EUS-guided Celiac Plexus Neurolysis Research Articles

Clinical efficacy of EUS-guided celiac plexus neurolysis versus EUS-guided celiac ganglion irradiation with iodine-125 seeds for pain relief in advanced pancreatic cancer: A long-term retrospective study.

To compare the efficacy of EUS-guided celiac plexus neurolysis (CPN) and celiac plexus irradiation with iodine-125 (125I) seeds with absolute ethanol for relieving pain in patients with advanced pancreatic cancer. We retrospectively analyzed data of 81 patients with advanced pancreatic cancer who underwent EUS-CPN or EUS-125I implantation between January 2017 and December 2020. Postoperative pain was assessed using visual analog scale (VAS) scores; self-assessments of quality of life and the median survival time were compared between the 2 groups. EUS-CPN and 125I implantation were performed in 43 and 38 patients, respectively. Postoperative VAS scores were significantly lower than the preoperative levels in both groups. One week after the operation, 26 patients (60.5%) in the EUS-CPN group achieved partial pain relief, whereas no patients in the EUS-125I seed group experienced pain relief. However, after 4 weeks postoperatively, VAS scores had decreased, and the rate of partial pain relief was higher for EUS-125I seeds than for EUS-CPN. Self-assessments of quality of life were similar in both groups during the first 1 month after the procedure. Both EUS-CPN and EUS-125I seeds can safely and effectively relieve pain in patients with advanced pancreatic cancer. Although EUS-125I seeds take additional time to show effects, the extent and duration of pain relief are better compared with CPN, and interestingly, the median survival time was different.

A meta-analysis on the efficacy of endoscopic ultrasonography for treatment of pancreatic cancer

ObjectiveThis study aimed to systematically evaluate the efficacy and safety of Endoscopic Ultrasonography (EUS) for the treatment of pancreatic cancer. MethodsThe PubMed, Embase, Web of Science, and Google Scholar databases were searched from the inception of the databases to June 2022. RevMan 5.3.0 software was utilized for data analysis. In total, 13 self-descriptive studies, which enrolled 382 patients, were finally included. ResultsIt was revealed that EUS for the treatment of pancreatic cancer exhibited a lower incidence of adverse reactions (Relative Risk Ration [RR = 0.23], 95 % Confidence interval [95 % CI 0.23–0.23]), a higher success rate (RR = 0.90, 95 % CI 0.90–0.90), and a low failure rate (RR = 0.06, 95 % CI 0.06–0.06). Moreover, EUS-guided Celiac Plexus Neurolysis (EUS-CPN) not only significantly relieved pancreatic cancer patients’ pain (RR = 0.83, 95 % CI 0.83–0.83), but also significantly eliminated pain in some patients (RR = 0.09, 95 % CI 0.09–0.09). The effects of EUS on pancreatic cancer treatment were satisfactory, and few adverse reactions were found. ConclusionOwing to the restricted sample size in this meta-analysis, primarily consisting of descriptive studies, it was imperative to conduct more rigorously designed, multi-center, long-term follow-up, larger sample, and Randomized Controlled Trials (RCTs) to validate the findings.

The Role of Endoscopy in the Palliation of Pancreatico-Biliary Cancers: Biliary Drainage, Management of Gastrointestinal Obstruction, and Role in Relief of Oncologic Pain.

Therapeutic endoscopy permits many and various treatments for cancer palliation in patients with bilio-pancreatic cancers, enabling different options, supporting patients during their route to oncologic treatments, and trying to improve their quality of life. Therefore, both endoscopic and endoscopic ultrasound (EUS)-guided techniques are performed in this scenario. We performed a literature review focusing on the role of endoscopy in the palliation of those advanced pancreatic and biliary cancers developing malignant biliary obstruction (MBO), gastric outlet obstruction (GOO), and pain unresponsive to medical therapies. Therefore, we explored and focused on the clinical outcomes of endoscopic procedures in this scenario. In fact, the endoscopic treatment is based on achieving biliary drainage in the case of MBO through endoscopic retrograde cholangiopancreatography (ERCP) or EUS-guided biliary drainage (EUS-BD), while GOO is endoscopically treated through the deployment of an enteral stent or the creation of EUS-guided gastro-entero-anastomosis (EUS-GEA). Furthermore, untreatable chronic abdominal pain is a major issue in patients unresponsive to high doses of painkillers, so EUS-guided celiac plexus neurolysis (CPN) or celiac ganglia neurolysis (CGN) helps to reduce dosage and have better pain control. Therefore, therapeutic endoscopy in the palliative setting is an effective and safe approach for managing most of the clinical manifestations of advanced biliopancreatic tumors.

