Celiac plexus neurolysis in pancreatic cancer:The endoscopic ultrasound approach

Pain in pancreatic cancer is often a major problem of treatment.Administration of opioids is frequently limited by side effects or insufficient analgesia.Endoscopic ultrasound-guided celiac plexus neurolysis(EUS-CPN)represents an alternative for the palliative treatment of visceral pain in patients with pancreatic cancer.This review focuses on the indications,technique,outcomes of EUS-CPN and predictors of pain relief.EUS-CPN should be considered as the adjunct method to standard pain management.It moderately reduces pain in pancreatic cancer,without eliminating it.Nearly all patients need to continue opioid use,often at a constant dose.The effect on quality of life is controversial and survival is not influenced.The approach could be done in the central position of the celiac axis,which is easy to perform,or in the bilateral position of the celiac axis,with similar results in terms of pain alleviation.The EUS-CPN with multiple intraganglia injection approach seems to have better results,although extended studies are still needed.Further trials are required to enable more confident conclusions regarding timing,quantity of alcohol injected and the method of choice.Severe complications have rarely been reported,and great care should be taken in choosing the site of alcohol injection.

Celiac plexus neurolysis in the management of unresectable pancreatic cancer:When and how?

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.

Endoscopic ultrasound-guided celiac plexus neurolysis using a reverse phase polymer

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.

Phenol-based endoscopic ultrasound-guided celiac plexus neurolysis for East Asian alcohol-intolerant upper gastrointestinal cancer patients:A pilot study

AIM:To investigate the effectiveness of phenol for the relief of cancer pain by endoscopic ultrasound-guided celiac plexus neurolysis(EUS-CPN).METHODS:Twenty-two patients referred to our hospital with cancer pain from August 2009 to July 2011for EUS-CPN were enrolled in this study.Phenol was used for 6 patients with alcohol intolerance and ethanol was used for 16 patients without alcohol intolerance.The primary endpoint was the positive response rate(pain score decreased to≤3)on postoperative day 7.Secondary endpoints included the time to onset of pain relief,duration of pain relief,and complication rates.RESULTS:There was no significant difference in the positive response rate on day 7.The rates were 83%and 69%in the phenol and ethanol groups,respectively.Regarding the time to onset of pain relief,in the phenol group,the median pre-treatment pain score was 5,whereas the post-treatment scores decreased to 1.5,1.5,and 1.5 at 2,8,and 24 h,respectively(P<0.05).In the ethanol group,the median pre-treatment pain score was 5.5,whereas the post-treatment scores significantly decreased to 2.5,2.5,and 2.5 at 2,8,and24 h,respectively(P<0.01).There was no significant difference in the duration of pain relief between the phenol and ethanol groups.No significant difference was found in the rate of complications between the 2groups;however,burning pain and inebriation occurred only in the ethanol group.CONCLUSION:Phenol had similar pain-relieving effects to ethanol in EUS-CPN.Comparing the incidences of inebriation and burning pain,phenol may be superior to ethanol in EUS-CPN procedures.

Endoscopic ultrasonography-guided celiac plexus neurolysis in patients with unresectable pancreatic cancer: An update

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.

CT-Guided Celiac Plexus Neurolysis in the Management of Pain Related to Unresectable Pancreatic Cancer: About 2 Cases

Celiac plexus neurolysis (CPN) has become a minimally invasive approach for the management of patients with unresectable pancreatic cancer and abdominal pain unresponsive to medical treatment. CPN has been shown to have long-lasting improvement in abdominal pain and decreased narcotic usage in 70% to 90% of patients. Therefore, the aim of this paper was to report our experience with CPN in the treatment of two cases of advanced pancreatic cancer, with satisfying results in controlling pain. The use of CT scan-guided CPN should be considered and performed relatively early in the course of disease to offer optimal pain relief and increase the patient’s quality of life.

Predictors of pain response after endoscopic ultrasound-guided celiac plexus neurolysis for abdominal pain caused by pancreatic malignancy

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.

