Pain is a common symptom of pancreatic disease and is frequently difficult to manage. Pain relief provided by narcotics is often suboptimal and is associated with significant side effects. An alternative approach to p...Pain is a common symptom of pancreatic disease and is frequently difficult to manage. Pain relief provided by narcotics is often suboptimal and is associated with significant side effects. An alternative approach to pain management in pancreatic disease is the use of celiac plexus block (CPB) or neurolysis (CPN). Originally performed by anesthesiologists and radiologists via a posterior approach,recent advances in endoscopic ultrasonography (EUS) have made this technique an attractive alternative. EUS guided celiac plexus block/ neurolysis is simple to perform and avoids serious complications such as paraplegia or pneumothorax that are associated with the posterior approach. EUS guided CPN should be considered first line therapy in patients with pain due to pancreatic cancer. It provides superior pain control compared to traditional management with narcotics. A trend for improved survival in pancreatic cancer patients treated with CPN has been reported,but larger studies are needed to confirm this finding. At this time,the use of EUS guided CPB cannot be recommended as routine therapy for pain in chronic pancreatitis since only one-half of the patients experience pain reduction and the beneficial effect tends to be short lived. EUS guided CPB and CPN should be used as part of a multidisciplinary team approach for pain management.展开更多
Pancreatic cancer is the second most common abdominal cancer in North America with an estimated 20%resectability at diagnosis,and overall 5-year survival of 5%.Pain is common in pancreatic cancer patients with 70%-80%...Pancreatic cancer is the second most common abdominal cancer in North America with an estimated 20%resectability at diagnosis,and overall 5-year survival of 5%.Pain is common in pancreatic cancer patients with 70%-80%suffering substantial pain.Celiac plexus neurolysis(CPN)is a technique that can potentially improve pain control in pancreatic cancer while preventing further escalation of opioid consumption.CPN is performed by injecting absolute alcohol into the celiac plexus neural network of ganglia.This review sets out to explore the current status of CPN in non-resectable pancreatic cancer.We will examine:(1)the efficacy and safety of percutaneous-CPN and endoscopic ultrasound guided-CPN;(2)specific technique modifications including bilateral(vs central)injections and celiac ganglia neurolysis;and(3)the issue of CPN timing,early at pancreatic cancer diagnosis vs traditional late use as salvage therapy.展开更多
AIM:To assess the feasibility of endoscopic ultrasound(EUS)guided celiac plexus neurolysis(CPN) using a poloxamer. METHODS:In this prospective evaluation,six Yorkshire pigs underwent EUS-guided CPN.Three received an i...AIM:To assess the feasibility of endoscopic ultrasound(EUS)guided celiac plexus neurolysis(CPN) using a poloxamer. METHODS:In this prospective evaluation,six Yorkshire pigs underwent EUS-guided CPN.Three received an injection of 10 mL of 0.25%Lidocaine plus methylene blue(group 1) and three received an injection of 10 mL of 0.25%Lidocaine plus blue colored poloxamer(PS137-25)(group 2) .Necropsy was performed immediately after the animals were sacrificed.The abdominal and pelvic cavities were examined for the presence of methylene blue and the blue colored poloxamer.RESULTS:EUS-guided CPN was successfully performed in all 6 pigs without immediate complication.Methylene blue was identified throughout the peritoneal and retroperitoneal cavity in group 1.The blue colored poloxamer was found in the retroperitoneal cavity immediately adjacent to the aorta,in the exact location of the celiac plexus in group 2.CONCLUSION:EUS-guided CPN using a reverse phase polymer in a non-survival porcine model was technically feasible.The presence of a poloxamer gel at the site of the celiac plexus at necropsy indicates a precise delivery of the neurolytic agent.展开更多