Role of interventional endoscopic ultrasound in a developing country.

Endoscopic ultrasound (EUS) has become an essential diagnostic and therapeutic tool. EUS was introduced in 2013 in Indonesia and is considered relatively new. This study aimed to describe the current role of interventional EUS at our hospital as a part of the Indonesian tertiary health center experience. This retrospective study included all patients who underwent interventional EUS (n=94) at our center between January 2015 and December 2020. Patient characteristics, technical success, clinical success, and adverse events associated with each type of interventional EUS procedure were evaluated. Altogether, 94 interventional EUS procedures were performed at our center between 2015 and 2020 including 75 cases of EUS-guided biliary drainage (EUS-BD), 14 cases of EUS-guided pancreatic fluid drainage, and five cases of EUS-guided celiac plexus neurolysis. The technical and clinical success rates of EUS-BD were 98.6% and 52%, respectively. The technical success rate was 100% for both EUS-guided pancreatic fluid drainage and EUS-guided celiac plexus neurolysis. The adverse event rates were 10.6% and 7.1% for EUS-BD and EUS-guided pancreatic fluid drainage, respectively. EUS is an effective and safe tool for the treatment of gastrointestinal and biliary diseases. It has a low rate of adverse events, even in developing countries.

Comparison of the Effects of Alcohol and Phenol Used for Celiac Neurolysis with Endoscopic Ultrasound in Patients with Pancreas Cancer: Retrospective Analysis

Objective: In this study we aimed to compare the efficacy of ethanol and phenol used in the EUS-guided celiac plexus neurolysis procedure on pain scores and complications. Material and Methods: Between January 2009 and June 2022, 28 patients who underwent celiac neurolysis underwent sedation via EUS (endoscopic ultrasonography) guidance in the endoscopy unit were included. We retrospectively analyzed the data of the EUS-guided celiac neurolysis procedures for pain management of patients with pancreatic cancer. Results: Patients in the alcohol group had lower pain scores. Conclusion: When alcohol and phenol-based neurolytic techniques were compared, better analgesic effect was obtained in the alcohol group.

Efficacy of EUS-guided celiac plexus neurolysis in combination with EUS-guided celiac ganglia neurolysis for pancreatic cancer-associated pain: a multicenter prospective trial.

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. 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 1week after the procedure to evaluate its effectiveness and the extent of pain relief. 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 72days. 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. 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. UMIN000031228.

Palliation in Gallbladder Cancer: The Role of Gastrointestinal Endoscopy.

Simple SummaryGallbladder cancer is burdened by poor prognosis, and palliation often represents the best option. Endoscopy plays a crucial role in the management of cholangitis, jaundice, gastric outlet obstruction, and pain. The aim of this study is to perform a review of the literature to assess the role of endoscopy in the palliative therapy of advanced gallbladder malignancy.Gallbladder cancer is a rare malignancy burdened by poor prognosis with an estimated 5-year survival of 5% to 13% due to late presentation, early infiltration of surrounding tissues, and lack of successful treatments. The only curative approach is surgery; however, more than 50% of cases are unresectable at the time of diagnosis. Endoscopy represents, together with surgery and chemotherapy, an available palliative option in advanced gallbladder cancers not eligible for curative treatments. Cholangitis, jaundice, gastric outlet obstruction, and pain are common complications of advanced gallbladder cancer that may need endoscopic management in order to improve the overall survival and the patients’ quality of life. Endoscopic biliary drainage is frequently performed to manage cholangitis and jaundice. ERCP is generally the preferred technique allowing the placement of a plastic stent or a self-expandable metal stent depending on the singular clinical case. EUS-guided biliary drainage is an available alternative for patients not amenable to ERCP drainage (e.g., altered anatomy). Gastric outlet obstruction is another rare complication of gallbladder malignancy growing in contact with the duodenal wall and causing its compression. Endoscopy is a less invasive alternative to surgery, offering different options such as an intraluminal self-expandable metal stent or EUS-guided gastroenteroanastomosis. Abdominal pain associated with cancer progression is generally managed with medical treatments; however, for incoercible pain, EUS-guided celiac plexus neurolysis has been described as an effective and safe treatment. Locoregional treatments, such as radiofrequency ablation (RFA), photodynamic therapy (PDT), and intraluminal brachytherapy (IBT), have been described in the control of disease progression; however, their role in daily clinical practice has not been established yet. The aim of this study is to perform a review of the literature in order to assess the role of endoscopy and the available techniques in the palliative therapy of advanced gallbladder malignancy.

