically ventilated medical patients intolerant of enteral nutrition and receiving metoclopramide underwent bilateral celiac plexus block. The anterior procedure was accomplished under sonographic guidance with the injection of either 25 mL bupivacaine 0.25% (celiac group, n = 10) or saline (control group, n = 9) bilaterally. Gastric emptying was assessed by the acetaminophen absorption method. After the block, nasogastric feeding was commenced, and nasogastric aspirates were collected once every 24 hours. Successful feeding was defined as 24-hourly gastric residual volume <250 mL with a feeding rate > or = 40 mL/h. Demographic data were similar for the 2 groups. The area under the plasma paracetamol absorption curve (383.8 +/- 248.1 mg . min . L(-1)) and the peak plasma paracetamol concentration (C(max); 3.28 +/- 2.15 mg/L) in the celiac group were significantly lower than the area under the curve value (1233.5 +/- 771.2) and C(max) value (10.14 +/- 6.04) in controls (P < 0.001 for all). After treatment, celiac plexus block reduced the mean gastric residual volume (celiac group: 430 +/- 32 mL to 205 +/- 30 mL, P < 0.001; control group: 450 +/- 33 mL to 461 +/- 19 mL, P > 0.05) and improved the proportion of patients with successful feeding (celiac block 80% vs controls 0%, P < 0.001). In critical illness, celiac plexus block is effective for treating feeding intolerance when IV drug therapy has failed to improve gastrointestinal dysfunction.

The role of neurolytic sympathetic blocks in treating cancer pain

Over 10 million Americans live with cancer and almost 1.5 million new cases of cancer will be diagnosed in 2009. Many of these patients will have severe pain even with optimal medical management. These patients may be offered advanced interventional procedures to manage their pain. For pain originating from the viscera, chemical neurolysis of the sympathetic nervous system may be an appropriate intervention. Common techniques employed to interrupt the sympathetic nervous system would include the celiac plexus block, the superior hypogastric plexus block, and the ganglion impar block. This article offers a discussion of the patient selection, indications, complications, and technical aspects of these pain-relieving interventions. For these patients with refractory cancer-related pain, minimally invasive, percutaneous neurolytic blocks have the potential to provide significant pain reduction and an overall improvement in their quality of life.

Decision-making in the cancer pain setting: Beyond the WHO ladder

The treatment of cancer-related pain is an area of great concern to patients and physicians alike. In the recent past, emotional reactions, societal pressure, and misinformation guided physicians in their choice of treatment modalities and often led to undertreated pain. The development of the World Health Organization ladder for guiding the treatment of cancer pain helped to not only guide physicians in the proper use of opioids, but also to break down social and legal barriers to their proper use. The World Health Organization ladder has also constrained physicians when used in a purely mechanistic manner. Despite the aggressive use of opioids and adjuvant medications, 10%-20% of patients with cancer pain suffer with severe pain. This underscores the need to move beyond the ladder concept and into a paradigm of multimodal care. The early inclusion of interventional pain management before patients have been maximized on opioids should be considered. Such procedures include percutaneous vertebroplasty, percutaneous kyphoplasty, and neurolytic celiac plexus block. Use of a multimodal pain management regimen should help to decrease suffering and side effects, and improve quality of life for cancer patients.

Endoscopic ultrasound-guided celiac plexus neurolysis

Endoscopic celiac plexus neurolysis (CPN) has become the procedure of choice for the management of patients with pancreatic cancer and abdominal pain unresponsive to medical treatment. It is necessary to differentiate between CPN and endoscopic celiac plexus block performed in patients with benign disease. In this review we describe the technique of this procedure with special emphasis on technical details.

Assessment of Celiac Plexus Block and Neurolysis Outcomes and Technique in the Management of Refractory Visceral Cancer Pain

To assess demographic and clinical factors associated with celiac plexus neurolysis outcomes. Retrospective clinical data analysis. A tertiary care, academic medical center. Forty-four patients with terminal visceral (mostly pancreatic) cancer who failed conservative measures. Interventions. Fifty celiac plexus alcohol neurolytic procedures done for pain control after a positive diagnostic block. A successful treatment was predefined as >50% pain relief sustained for > or =1 month. The following variables were analyzed for their association with treatment outcome: age, gender, duration of pain, origin of tumor, opioid dose, type of radiological guidance used, single- vs double-needle approach, type of block (e.g., antero- vs retrocrural), immediate vs delayed neurolysis, volume of local anesthetic employed for both diagnostic and neurolytic blocks, and use of sedation. Those variables correlated with a positive outcome included lower opioid dose and the absence of sedation. Strong trends for a positive association with outcome were found for the use of computed tomography (vs fluoroscopy), and using <20 mL of local anesthetic for the diagnostic block. Celiac plexus neurolysis may provide intermediate pain relief to a significant percentage of cancer sufferers. Both careful selection of candidates based on clinical variables, and technical factors aimed at enhancing the specificity of blocks may lead to improved outcomes.