Pancreatic cancer produces disabling abdominal pain,and the pain medical management for pancreatic cancer is often challenging because it mainly relies on the use of narcotics(major opioids).However,opioids often prov...Pancreatic cancer produces disabling abdominal pain,and the pain medical management for pancreatic cancer is often challenging because it mainly relies on the use of narcotics(major opioids).However,opioids often provide suboptimal pain relief,and the use of opioids can lead to patient tolerance and several side effects that considerably reduce the quality of life of pancreatic cancer patients.Endosonography-guided celiac plexus neurolysis(EUS-CPN)is an alternative for pain control in patients with nonsurgical pancreatic cancer;EUS-CPN consists of the injection of alcohol and a local anesthetic into the area of the celiac plexus to achieve chemical ablation of the nerve tissue.EUS-CPN via the transgastric approach is a safer and more accessible technique than the percutaneous approach.We have reviewed most of the studies that evaluate the efficacy of EUSCPN and that have compared the different approaches that have been performed by endosonographers.The efficacy of EUS-CPN varies from 50%to 94%in the different studies,and EUS-CPN has a pain relief duration of 4–8 wk.Several factors are involved in its efficacy,such as the onset of pain,previous use of chemotherapy,presence of metastatic disease,EUS-CPN technique,type of needle or neurolytic agent used,etc.According to this review,injection into the ganglia may be the best technique,and a good visualization of the ganglia is the best predictor for a good EUS-CPN response,although more studies are needed.However,any of the 4 different techniques could be used to perform EUS-CPN effectively with no differences in terms of complications between the techniques,but more studies are needed.The effect of EUS-CPN on pain improvement,patient survival and patient quality of life should be evaluated in well-designed randomized clinical trials.Further research also needs to be performed to clarify the best time frame in performing a EUS-CPN.展开更多
BACKGROUND Endoscopic ultrasound-guided celiac plexus neurolysis(EUS-CPN)has gained popularity as a minimally invasive approach and is currently widely used to treat pancreatic cancer-associated pain.However,response ...BACKGROUND Endoscopic ultrasound-guided celiac plexus neurolysis(EUS-CPN)has gained popularity as a minimally invasive approach and is currently widely used to treat pancreatic cancer-associated pain.However,response to treatment is variable.AIM To identify the efficacy of EUS-CPN and explore determinants of pain response in EUS-CPN for pancreatic cancer-associated pain.METHODS A retrospective study of 58 patients with abdominal pain due to inoperable pancreatic cancer who underwent EUS-CPN were included.The efficacy for palliation of pain was evaluated based on the visual analog scale pain score at 1 wk and 4 wk after EUS-CPN.Univariable and multivariable logistic regression analyses were performed to explore predictors of pain response.RESULTS A good pain response was obtained in 74.1%and 67.2%of patients at 1 wk and 4 wk,respectively.Tumors located in the body/tail of the pancreas and patients receiving bilateral treatment were weakly associated with a good outcome.Multivariate analysis revealed patients with invisible ganglia and metastatic disease were significant factors for a negative response to EUS-CPN at 1 wk and 4 wk,respectively,particularly for invasion of the celiac plexus(odds ratio(OR)=13.20,P=0.003 for 1 wk and OR=15.11,P=0.001 for 4 wk).No severe adverse events were reported.CONCLUSION EUS-CPN is a safe and effective form of treatment for intractable pancreatic cancer-associated pain.Invisible ganglia,distant metastasis,and invasion of the celiac plexus were predictors of less effective response in EUS-CPN for pancreatic cancer-related pain.For these patients,efficacy warrants attention.展开更多
The continued need to develop less invasive alternatives to surgical and radiologic interventions has driven the development of endoscopic ultrasound(EUS)-guided treatments.These include EUS-guided drainage of pancrea...The continued need to develop less invasive alternatives to surgical and radiologic interventions has driven the development of endoscopic ultrasound(EUS)-guided treatments.These include EUS-guided drainage of pancreatic fluid collections,EUS-guided necrosectomy,EUS-guided cholangiography and biliary drainage,EUSguided pancreatography and pancreatic duct drainage,EUS-guided gallbladder drainage,EUS-guided drainage of abdominal and pelvic fluid collections,EUS-guided celiac plexus block and celiac plexus neurolysis,EUSguided pancreatic cyst ablation,EUS-guided vascular interventions,EUS-guided delivery of antitumoral agents and EUS-guided fiducial placement and brachytherapy.However these procedures are technically challenging and require expertise in both EUS and interventional endoscopy,such as endoscopic retrograde cholangiopancreatography and gastrointestinal stenting.We undertook a systematic review to record the entire body of literature accumulated over the past 2decades on EUS-guided interventions with the objective of performing a critical appraisal of published articles,based on the classification of studies according to levels of evidence,in order to assess the scientific progress made in this field.展开更多
