EUS-guided Celiac Plexus Block Research Articles

“A Prospective Randomized Trial of 1 Versus 2 Injections During a Single EUS-Guided Celiac Plexus Block (CPB) Procedure for Chronic Pancreatitis Pain: Final Results”

“A Prospective Randomized Trial of 1 Versus 2 Injections During a Single EUS-Guided Celiac Plexus Block (CPB) Procedure for Chronic Pancreatitis Pain: Final Results”

EUS-Guided Celiac Plexus Block and Celiac Plexus Neurolysis

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.

Risk Assessment of Infectious Complications in Patients Undergoing Endoscopic Ultrsound (EUS) Guided Celiac Plexus Block (CPB): A Multicenter Experience

EUS-guided CPB has been reported to be a promising alternative method for managing abdominal pain due to GI malignancy or chronic pancreatitis. Sparse data exists on the safety of this technique. There is some data on infectious complications associated with EUS fine needle aspiration. The aim of this study was to evaluate the risk of developing an infectious complication associated with EUS CPB and the role antibiotics and proton pump inhibitors (PPI) may play in both the reduction and development of such complications, respectively. Methods: This multicenter study is comprised of two cohorts: Prospective data collected from institution #1 between January 1, 2000 and December 1, 2002 on 28 consecutive patients (pts) and retrospective data collected between December 1, 1999 and November 1, 2004 on 13 pts identified through a search of our endoscopic database at institution #2; all undergoing EUS-guided CPB for chronic abdominal pain. The following parameters were recorded: CPB indication, age, co-morbidities, antibiotic (pre- or post-procedure) use and current use of PPI, aspirin or other anticoagulation. Pts were followed for signs or symptoms suggesting a complication including pain, fever, bleeding and leukocytosis. Results: A total of 41 EUS CPB's were performed. 46.3% of pts were on a PPI. In 21.9% of cases, the prophylactic use of antibiotics occurred for other reasons (i.e. co-morbidities, prosthetic heart valves). 58.5% of procedures were not associated with pre- or post-procedure antibiotic use. There were no complications noted in 95.1% of cases. However, 4.9% of cases were followed by mild self-limited epigastric discomfort. There were no reports of fever, leukocytosis, bleeding or abscess formation. No significant differences existed in the complication risk between the PPI versus no PPI groups (p > 0.05) or the antibiotic versus no antibiotic groups (p > 0.05). There was no significant difference between the 2 cohort groups in terms of complications and the use of antibiotics or PPI's (p > 0.05). Conclusions: No infectious complications were observed following EUS CPB. No correlation of infectious complications was observed with the use of a PPI or antibiotics. The results of this multicenter study raise the question as to the need for prophylactic antibiotics prior to EUS CPB. Further studies using a prospective randomized comparison of antibiotics and PPI's or assessing the presence of bacteremia after EUS-guided CPB are warranted.

A Prospective Evaluation of EUS-Guided Celiac Plexus Block in Patients with Chronic Pancreatitis and Pancreas Cancer

Introduction: Abdominal pain of pancreatic cancer or chronic pancreatitis (CP) is often difficult to manage. The side effects and potential for dependence are drawbacks to narcotic use. EUS-guided celiac plexus block (EUS-CB) is a minimally invasive option, however, findings of studies are mixed and quality of life following EUS-CB has not been previously assessed. Objective: To measure the clinical response and quality of life in consecutive patients undergoing EUS-CB. Methods: Ten consecutive patients (6 CP, 4 pancreatic cancer) have been enrolled to date. Baseline pain rating (scale of 1-10), medication usage, and underlying diagnosis were collected prior to the EUS-CB. The patient completed an SF-36 survey at entry and 4 weeks later. Patients with CP received 10 cc of 0.75% bupivicaine followed by 80 mg of triamcinolone in one or two injections. Patients with pancreatic cancer received 10 cc 0.75% bupivicaine followed by 10 cc of alcohol. Under flouorscopic guidance, all patients received an injection of contrast to document proper localization of the injection. Follow up phone calls were made at 24 hours, 2, 4, 6, and 8 weeks, and monthly thereafter until no further response was noted. A response was defined as a 40% decrease in pain score. Results: There were no procedure-related complications. Overall, there was a 60% response (4/6 chronic pancreatitis, 2/4 pancreas cancer) to EUS-CB as measured by a decrease in pain score. 5 patients (1 pancreatic cancer 1, 4 CP). All responders had onset of pain relief within 2 weeks. The overall general health scores from the SF-36 revealed no statistically significant difference at 4 weeks after the EUS-CB for the pancreatic cancer group (p=0.91) or chronic pancreatitis (p=0.93). There was no statistically significant difference in pain scores between patients with CP or pancreatic cancer (p=0.26). The mean duration of pain relief for CP was 11.3 weeks (SD 12.2, range 0-28) and 3.5 weeks (SD 4.1, range 0-8) for pancreatic cancer. Conclusions: Our preliminary results reveal that EUS-CB was safe, effective, and short-lived in decreasing pain in over half of patients, however, further recruitment is necessary to fully evaluate clinical and statistical significance and the impact of EUS-CB on quality of life.