Neurolysis of the Median Nerve to the Carpal Canal by the Way Mini-Open: Review of 68 Files at Brazzaville University Hospital

Objective: To evaluate the results of neurolysis of the median nerve to the carpal tunnel in patients operated by the mini-open technique. Methods: The prospective study included 68 patients (16 men and 52 women) aged 43 to 80 years (mean age: 64 years). Patients were evaluated in pre- and post-operative by a questionnaire. The mini open technique with cutaneous approach to the heel of the hand following the 4th ray was performed in all patients under local, locoregional or general anesthesia. Results: The results were evaluated in 3 consultations, in the 1st, 3rd and 6th month. We obtained very good results in 54.4% of the cases (n = 37) and 30.9% (n = 21) of good results and 14.70% (n = 10) of poor results. No vascular, tendinous or neurological complications were noted. Two patients were reoperated for incomplete resection of the carpal ring ligament. The mini-open technique has achieved good results in all neurolysis despite the delay in surgical management. Conclusion: The results of the surgical treatment of the carpal tunnel syndrome depend on the precocity of the diagnosis and the surgical indication.

Percutaneous, computed tomography guided neurolysis using continuous radiofrequency for pain reduction in oncologic patients

Aim:This study evaluates the efficacy and safety of percutaneous computed tomography(CT)-guided neurolysis using continuous radiofrequency for pain reduction in oncologic patients.Methods:Over the course of 16 months,22 patients underwent radiofrequency neurolysis as palliative therapy for pain reduction in celiac and splachnic plexus(n=9),thoracic(n=1),lumbar(n=2)and superior hypogastric plexus(n=5),as well as stellate ganglion(n=5).Pain levels before treatment,one week after treatment,and at the last follow-up(average follow-up 6 months)were compared by means of a Numeric Visual Scale(NVS)questionnaire and a Brief Pain Inventory(Short Form)questionnaire.Results:Median procedure time was 44 min.Median number of CT scans,performed to control correct positioning of the cannula and precise electrode placement,was 8.Pain scores of questionnaires prior to treatment(mean value 9.50 NVS units,range 8-10 NVS units)and post treatment(mean value 3.27 NVS units,range 2-6 NVS units)showed a mean decrease of 6.23 NVS units in terms of pain reduction and life quality improvement(P<0.05).Overall mobility improved in 18/18(100%)patients.No complication was observed.Conclusion:This study concludes that CT-guided neurolysis by means of continuous radiofrequency ablation is a safe and efficient technique for pain palliation in oncologic patients.

Endoscopic ultrasound-guided ethanol ablation therapy for tumors

Endoscopic ultrasonography (EUS) has evolved into a useful therapeutic tool for treating a broad range of tumors since being introduced into clinical practice as a diagnostic modality nearly three decades ago. In particular, EUS-guided fine-needle injection has proven a successful minimally invasive approach for treating benign lesions such as pancreatic cysts, relieving pancreatic pain through celiac plexus neurolysis, and controlling local tumor growth of unresectable malignancies by direct delivery of anti-tumor agents. One such ablative agent, ethanol, is capable of safely ablating solid or cystic lesions in hepatic tissues via percutaneous injection. Recent research and clinical interest has focused on the promise of EUS-guided ethanol ablation as a safe and effective method for treating pancreatic tumor patients with small lesions or who are poor operative candidates. Although it is not likely to replace radical resection of localized lesions or systemic treatment of metastatic tumors in all patients, EUS-guided ablation is an ideal method for patients who refuse or are not eligible for surgery. Moreover, this treatment modalitymay play an active role in the development of future pancreatic tumor treatments. This article reviews the most recent clinical applications of EUS-guided ethanol ablation in humans for treating pancreatic cystic tumors, pancreatic neuroendocrine tumors, and metastatic lesions.

What are the current and potential future roles for endoscopic ultrasound in the treatment of pancreatic cancer?

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.