EUS-CGN versus EUS-CPN in pancreatic cancer: A qualitative systematic review.

Background:Comparison between endosonographic ultrasonography (EUS)-guided celiac ganglia neurolysis (CGN) and EUS-guided celiac plexus neurolysis (CPN) in pain management for pancreatic cancer has engendered controversy. To analyze the effectiveness and safety of EUS-CGN and figure out whether EUS-CGN is better than EUS-CPN, a qualitative systematic review was conducted.Methods:Studies were searched from Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE up to April 2020. We only included studies with full-text and in English and assessed study quality with Newcastle-Ottawa Scale or Cochrane risk-of-bias tool. We recorded details of study design, participants, procedure performed, protocol of follow-up, pain response, quality of life, survival, and adverse events. The study was conducted under Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement 2009.Results:Five studies involving 319 patients were included. Short-term pain response rates ranged from 65.0% to 88.46% in EUS-CGN group and most studies reported its superiority over EUS-CPN. As for adverse events, the incidence of transient hypotension and gastrointestinal symptoms seemed comparable, while results of initial pain exacerbation varied among studies. Besides, EUS-CGN might provide a shorter survival.Conclusion:EUS-CGN can be safely performed while it may shorten survival. In terms of short-term pain response, EUS-CGN is better than EUS-CPN while no conclusion of long-term pain control can be drawn.

EUS-Guided Celiac Plexus Interventions

AbstractEndoscopic ultrasound (EUS)-guided celiac plexus intervention comprises EUS-guided celiac plexus block (EUS-CPB) and EUS-guided celiac plexus neurolysis (EUS-CPN). EUS-CPB and EUS-CPN are one of the used methods of pain management in patients of pancreatic cancer and chronic pancreatitis, respectively, along with medical therapy. Both the procedures are associated with minimal complications and improves quality of life. The role of EUS-guided celiac plexus intervention is increasing in gall bladder carcinoma for pain control.

Sarcopenia represents a negative prognostic factor in pancreatic cancer patients undergoing EUS celiac plexus neurolysis.

Background and Objectives:Increasing evidence suggests a prognostic role of sarcopenia in pancreatic cancer patients. The aim of this study was to assess the influence of sarcopenia on treatment outcomes after EUS-guided celiac plexus neurolysis (CPN).Materials and Methods:Data regarding 215 patients treated with EUS CPN between 2004 and 2019 were reviewed. Determination of body composition was conducted on contrast-enhanced CT scan, and pain response was considered as the primary outcome. Univariate and multivariate logistic regression was performed to identify the independent predictors of pain response.Results:Treatment was successful in 187 patients (86.9%). The median age was 62 (range 39–84) years, and most patients were male (61.8%). Of the whole study population, 139 patients (64.6%) were defined as sarcopenic, of which 116 (83.4%) responded to the treatment and 5 (3.5%) experienced a complete response. Among 76 nonsarcopenic participants, 71 (93.4%) responded to the treatment and 22 (28.9%) obtained a complete response (P = 0.03 and <0.001, respectively). The median duration of pain relief was 8 (2–10) and 15 (8–16) weeks in sarcopenic and nonsarcopenic patients, respectively (P = 0.01). The median overall survival after neurolysis was 4 months (3–5) in sarcopenic participants and 7 months (6–8) in nonsarcopenic participants (P = 0.05). Tumoral stage, interval from the diagnosis to treatment, and sarcopenia resulted as significant prognostic factors for treatment response both in univariate and multivariate regression analyses. No severe treatment-related adverse events were reported in the whole study population, with no difference between the two groups.Conclusions:Sarcopenia represents a predictor of poorer response to EUS CPN.