Endoscopic ultrasound-guided (neurolytic) celiac plexus block.

Celiac plexus neurolysis is an established technique for relieving pain in cancers of the upper abdomen. This article reviews the novel technique of endoscopic ultrasound (EUS)-guided neurolytic celiac plexus block. This recently described procedure is a therapeutic extension of curvilinear array endosonographic fine needle aspiration. The indications, patient preparation, and technical aspects of the procedure are described in detail. The potential complications are mentioned and the results of the published studies are reviewed. We believe that where the expertise is available, this procedure can be integrated into the diagnostic EUS of patients with inoperable upper abdominal malignancy. As such, this would be the safest and most cost-effective approach for celiac plexus neurolysis in these patients. The role of EUS-guided celiac plexus block in patients with chronic pancreatitis may be emerging and needs further study.

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.

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.

EUS-guided celiac plexus block for the management of pancreatic pain

EUS-guided celiac plexus block for the management of pancreatic pain

A prospective randomized comparison of endoscopic ultrasound- and computed tomography-guided celiac plexus block for managing chronic pancreatitis pain

OBJECTIVE: Computed tomography (CT)-guided celiac plexus neurolysis has been used for controlling the chronic abdominal pain associated with intra-abdominal malignancy and chronic pancreatitis. Endoscopic ultrasound (EUS)-guided celiac plexus neurolysis has been reported to have some success in controlling pain from pancreatic cancer. The aim of this study is to assess the efficacy of EUS-guided celiac plexus block versus CT-guided celiac plexus block for controlling the chronic abdominal pain associated with chronic pancreatitis. METHODS: Patients enrolled were randomly assigned to EUS-guided or CT-guided celiac plexus block. Pain scores were determined pre- and postceliac block for both techniques. Follow-up was obtained by a nurse at 1 day postblock, then weekly thereafter for 24 wk. Patients also rated overall experience with these procedures. The EUS celiac block was performed with a 22-gauge sterile needle inserted into the celiac region with guidance of real-time linear array endosonography followed by injection of 10 ml of bupivacaine (0.75%) and 3 ml (40 mg) of triamcinolone on both sides of the celiac area. RESULTS: Twenty-two consecutive patients (10 men, 12 women), were ultimately enrolled in this study between 7/1/95 and 12/30/95; four patients were excluded for protocol violations. We performed EUS-guided celiac block in 10 patients and CT-guided celiac block in eight. A significant improvement in pain scores with reduction in pain medication usage occurred in 50% (five of 10) of patients having the EUS block. The mean postprocedure follow-up was 15 weeks (range: 8–24 wk). Persistent benefit was experienced by 40% of patients at 8 wk and by 30% at 24 wk. In the patients with CT block, however, only 25% (two of eight) had relief. The mean follow-up was 4 wk (range: 2–6 wk). Only 12% (one of eight) had some relief at 12 wk of follow-up. There were no complications. EUS-guided celiac block was the preferred technique among patients who experienced both techniques. A cost comparison between both celiac block techniques shows EUS to be less costly than CT. CONCLUSIONS: EUS-guided celiac block provided more persistent pain relief than CT-guided block and was the preferred technique among the subjects studied. EUS-guided celiac block appears to be a safe, effective, and less costly method for controlling the abdominal pain that can accompany chronic pancreatitis in some patients.