Hemorrhagic Gastritis and Duodenitis Following Celiac Plexus Neurolysis

Neurolytic celiac plexus block is a well established intervention to palliate pain, and it potentially improves quality of life in patients suffering from an upper abdominal malignancy, specifically pancreatic cancer. We describe a 61-year-old female with a history of pancreatic cancer, unexplained transfusion dependent anemia with a normal recent upper endoscopy, and abdominal pain, who had previously undergone gastrojejunostomy and a Roux-en-Y hepaticojejunostomy as well as chemotherapy and radiation therapy. She suffered from intractable abdominal pain and elected to undergo palliative celiac plexus neurolysis. The patient initially appeared to tolerate celiac plexus block well, however, 45 minutes after the procedure, the patient had bright red blood per rectum followed by bloody diarrhea. Her abdomen was soft and non-tender with minimal distention and positive bowel sounds. The patient's hemoglobin decreased to 7.5 g/dl from 9.0 g/dl, and she received a blood transfusion. Upper endoscopy and enteroscopy demonstrated diffuse hemorrhagic gastritis and duodenitis. The bleeding was controlled and the patient remained hemodynamically stable. Ultimately, the patient did well and was discharged home. We report a case of a patient with known history of gastritis and duodenitis, who developed severe upper GI bleeding immediately following the celiac plexus neurolysis. There are no published reports documenting similar cases. It is difficult to offer a precise physiologic explanation for this complication. However, we speculate that inhibition of sympathetic tone from the celiac plexus neurolysis caused increased blood flow to the GI system, and this resulted in active bleeding from previously indolent hemorrhagic gastritis and duodenitis. It may be beneficial for patients with a history of gastritis, duodenitis or GI bleeding to undergo a careful upper GI evaluation prior to celiac plexus neurolysis.

Pain Review.

Cleveland Clinic, Cleveland, Ohio. vroomab@ccf.orgPain Review. By Steven D. Waldman, M.D., J.D. Philadelphia, Saunders–Elsevier, 2009. Pages: 780. Price: $79.95.Pain medicine fellows frequently ask for the name of a good reference to read during training or when studying for a pain medicine board examination. Among other prominent names in pain medicine literature, “Waldman” is frequently offered in response. Steven D. Waldman, M.D., J.D., has produced numerous atlases and texts over the past decade and will have three new texts published in 2009 alone, so his name is only a partial answer. Fellows need to know which Waldman to choose. With the publication of Pain Review —his most succinct, well-organized, and practical review book to date—the answer is now quite clear.Pain Review is a durable soft-cover text organized into nine sections of 355 (yes, 355) chapters. These chapters are well written and surprisingly thorough given that some are only one page in length. They are user-friendly, as is the book’s overall structure. Dr. Waldman seems to have followed the American Board of Anesthesiology Pain Medicine Examination Specification Outline in organizing his text into the following sections: Anatomy, Neuroanatomy, Painful Conditions, Diagnostic Testing, Interventional Therapy, Physical and Behavioral Modalities, Pharmacology, Special Patient Populations, and Ethics.Dr. Waldman spends a greater percentage of the review’s pages on procedures than might be necessary for the certification examination (because this only counts for approximately 20% of the examination content), but residents or fellows who have not performed these procedures will certainly be grateful. Many readers will also appreciate the 767 multiple-choice questions and answer key provided.Unlike Dr. Waldman’s other texts, the purchase of Pain Review allows for activation of the Web site expertconsult.com*using an encrypted password. This site is helpful when one is in need of a quick on-line reference from a remote location or a pain clinic. The index feature steers users to several listings of an ilioinguinal nerve block, for example, within the Web site, much as Dr. Ronald D. Miller’s on-line version of Miller’s Anesthesia 1does.Pain Review is the best Waldman book for examination review, but it is not the consummate text for pain medicine residents or fellows. His two-volume Pain Management 2is a more thorough compendium of this field. The critical care and ethics portions of his new text are slightly underserved relative to the approximate 5% each topic is represented in the certification examination. They inherently deserve more attention than is given. Although Pain Review does contain some fluoroscopic images, such as the two-needle and the transaortic celiac plexus block, Waldman’s Atlas of Interventional Pain Management 3is more thorough in this regard.When you have published as much as Dr. Waldman, you run the risk of overexposure. At the end of each chapter, Dr. Waldman offers suggested readings, many of which are his other texts. He cites other helpful reference books, too, but not much in the way of recently published articles in pain medicine or anesthesiology journals. Some readers might also object to how the descriptions of many procedures, such as the sphenopalatine ganglion block or the gasserian ganglion block, are taken verbatim from his Atlas of Interventional Pain Management .2Small oversights are found commonly in Pain Review but do not detract appreciably from its overall value. “Three millimeters of either 2% viscous lidocaine or . . .” on page 391 obviously was meant to be “milliliters.” Figure 28-1 is entitled a “thoracic dermatomal chart” but is a chart of only cervical dermatomes. Figure 30-2 is described as a “T2-weighted MR image” but is actually a fluoroscopic image of a discogram. Regarding the answer key, it would be nice to have written explanations to the answers, though this would have extended the length of the book. In lieu of this, listing the page number where the answer could be gleaned from the reading would have been helpful.Although there is still room for improvement, Pain Review will help many board-eligible and recertifying pain physicians prepare for pain medicine board examinations. It covers the examination topics well and anticipates the needs of pain medicine fellows with a large data bank of practice questions and the useful Internet application.Cleveland Clinic, Cleveland, Ohio. vroomab@ccf.org