Secondary release of the peripheral nerve with autologous fat derivates benefits for functional and sensory recovery

The reconstruction of nerve continuity after traumatic nerve injury is the gold standard in hand surgery.Immediate,tension-free,end-to-end nerve suture ensures the best prognosis.The recovery is mostly promising;however,in a few cases,insufficient outcomes in motor or sensory function are observed.Intra-and extra-fascicular scarring accompanies the nerve regeneration process and limits final outcomes.Secondary nerve release in those cases is recommended.Unfortunately,scarring recurrence cannot be eliminated after secondary revision and neurolysis.The supportive influences of mesenchymal stem cells in the process of nerve regeneration were observed in many preclinical studies.However,a limited number of studies in humans have analyzed the clinical usage of mesenchymal stem cells in peripheral nerve reconstruction and revisions.The objective of this study was to evaluate the effects of undifferentiated adipose-derived stromal/stem cell injection during a last-chance surgery(neurolysis,nerve release)on a previously reconstructed nerve.Three patients(one female,two males;mean age 59±4.5 years at the time of injury),who experienced failure of reconstructions of median and ulnar nerves,were included in this study.During the revision surgery,nerve fascicles were released,and adiposederived stromal/stem cells were administered through microinjections along the fascicles and around the adjacent tissues after external neurolysis.During 36 months of followup,patients noticed gradual signs of sensory and in consequence functional recovery.No adverse effects were observed.Simultaneous nerve release with adipose-derived stromal/stem cells support is a promising method in patients who need secondary nerve release after nerve reconstruction.This method can constitute an alternative procedure in patients experiencing recovery failure and allow improvement in cases of limited nerve regeneration.The study protocol was approved by the Institutional Review Board(IRB)at the Centre of Postgraduate Medical Education(No.62/PB/2016)on September 14,2016.

Review of current and evolving clinical indications forendoscopic ultrasound

For the first several years after its development,endoscopic ultrasound(EUS) was primarily limited to identification of pancreatic malignancies. Since this time, the field of EUS has advanced at a tremendous speed in terms of additional clinical diagnostic and therapeutic uses. The combination of ultrasound with endoscopy provides a unique interventional modality that is a minimally invasive alternative to various surgical interventions. Given the expanding recommended indications for EUS, this article will serve to review the most common uses with supporting evidence, while also exploring innovative endeavors that may soon become common clinical practice.

Current role of endoscopic ultrasound in the diagnosis and management of pancreatic cancer

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.

Potential Compressive Sites of the Anterior Interosseous Nerve in the Proximal Forearm: An Anatomic Study

Background: The etiology and treatment of spontaneous paralysis variants of anterior interosseous nerve (AIN) syndrome remains controversial. Variation and multiple sites of potential compression complicate the successful performance of neurolysis. This anatomic study of the AIN and sites of potential compression in the proximal forearm facilitates critical steps involved in neurolytic procedures and management. Methods: Upper extremities of twelve cadavers were examined to evaluate potential sites of AIN compression in the proximal forearm. Potential sites of musculoaponeurotic compression were evaluated, including: lacertus fibrosus;inferior fibrous arch of the humeral head of the pronator teres (PT) muscle;inferior fibrous arch of the ulnar head of the PT muscle;fibrous arch in the flexor digitorum superficialis (FDS) muscle;Gantzer’s muscle;and vascular structures near the AIN and median nerve. Results: The AIN arose at a mean distance of 54.5 mm distal to the elbow from the posterior (n = 9) or ulnar side (n = 3) of the median nerve. Relative positions of AIN branches were variable. A fibrous arch was found between the lacertus fibrosus and the PT in two cases. Nine cadavers had two fibrous arches in the PT and FDS, and three cadavers had one arch. An accessory head in the FDS was found to be a risk of AIN compression. Gantzer’s muscle was present in six cases, crossing the AIN superficially. Two potentially compressive vascular arches were identified. Conclusions: Our observations confirm that multiple musculoaponeurotic and/or vascular structures can contribute to AIN compression in the proximal forearm. Understanding the complex anatomic relationships of this nerve is crucial to improving outcomes of neurolysis in cases of non-regressive AIN paralysis.

