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

Abstract

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 EUS-CPN 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.

Neuropancreatology: The Nervous System and Pain Management in Pancreatic Diseases

“…CPB is a palliative procedure that is usually considered when the medical management fails to achieve pain relief. Bupivacaine 0.25% 10–20 mL followed by 10–20 mL 98% ethanol is the most widely used neurolytic protocol [ 19 ].…”

“…The efficacy of EUS-CPB in achieving pain relief ranges from 50 to 94%. However, it is frequently limited over time [ 19 ].…”

“…As for chronic pancreatitis, CPB is rarely used in clinical practice. Indeed, the limited efficacy in the long term, procedural risks (e.g., bleeding, infections) and side effects (e.g., postural hypotension, diarrhea) make it more suitable for the palliative care of patients with malignancies [ 19 , 20 ]. One trial compared the EUS- and CT-guided approaches in patients with chronic pancreatitis.…”

“…Pharmacologic analgesic therapy is the first approach in the vast majority of cases that present with pain. Operative approaches can be indicated in refractory pain in pancreatic cancer and chronic pancreatitis [ 19 , 20 ].…”

Advanced Endoscopic Palliation of Unresectable Periampullary Carcinoma: A Systematic Review

“…In the recent review by Perez-Aguado et al [14] 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 weeks. Any of the 4 different techniques could be used to perform EUS-CPN effectively with no differences in terms of complications between the techniques.…”