Pancreatic adenocarcinoma is the fourth leading cause of cancer-related death in the United States. Due to the aggressive tumor biology and late manifestations of the disease, long-term survival is extremely uncommon ...Pancreatic adenocarcinoma is the fourth leading cause of cancer-related death in the United States. Due to the aggressive tumor biology and late manifestations of the disease, long-term survival is extremely uncommon and the current 5-year survival rate is 7%. Over the last two decades, endoscopic ultrasound(EUS) has evolved from a diagnostic modality to a minimally invasive therapeutic alternative to radiologic procedures and surgery for pancreatic diseases. EUSguided celiac plexus intervention is a useful adjunct to conventional analgesia for patients with pancreatic cancer. EUS-guided biliary drainage has emerged as a viable option in patients who have failed endoscopic retrograde cholangiopancreatography. Recently, the use of lumen-apposing metal stent to create gastrojejunal anastomosis under EUS and fluoroscopic guidance in patients with malignant gastric outlet obstruction has been reported. On the other hand, anti-tumor therapies delivered by EUS, such as the injection of anti-tumor agents, brachytherapy and ablations are still in the experimental stage without clear survival benefit. In this article, we provide updates on well-established EUS-guided interventions as well as novel techniques relevant to pancreatic cancer.展开更多
Endoscopic ultrasound(EUS)has emerged as an invaluable tool for the diagnosis,staging and treatment of pancreatic ductal adenocarcinoma(PDAC).EUS is currently the most sensitive imaging tool for the detection of solid...Endoscopic ultrasound(EUS)has emerged as an invaluable tool for the diagnosis,staging and treatment of pancreatic ductal adenocarcinoma(PDAC).EUS is currently the most sensitive imaging tool for the detection of solid pancreatic tumors.Conventional EUS has evolved,and new imaging techniques,such as contrast-enhanced harmonics and elastography,have been developed to improve diagnostic accuracy during the evaluation of focal pancreatic lesions.More recently,evaluation with artificial intelligence has shown promising results to overcome operator-related flaws during EUS imaging evaluation.Currently,an appropriate diagnosis is based on a proper histological assessment,and EUSguided tissue acquisition is the standard procedure for pancreatic sampling.Newly developed cutting needles with core tissue procurement provide the possibility of molecular evaluation for personalized oncological treatment.Interventional EUS has modified the therapeutic approach,primarily for advanced pancreatic cancer.EUS-guided fiducial placement for local targeted radiotherapy treatment or EUS-guided radiofrequency ablation has been developed for local treatment,especially for patients with pancreatic cancer not suitable for surgical resection.Additionally,EUS-guided therapeutic procedures,such as celiac plexus neurolysis for pain control and EUS-guided biliary drainage for biliary obstruction,have dramatically improved in recent years toward a more effective and less invasive procedure to palliate complications related to PDAC.All the current benefits of EUS in the diagnosis and management of PDAC will be thoroughly discussed.展开更多