Tu1371 COMBINED EUS-GUIDED CELIAC PLEXUS NEUROLYSIS AND IODINE-125 VERSUS EUS-GUIDED CELIAC PLEXUS NEUROLYSIS FOR PALLIATION OF PAIN IN PANCREATIC CANCER: A PROSPECTIVE, RANDOMIZED STUDY

EUS-guided celiac plexus neurolysis (EUS-CPN) is frequently used for palliating pain in patients with pancreatic cancer, but the efficacy is suboptimal. Iodine-125 (I125) is a radioisotope of iodine. It can continually release radiation at low doses to nearby areas. We performed a single-blind, randomized trial to compare the efficacy and safety of combination of EUS-CPN with I125to EUS-CPNalone for palliation of pain in patient with pancreatic cancer.

EUS-guided Celiac Plexus Neurolysis for the Treatment of Abdominal Pain in Pancreatic Cancer

EUS-guided Celiac Plexus Neurolysis for the Treatment of Abdominal Pain in Pancreatic Cancer

Endoscopic Ultrasound-Guided Celiac Plexus Block and Celiac Neurolysis: A Systematic Review of Efficacy, Safety, and Protocols

Introduction: The advent of endoscopic ultrasound (EUS)-guided celiac plexus block (CPB) and celiac plexus neurolysis (CPN) has provided immeasurable benefit for patients with pain from chronic pancreatitis and pancreatic malignancies. There are differences in efficacy based on indication and protocol used for CPN and CPB. Here we aim to characterize efficacy, safety, and variations in protocol of both EUS-guided CPB and CPN by performing a systematic review of the literature. Methods: Using predefined keywords a search was performed using the EMBASE, Medline, and Cochrane databases through January 2018. Abstracts that discussed the outcomes of EUS-guided CPN and/or CPB were considered for inclusion. Data was abstracted from all papers, including demographic information, indication for CPN and CPB, protocol used for CPN and CPB, outcomes of intervention, and complication rates of endoscopy. Weighted data was used to calculate the efficacy and complications. Results: Following a database search, 437 abstracts were reviewed. 35 studies were selected for data abstraction of which 8 were randomized trials, 16 prospective, and 11 retrospective. 1290 patients underwent CPN and 714 underwent CPB. In those undergoing CPB and CPN, the main indications were chronic pancreatitis (98%, 698/714) and pancreatic cancer (99%, 1278/1290) respectively. In studies reporting the rate of response, overall initial response was 64% (873/1369). CPN and CPB had an initial response rate of 65% (482/745, range 25-100%) and 63% (391/624, range 0-100%) respectively. When celiac ganglia were targeted, response was 74% (68/92, range 65-94%). Duration of response varied widely across all studies and interpretation was limited by duration of follow-up. No deaths or perforations were reported. There was 1 upper gastrointestinal bleed and 1 peri-pancreatic abscess attributed to the intervention. The most common side effects were transient diarrhea and transient hypotension. In regards to anesthetic agents used, bupivacaine 0.25-0.75%, lidocaine 1.0-2.0%, and xylocaine 1.0% were all used. Triamcinolone was used in doses ranging from 40-160 mg. Finally, alcohol 95-99% was used in doses ranging from <5 ml to 20 ml. One study looked at the efficacy of phenol 7% as a neurolytic agent in those intolerant of alcohol. Conclusion: Overall, CPB and CPN appear to be effective and safe modalities at controlling pain. Due to variations in protocol, clinical guidelines are required to outline best-practice for both EUS-guided CPB and CPN.

EUS-guided celiac ganglion radiofrequency ablation versus celiac plexus neurolysis for palliation of pain in pancreatic cancer: a randomized controlled trial (with videos)