EUS in pediatric patients

The knowledge of EUS use in children is limited. We investigated the indications, feasibility, safety, and clinical utility of EUS in the management of pediatric GI, pancreatobiliary, and mediastinal diseases. Retrospective study. Two tertiary referral university hospitals. Consecutive children age younger than 18 years referred over a 7-year period for EUS evaluation. Forty EUS scans were performed in 38 children with a mean age of 13.5 years. The indications for pancreatobiliary endosonography were pancreatitis (n = 10), solid pancreatic mass (n = 7), cystic pancreatic mass (n = 1), cyst in the setting of chronic pancreatitis (n = 1), suspected annular pancreas (n = 1), celiac plexus block (n = 1), suspected common bile duct stone (n = 1), abdominal pain and atrophic pancreas (n = 1), ampullary adenoma (n = 1), and abnormal MRCP in a patient with jaundice (n = 1). The indications for gastric EUS were mucosal lesions (n = 2) and subepithelial lesions (n = 4). The indications for mediastinal endosonography were mediastinal masses/lymph nodes (n = 5). The remaining evaluations were performed for esophageal stricture (n = 1), unexplained abdominal pain (n = 1), unexplained abdominal pain with celiac axis block (n = 1), and perirectal fluid collection (n = 1). EUS-guided FNA (EUS-FNA) was performed in 12 (30%) cases and established the correct diagnosis in 9 (75%). EUS-guided fine-needle injections for celiac axis block were performed in 2 (5%) cases. The procedure was successful in all patients, and no complications related to sedation, EUS, or EUS-FNA were encountered. Retrospective study. EUS and EUS-FNA are feasible and safe and have a significant impact on the management of pediatric GI, pancreatobiliary, and mediastinal diseases.

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.

Endoscopic therapy for chronic pancreatitis: Technical success, clinical outcomes, and complications

Chronic pancreatitis (CP) can cause failure of both the exocrine and endocrine portions of the gland. Pain is the most recalcitrant clinical complaint in CP. Generally, conservative measures are first attempted to manage pain. These include cessation of alcohol use and smoking, enzyme replacement therapy, and finally, opioid analgesia. Endoscopy can be employed to treat the pain and complications due to CP. The results of the only two prospective randomized controlled trials suggest that surgery has a more durable effect than endoscopic therapy in controlling pain. Both trials suffer from severe limitations, however, and endoscopy remains the preferred approach for many patients because of its minimally invasive nature. Endoscopic ultrasound celiac plexus block has limited value in helping to control pain. More randomized trials are needed, along with further technologic innovation to improve the current treatment modalities. When considering interventional therapy for a patient with CP, a tailored and multidisciplinary therapeutic approach should be taken.

EUS-guided celiac plexus neurolysis vs. block: assessing interference with pancreatic surgery and adhesions in a pig survival model

Background/Purpose: Celiac plexus neurolysis (CPN) is used for pain management in pancreatic cancer. It involves the injection of alcohol to destroy the celiac neural structures, aimed at achieving longer-lasting analgesia than a steroid/anesthetic block alone (CPB). However, one concern in chronic pancreatitis is that subsequent surgery may prove difficult due to adhesions. The aim of the study was to determine the degree of interference and the adhesion burden from CPN vs. CPB in a blinded pig survival model.