The Treatment of Morton’s Neuroma, a Significant Cause of Metatarsalgia for People Who Exercise

Morton’s Neuroma is a common metatarsalgia in athletes created due to the entrapment of the inter-digital nerve inside the transverse inter-metatarsal ligament. The purpose of the present study is to draw the necessary conclusions from the use of a particular surgical treatment to release the digital nerve, accompanied by neurolysis in adults who exercise. On the whole, twenty five patients with twenty-five suffering extremities were treated. Five of them simultaneously had a Hallux Valgus type deformity and that supports the belief of the mechanical induce of this condition. Both ultrasonography and Magnetic Resonance Imaging (MRI) were used for the clinical evaluation of this condition. The pain was estimated via the Visual Analogue Scale (VAS). The patients were re-examined after three (1st postoperative), twelve (2nd postoperative) and twenty-four (3rd postoperative) months. A significant improvement (p 0.0001) was noticed from the correlation between the pain before the surgery and the pain after the surgery via the Visual Analogue Scale (VAS). Most patients (15/25) did not display any discomfort or sensory disorder after surgery. The correct clinical evaluation as well as the correct and effective surgical intervention with the simultaneous repair of all the mechanical deformities of the foot provided better post-surgery progress in patients and increased the percentage of their rehabilitation of their previous activities.

Advanced Endoscopic Palliation of Unresectable Periampullary Carcinoma: A Systematic Review

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.

Validation of targeted microsurgical spermatic cord denervation: comparison of outcomes to traditional complete microsurgical spermatic cord denervation

The aim of this study was to validate the effectiveness of targeted microsurgical spermatic cord denervation (MSCD) of the trifecta nerve complex in comparison to traditional full MSCD with complete skeletonization of the spermatic cord in men with chronic orchialgia. Retrospective chart review was performed by a single fellowship-trained microsurge on between 2011 and 2016. Patie nts had follow-ups at 6 weeks, 6 mon ths, and 1 year postoperatively. Thirty-nine men with chronic orchialgia un derwe nt full MSCD between 2011 and 2013. In July 2013, after the publication of an anatomic study with identification of Wallerian degeneration of the trifecta nerve complex in men with chronic orchialgia, the technique was changed to targeted MSCD. From July 2013 to March 2016, 43 men underwent targeted MSCD. When comparing the full MSCD group to the targeted MSCD group, there was no significant difference in resolution of pain (66.7% vs 69.8%, P = 0.88), no difference in partial relief of pain (17.9% vs 23.3%, P =0.55), and no difference in failure to respond rates (15.4% vs 7.0%, P= 0.22) between the two groups. There was no differenee in mean change of visual analog pain scale scores between the two groups (P= 0.27). Targeted MSCD had a shorter operative time (53 min vs 21 min, P = 0.0001). Targeted MSCD offers patients comparable outcomes to traditional full MSCD, with a shorter operative time, a less technically challenging surgery, and potentially less risk to cord structures which should be preserved.

Nerve decompression in diabetics with chronic nerve compression:update 2022

The number of people with diabetes worldwide has reached epidemic proportions.Diabetics are well-known to have chronic nerve compressions,and the prevalence of compressions exceeds 50% in those with neuropathy.The loss of sensation in the feet of people with diabetic neuropathy is the primary cause of their ulceration and amputation,as well as pain.The aim of this article is to update the reader on the current status of lower extremity nerve decompression in patients with diabetic neuropathy.A review of the history and literature related to the current approach to the patient with chronic nerve compression plus diabetic neuropathy was undertaken.The current evidence is overwhelmingly clear,in diabetics with neuropathy and a positive Tinel sign over the tibial nerve at the tarsal tunnel,that decompression,by neurolysis of lower extremity nerves,can relieve pain,restore sensation,and prevent ulceration and amputation.Furthermore,economic cost-benefit analysis by the Markov technique demonstrates that lower extremity nerve compression is not only cost-effective compared to standard medical care,but also increases the quality of life and life expectancy.The remaining barriers to acceptance and implementation of this proven surgical approach must lie in the education of physicians in training and re-education of diabetes educators,primary care providers and endocrinologists.