Background and Aims: Periampullary malignancies often present at an advanced unresectable stage requiring palliation of symptoms for the better quality of life. Though they require multispecialty support;role of endos...Background and Aims: Periampullary malignancies often present at an advanced unresectable stage requiring palliation of symptoms for the better quality of life. Though they require multispecialty support;role of endoscopic interventions in palliation is paramount because of the advancement in technology and increase experience of Gastroenterologist. Methods: We did extensive review of articles regarding endoscopic advances in the management of Unresectable Periampullary Malignancies. Several systematic reviews, Meta analysis, and Randomized controlled trials published over the last 2 decades were thoroughly searched on PUBMED and GOOGLE SCHOLAR. Results: Advanced Endoscopic procedures have been emerging as a superior modality than conventional measures because of minimal invasiveness and greater clinical and technical success. Conclusion: Periampullary malignancies often present at an advanced unresectable stage requiring palliation of symptoms for the better quality of life. Several endoscopic interventions have already been established as the standard of care in palliation of symptoms of unresectable periampullary malignancies, we can say with confidence that with growing advances in EUS, advancement in technologies and increasing experiences, the role of gastroenterologist will be pivotal in these groups of patients.展开更多
文摘Pain is a common symptom of pancreatic disease and is frequently difficult to manage. Pain relief provided by narcotics is often suboptimal and is associated with significant side effects. An alternative approach to pain management in pancreatic disease is the use of celiac plexus block (CPB) or neurolysis (CPN). Originally performed by anesthesiologists and radiologists via a posterior approach,recent advances in endoscopic ultrasonography (EUS) have made this technique an attractive alternative. EUS guided celiac plexus block/ neurolysis is simple to perform and avoids serious complications such as paraplegia or pneumothorax that are associated with the posterior approach. EUS guided CPN should be considered first line therapy in patients with pain due to pancreatic cancer. It provides superior pain control compared to traditional management with narcotics. A trend for improved survival in pancreatic cancer patients treated with CPN has been reported,but larger studies are needed to confirm this finding. At this time,the use of EUS guided CPB cannot be recommended as routine therapy for pain in chronic pancreatitis since only one-half of the patients experience pain reduction and the beneficial effect tends to be short lived. EUS guided CPB and CPN should be used as part of a multidisciplinary team approach for pain management.
文摘Pancreatic cancer is the second most common abdominal cancer in North America with an estimated 20%resectability at diagnosis,and overall 5-year survival of 5%.Pain is common in pancreatic cancer patients with 70%-80%suffering substantial pain.Celiac plexus neurolysis(CPN)is a technique that can potentially improve pain control in pancreatic cancer while preventing further escalation of opioid consumption.CPN is performed by injecting absolute alcohol into the celiac plexus neural network of ganglia.This review sets out to explore the current status of CPN in non-resectable pancreatic cancer.We will examine:(1)the efficacy and safety of percutaneous-CPN and endoscopic ultrasound guided-CPN;(2)specific technique modifications including bilateral(vs central)injections and celiac ganglia neurolysis;and(3)the issue of CPN timing,early at pancreatic cancer diagnosis vs traditional late use as salvage therapy.
基金Supported by A grant from Generalitat de Catalunya(AGAUR,BE-100022)
文摘AIM:To assess the feasibility of endoscopic ultrasound(EUS)guided celiac plexus neurolysis(CPN) using a poloxamer. METHODS:In this prospective evaluation,six Yorkshire pigs underwent EUS-guided CPN.Three received an injection of 10 mL of 0.25%Lidocaine plus methylene blue(group 1) and three received an injection of 10 mL of 0.25%Lidocaine plus blue colored poloxamer(PS137-25)(group 2) .Necropsy was performed immediately after the animals were sacrificed.The abdominal and pelvic cavities were examined for the presence of methylene blue and the blue colored poloxamer.RESULTS:EUS-guided CPN was successfully performed in all 6 pigs without immediate complication.Methylene blue was identified throughout the peritoneal and retroperitoneal cavity in group 1.The blue colored poloxamer was found in the retroperitoneal cavity immediately adjacent to the aorta,in the exact location of the celiac plexus in group 2.CONCLUSION:EUS-guided CPN using a reverse phase polymer in a non-survival porcine model was technically feasible.The presence of a poloxamer gel at the site of the celiac plexus at necropsy indicates a precise delivery of the neurolytic agent.