Although EUS-guided celiac plexus neurolysis (EUS-CPN) is frequently performed, its efficacy for palliation of pain in pancreatic cancer is suboptimal. Recently, EUS-guided radiofrequency ablation (EUS-RFA) has been proposed as a palliative treatment option for pancreatic neoplasms. We performed a single-blind, randomized trial to compare the effectiveness of EUS-CPN and EUS-RFA for palliation of pain in pancreatic cancer. Patients with abdominal pain because of locally advanced or metastatic pancreatic cancer underwent EUS-CPN (n= 14) or EUS-RFA (n= 12). EUS-RFA was performed using a 1F monopolar probe passed via a 19-gauge FNA needle, by targeting the area of celiac plexus or visualized ganglia. Primary outcome was pain severity as measured by the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire pancreatic cancer module (PAN26) administered pretreatment and at 2 and 4 weeks post-treatment. Secondary outcome measures were comparison of quality of life as determined by the PAN26 and EORTC Quality of Life Questionnaire core questionnaire (C30) and opioid analgesia use between the 2 groups. Both the PAN26 (49.0 vs 57.0, P< .001) and C30 (51.9 vs 64.4, P= .032) revealed less pain for EUS-RFA than for EUS-CPN. Also, the EUS-RFA cohort experienced significantly less-severe GI symptoms, were able to plan more for the future, and had better emotional functioning compared with the EUS-CPN group. Compared with EUS-CPN, EUS-RFA provided more pain relief and improved the quality of life for patients with pancreatic cancer. (Clinical trials registration number: NCT03152487.).

A comparison of percutaneous and endoscopic-guided celiac plexus block/neurolysis in pancreatic cancer patients.

413 Background: Pancreatic Cancer is associated with severe pain and often intractable due to its multifactorial nature. Celiac plexus neurolysis (CPN) has been shown to be effective in controlling pain and conventionally was performed percutaneously (PC) with fluoroscopic or CT guidance. However EUS guidance is being increasingly used and has shown to provide effective analgesia. The aim of this retrospective study is to compare PC-guided and EUS-guided CPN for pain control. Methods: Our retrospective cohort study included pancreatic cancer patients who underwent CPN for pain control from 2008 to 2015 at Johns Hopkins. The primary outcome was a good pain response defined as a drop in NRS pain scores to less than 1 or drop of at least 3 post-procedurally or at 1 month. Secondary outcomes were changes in opiate usage (morphine equivalents), QOL (FACT-Hep) scores and opiate-related side effects. Results: 151 patients underwent PC-CPN and 49 patients underwent EUS-CPN. Patients had their procedure on average 5 months after diagnosis. At baseline, EUS patients had significant higher median baseline pain scores, 9 (4-10) compared to 6 (5-7). A good pain response was seen in 86% of PC patients compared to 73% of EUS patients post-procedurally (p = 0.01). However, at 1 month 43% of EUS patients had a good pain response compared to 28% of PC patients, which trended towards statistical significance (p = 0.08). Following the procedure at 1 month, opiate dosage increased in both groups and no reduction in the proportion of patients with opiate related side effects was seen. EUS patients had significantly higher QOL scores at 1 month, 86 (79-92) vs 72 (67-82) (p &lt; 0.001). Median time from procedure to death was significantly higher in EUS patients than PC patients (HR: 0.63, 95% CI: 0.44, 0.89, p = 0.008). No differences in adverse events between the two groups were seen. Conclusions: Both EUS and PC guided CPN were effective at reducing post-procedural pain in pancreatic cancer patients but their effectiveness waned by 1 month. Percutaneous patients had significantly lower pain scores immediately following the procedure. However, EUS patients seemed to have more durable pain relief with lower pain scores at 1 month and improved QOL.

EUS-guided celiac ganglia neurolysis: a clinical and human cadaver study (with video)

There is little evidence that structures targeted during EUS-guided celiac ganglia neurolysis (EUS-CGN) are celiac ganglia and that selective ethanol injection into ganglia is feasible. We aimed to visualize celiac ganglia, confirm that these structures are ganglia, and visualize ethanol spread after EUS-CGN and EUS-guided celiac plexus neurolysis (EUS-CPN). First, celiac ganglia were sought during 97 consecutive EUS procedures. Second, ganglia were identified in a prosected human cadaver by placing a linear echoendoscope next to the celiac trunk and removing the underlying tissue for histology. Finally, various EUS-CGN and EUS-CPN techniques were performed in human cadavers; EUS-CGN was performed with 1 mL ethanol in 1 ganglion, 1 mL per ganglion (both low volume), and 4 mL per ganglion (high volume). EUS-CPN was performed with a central (20 mL) and a bilateral (2*10 mL) approach. Transverse sections (75 μm) were obtained and photographed to allow visualization of the spread of ethanol. A total of 204 ganglia were detected in 83 patients. Mean (± standard deviation) size of the long axis was 8.1mm (± 7.4mm). Histology of the removed region in the cadaver showed only nerve cell bodies. After low-volume EUS-CGN in cadavers, ethanol spread well beyond the targeted ganglion. After high-volume EUS-CGN in cadavers, a larger ethanol spread was seen, which also reached unidentified ganglia; the spread was comparable to the spread after EUS-CPN. Specific EUS-CGN is not feasible because ethanol spreads well beyond the targeted ganglion. Unidentified celiac ganglia are better reached with high-volume EUS-CGN, and this would likely result in a more thorough neurolysis. High-volume EUS-CGN should be preferred to low-volume EUS-CGN.

