Frank G. Gress

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.

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.

BACKGROUND: In many institutions, computed tomography (CT)-guided percutaneous fine-needle aspiration (FNA) has become the procedure of choice for biopsies of pancreatic mass lesions. This method of biopsy and others, such as endoscopic retrograde cholangiopancreatography (ERCP) cytology, are problematic because of a substantial false-negative rate. OBJECTIVE: To investigate the yield of endoscopic ultrasonography-guided FNA biopsies in patients who had negative results on CT-guided biopsy or negative cytologic findings on ERCP sampling. DESIGN: Prospective cohort study. SETTING: Tertiary care university medical center. PATIENTS: 102 patients (median age, 65 years; 58 men and 44 women) with suspected pancreatic cancer who fulfilled the above criteria were prospectively identified and underwent endoscopic ultrasonography-guided FNA biopsy. MEASUREMENTS: The operating characteristics of endoscopic ultrasonography-guided FNA for diagnosing pancreatic masses were determined. Surgical pathology or long-term follow-up (median, 24 months) was used to identify false-positive or false-negative results. RESULTS: Median mass size was 3.5 cm x 2.7 cm. A median of 3.4 passes were performed. Cytologic results on endoscopic ultrasonography-guided FNA biopsy were positive in 57 patients, negative in 37, and inconclusive or nondiagnostic in 8. No false-positive results were observed. A diagnosis of pancreatic cancer was subsequently confirmed in 3 patients who had tested negative (false-negative results) and 1 of the 8 patients with nondiagnostic results. Of these 4 patients, 3 had cytologic evidence of chronic pancreatitis on endoscopic ultrasonography-guided FNA biopsy. The 95% CI for the likelihood ratio for a positive test result contained all values greater than or equal to 9.7. The likelihood ratio for a negative test result was 0.05 (CI, 0.02 to 0.15). The posterior probability of pancreatic cancer after a definitely positive result was at least 93.5% by a conservative lower 95% confidence limit; after a definitely negative test result, it was 6.9%. The prevalence of pancreatic cancer was 59.8% (61 of 102 patients). Self-limited complications occurred in 3 of the 102 patients (2.9% [CI, 0.6% to 8.4%]). CONCLUSION: Endoscopic ultrasonography-guided FNA biopsy may play a valuable role in the evaluation of a pancreatic mass when results on other biopsy methods are negative but pancreatic cancer is suspected.