文摘Pancreatic cancer produces disabling abdominal pain,and the pain medical management for pancreatic cancer is often challenging because it mainly relies on the use of narcotics(major opioids).However,opioids often provide suboptimal pain relief,and the use of opioids can lead to patient tolerance and several side effects that considerably reduce the quality of life of pancreatic cancer patients.Endosonography-guided celiac plexus neurolysis(EUS-CPN)is an alternative for pain control in patients with nonsurgical pancreatic cancer;EUS-CPN consists of the injection of alcohol and a local anesthetic into the area of the celiac plexus to achieve chemical ablation of the nerve tissue.EUS-CPN via the transgastric approach is a safer and more accessible technique than the percutaneous approach.We have reviewed most of the studies that evaluate the efficacy of EUSCPN and that have compared the different approaches that have been performed by endosonographers.The efficacy of EUS-CPN varies from 50%to 94%in the different studies,and EUS-CPN has a pain relief duration of 4–8 wk.Several factors are involved in its efficacy,such as the onset of pain,previous use of chemotherapy,presence of metastatic disease,EUS-CPN technique,type of needle or neurolytic agent used,etc.According to this review,injection into the ganglia may be the best technique,and a good visualization of the ganglia is the best predictor for a good EUS-CPN response,although more studies are needed.However,any of the 4 different techniques could be used to perform EUS-CPN effectively with no differences in terms of complications between the techniques,but more studies are needed.The effect of EUS-CPN on pain improvement,patient survival and patient quality of life should be evaluated in well-designed randomized clinical trials.Further research also needs to be performed to clarify the best time frame in performing a EUS-CPN.
基金Supported by National Natural Science Foundation of China,No.81800467 and No.81770637.
文摘BACKGROUND Endoscopic ultrasound-guided celiac plexus neurolysis(EUS-CPN)has gained popularity as a minimally invasive approach and is currently widely used to treat pancreatic cancer-associated pain.However,response to treatment is variable.AIM To identify the efficacy of EUS-CPN and explore determinants of pain response in EUS-CPN for pancreatic cancer-associated pain.METHODS A retrospective study of 58 patients with abdominal pain due to inoperable pancreatic cancer who underwent EUS-CPN were included.The efficacy for palliation of pain was evaluated based on the visual analog scale pain score at 1 wk and 4 wk after EUS-CPN.Univariable and multivariable logistic regression analyses were performed to explore predictors of pain response.RESULTS A good pain response was obtained in 74.1%and 67.2%of patients at 1 wk and 4 wk,respectively.Tumors located in the body/tail of the pancreas and patients receiving bilateral treatment were weakly associated with a good outcome.Multivariate analysis revealed patients with invisible ganglia and metastatic disease were significant factors for a negative response to EUS-CPN at 1 wk and 4 wk,respectively,particularly for invasion of the celiac plexus(odds ratio(OR)=13.20,P=0.003 for 1 wk and OR=15.11,P=0.001 for 4 wk).No severe adverse events were reported.CONCLUSION EUS-CPN is a safe and effective form of treatment for intractable pancreatic cancer-associated pain.Invisible ganglia,distant metastasis,and invasion of the celiac plexus were predictors of less effective response in EUS-CPN for pancreatic cancer-related pain.For these patients,efficacy warrants attention.
文摘The continued need to develop less invasive alternatives to surgical and radiologic interventions has driven the development of endoscopic ultrasound(EUS)-guided treatments.These include EUS-guided drainage of pancreatic fluid collections,EUS-guided necrosectomy,EUS-guided cholangiography and biliary drainage,EUSguided pancreatography and pancreatic duct drainage,EUS-guided gallbladder drainage,EUS-guided drainage of abdominal and pelvic fluid collections,EUS-guided celiac plexus block and celiac plexus neurolysis,EUSguided pancreatic cyst ablation,EUS-guided vascular interventions,EUS-guided delivery of antitumoral agents and EUS-guided fiducial placement and brachytherapy.However these procedures are technically challenging and require expertise in both EUS and interventional endoscopy,such as endoscopic retrograde cholangiopancreatography and gastrointestinal stenting.We undertook a systematic review to record the entire body of literature accumulated over the past 2decades on EUS-guided interventions with the objective of performing a critical appraisal of published articles,based on the classification of studies according to levels of evidence,in order to assess the scientific progress made in this field.