Intraprocedural increase in heart rate during EUS-guided celiacplexus neurolysis: Clinically relevant or just a physiologicchange?

Although EUS-guided celiac plexus neurolysis (EUS-CPN) is performed frequently for palliation of pain in pancreatic cancer, response to treatment is variable. Although intraprocedural increases in heart rate during alcohol injection are observed frequently, their significance and relationship to treatment outcome are unknown. The objective of this study was to examine whether a correlation exists between an increase in heart rate and treatment outcomes in patients undergoing EUS-CPN for pain relief in pancreatic cancer. This is a prospective observational study of patients with abdominal pain caused by inoperable pancreatic cancer who underwent EUS-CPN. Heart rate change was defined as an increase of≥15 beats per minute (bpm) for≥30 seconds during alcohol injection. Main outcome measures were to compare pain, quality of life, opioid use, and survival between heart rate change and no-change groups. Heart rate change was observed in 25 of 51 patients (49.0%) who underwent EUS-CPN over a 12-month period. Although the heart rate change cohort had significantly better adjusted scores for pain (60 vs 73; P= .042) and components of quality of life such as nausea and/or vomiting (65 vs 81; P= .004), financial difficulties (41 vs 57; P= .02), weight loss (45 vs 65; P= .007), and satisfaction with body image (52 vs 62; P= .035), there was no significant difference in postprocedural opioid use or survival between groups. Because patients with an increase in intraprocedural heart rate experienced significant improvement in pain and quality of life components, this observation must be further explored in order to improve the technique and outcomes of EUS-CPN.

Endoscopic Ultrasound Guided Intervention

Endoscopic ultrasound (EUS) has recently become widely used for the diagnosis and treatment of gastrointestinal disease. With applications of linear EUS and EUS-guided fine needle aspiration, many EUS-guided interventions are now emerging as feasible treatment options for patients with pancreatobiliary disease. EUS-guided drainage from pseudocyst, bile duct, pancreatic duct, and the gallbladder are becoming routine procedure. EUS-guided celiac plexus neurolysis and block can relieve intractable pancreatic pain. Moreover, EUS-guided local tumor therapy (ethanol ablation and radiofrequency ablation) may be feasible in selected patients. Safe EUS-guided intervention requires a good deal of experience but is becoming widely used to treat pancreatobiliary disease. (Korean J Med 2015,89:507-514)

A multimodal, one-session endoscopic approach for management of patients with advanced pancreatic cancer.

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. 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. 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) 72h following celiac plexus neurolysis. At follow-up (median survival 4months; range 3-8), only 3 (20%) needed of narcotic treatment in the last period. 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.

Endoscopic ultrasound-fine needle injection for oncological therapy.

The minimal invasiveness and precision of endoscopic ultrasound (EUS) has lead to both its widespread use as a diagnostic and staging modality for gastrointestinal and pancreaticobiliary malignancies, and to its expanding role as a therapeutic modality. EUS-guided celiac plexus neurolysis is now a well-accepted modality for palliation of pain in patients with pancreatic cancer. EUS-guided ablation, brachytherapy, fiducial marker placement, and antitumor agent injection have been described as methods of performing minimally invasive oncological therapy. EUS-fine needle injection may be performed as adjunctive, alternative, or palliative treatment. This review summarizes the studies to date that have described these methods. A literature search using the PubMed/MEDLINE databases was performed. While most published studies to date are limited with disappointing outcomes, the concept of a role of EUS in oncological therapy seems promising.