文摘Pancreatic adenocarcinoma is the fourth leading cause of cancer-related death in the United States. Due to the aggressive tumor biology and late manifestations of the disease, long-term survival is extremely uncommon and the current 5-year survival rate is 7%. Over the last two decades, endoscopic ultrasound(EUS) has evolved from a diagnostic modality to a minimally invasive therapeutic alternative to radiologic procedures and surgery for pancreatic diseases. EUSguided celiac plexus intervention is a useful adjunct to conventional analgesia for patients with pancreatic cancer. EUS-guided biliary drainage has emerged as a viable option in patients who have failed endoscopic retrograde cholangiopancreatography. Recently, the use of lumen-apposing metal stent to create gastrojejunal anastomosis under EUS and fluoroscopic guidance in patients with malignant gastric outlet obstruction has been reported. On the other hand, anti-tumor therapies delivered by EUS, such as the injection of anti-tumor agents, brachytherapy and ablations are still in the experimental stage without clear survival benefit. In this article, we provide updates on well-established EUS-guided interventions as well as novel techniques relevant to pancreatic cancer.
文摘Endoscopic ultrasound(EUS)has emerged as an invaluable tool for the diagnosis,staging and treatment of pancreatic ductal adenocarcinoma(PDAC).EUS is currently the most sensitive imaging tool for the detection of solid pancreatic tumors.Conventional EUS has evolved,and new imaging techniques,such as contrast-enhanced harmonics and elastography,have been developed to improve diagnostic accuracy during the evaluation of focal pancreatic lesions.More recently,evaluation with artificial intelligence has shown promising results to overcome operator-related flaws during EUS imaging evaluation.Currently,an appropriate diagnosis is based on a proper histological assessment,and EUSguided tissue acquisition is the standard procedure for pancreatic sampling.Newly developed cutting needles with core tissue procurement provide the possibility of molecular evaluation for personalized oncological treatment.Interventional EUS has modified the therapeutic approach,primarily for advanced pancreatic cancer.EUS-guided fiducial placement for local targeted radiotherapy treatment or EUS-guided radiofrequency ablation has been developed for local treatment,especially for patients with pancreatic cancer not suitable for surgical resection.Additionally,EUS-guided therapeutic procedures,such as celiac plexus neurolysis for pain control and EUS-guided biliary drainage for biliary obstruction,have dramatically improved in recent years toward a more effective and less invasive procedure to palliate complications related to PDAC.All the current benefits of EUS in the diagnosis and management of PDAC will be thoroughly discussed.
文摘Background and Aims: Periampullary malignancies often present at an advanced unresectable stage requiring palliation of symptoms for the better quality of life. Though they require multispecialty support;role of endoscopic interventions in palliation is paramount because of the advancement in technology and increase experience of Gastroenterologist. Methods: We did extensive review of articles regarding endoscopic advances in the management of Unresectable Periampullary Malignancies. Several systematic reviews, Meta analysis, and Randomized controlled trials published over the last 2 decades were thoroughly searched on PUBMED and GOOGLE SCHOLAR. Results: Advanced Endoscopic procedures have been emerging as a superior modality than conventional measures because of minimal invasiveness and greater clinical and technical success. Conclusion: Periampullary malignancies often present at an advanced unresectable stage requiring palliation of symptoms for the better quality of life. Several endoscopic interventions have already been established as the standard of care in palliation of symptoms of unresectable periampullary malignancies, we can say with confidence that with growing advances in EUS, advancement in technologies and increasing experiences, the role of gastroenterologist will be pivotal in these groups of patients.
