EUS-guided radiofrequency ablation of solid pancreatic lesions: An updated review.

Recent years have brought to light newly developed therapeutic modalities for the treatment of premalignant and malignant pancreatic lesions. The role of EUS-guided radiofrequency ablation (EUS-RFA) as a treatment modality for malignant pancreatic lesions is still under evaluation. Several animal studies and human studies have demonstrated the safety and efficacy of EUS-RFA in the management of premalignant and malignant pancreatic lesions. EUS-RFA therapy can potentially ablate these lesions safely and with minimally invasive techniques. In this article, we provide an updated review of the application of EUS-RFA of pancreatic lesions. We also review the clinical efficacy and safety of this technique and future directions.

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.

Background and Objective: 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. Methods: 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. Results: 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. Conclusions: 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.

Role of Endoscopic Ultrasound in Pancreatic Cancer Diagnosis and Management.

The emergence of endoscopic ultrasound (EUS) has significantly impacted the diagnosis and management of pancreatic cancer and its associated sequelae. While the definitive role of EUS for pancreatic cancer remains incompletely characterized by currently available guidelines, EUS undoubtedly offers high diagnostic accuracy, the precise staging of pancreatic neoplasms, and the ability to perform therapeutic and palliative interventions. However, current challenges to EUS include limited specialized expertise and variability in operator proficiency. As the technology and techniques continue to evolve and become more refined, EUS is poised to play an increasingly integral role in shaping pancreatic cancer care.

Endoscopic Ultrasound-Guided Pain Management.

The diagnosis and management of pancreatic cancer has become a standard role for the endoscopic oncologist. Pancreatic cancer can produce disabling abdominal pain, and the medical management of this pain is often challenging. Endoscopic ultrasound-guided celiac plexus neurolysis and celiac ganglia neurolysis serve as an alternative or adjunct for pain control in these patients. There remains a great deal of practice variability with regard to techniques and approaches. This article summarizes the latest scientific evidence and highlights contemporary best practice advice for these procedures.

Efficacy and Safety of Celiac Plexus Neurolysis in the Treatment of Chronic Pain Secondary to Oncological Pathology of the Upper Hemiabdomen: A Systematic Review and Meta-Analysis.

Objectives: The management of chronic pain among patients with abdominal cancer is complex; against that, the neurolysis of the celiac plexus (CPN) is the best technique at the moment to determine the efficacy and safety in the treatment of chronic pain secondary to oncological pathology of the upper abdomen. Material and Methods: This was a systematic review of controlled clinical trials between 2000 and 2021, in the sources MEDLINE/PubMed, Cochrane, Scopus, Web of Science, and Google Scholar. Three independent evaluators analysed the results of the bibliographical research. The quality of the studies was assessed with the Jadad scale and the mean difference (95% confidence interval) and heterogeneity of the studies (I2) were calculated with Review Manager 5.3. Results: Seven hundred and forty-four publications were identified, including 13 studies in the qualitative synthesis and three studies in the quantitative synthesis. No difference was found in the decrease in pain intensity between 1 and 12 weeks after the intervention, comparing the experimental group with the control (P > 0.05). The adverse effects related to neurolysis were not serious and transitory, mentioning the most frequent adverse effects and reporting a percentage between 21% and 67% (with 17% for echoendoscopic neurolysis and 49% for percutaneous neurolysis). Conclusion: Celiac plexus neurolysis for the treatment of severe chronic pain secondary to oncological pathology in the upper hemiabdomen produces similar pain relief as conventional pharmacological analgesic treatment. It is a safe analgesic technique since the complications are mild and transitory.

EUS-guided interventional therapies for pancreatic diseases.

Endoscopic ultrasound (EUS) is an integrated diagnostic technique merging endoscope and ultrasound to examine the digestive system. EUS has emerged as a primary diagnostic method for pancreatic diseases due to its distinctive benefits. Over the past four decades, EUS has undergone a transformation, shifting its role from primarily diagnostic to increasingly therapeutic. Additionally, in recent years, EUS has emerged as an increasingly prominent adjunctive or alternative approach to conventional surgical interventions. This review provides a comprehensive analysis of current technological approaches in the treatment of pancreatic diseases. The dynamic interplay with diverse therapeutic approaches has reinvigorated EUS and shaped its trajectory in the management of pancreatic diseases.

Comparison of analgesic effect in celiac plexus neurolysis: Ethanol injection with or without iodine-125 radioactive seeds implantation.

Context: Currently, short-term recurrence of pain is the biggest clinical challenge of celiac plexus neurolysis for patients with refractory abdominal cancer pain. Aim: To evaluate the analgesic effect and safety of celiac plexus neurolysis using ethanol injection combined with iodine-125 (125I) radioactive seed implantation for refractory abdominal cancer pain. Settings and Design: The study was a randomized controlled trial. Methods and Materials: About 10 patients with severe refractory abdominal cancer pain were enrolled in this study. The patients were randomly divided into group A (ethanol injection combined with 125I radioactive seed implantation, n = 5) and group B (ethanol injection alone, n = 5). The primary end point was pain relief measured by means of numerical rating scale (NRS). And the secondary end point was mean administration of analgesic drugs and the safety of the procedure. Statistical Analysis Used: Repeated measures of analysis of variance were used for statistical analysis. Results: The NRS scores were significantly reduced by 24 h postprocedure in both groups (group A: P = 0.001 and group B: P = 0.001). Group A did not show significant recurrence based on NRS scores during the follow-up period. In contrast, the NRS scores recurred significantly in group B by 1 month postprocedure (P = 0.026). The intake of analgesic drugs was significantly reduced in both the groups postprocedure (group A: P = 0.013 and group B: P = 0.013). Overall, it was significantly lower in group A than in group B (P = 0.041). No treatment-related deaths or major complications were observed. Conclusions: Celiac plexus neurolysis using ethanol injection in combination with 125I radioactive seed implantation has a longer analgesic duration than using ethanol injection alone. It could be a safe and long-lasting analgesic approach for managing refractory abdominal cancer pain.

Computed tomography-guided single celiac plexus neurolysis analgesic efficacy and safety: a systematic review and meta-analysis.

PURPOSE: To perform a systematic review and meta-analysis of published studies to evaluate the analgesic efficacy and safety of computed tomography (CT)-guided single celiac plexus neurolysis (CPN) with the injection of a neurolytic agent into the celiac plexus in one session (CT-guided single CPN). METHODS: PubMed, the Cochrane Library, and Ichushi-Web were searched for English or Japanese articles published up to February 2022, which reported findings about patients who underwent CT-guided single CPN. The outcome measures assessed in the systematic review and meta-analysis were the pain measurement scales from 0 to 10 before and after the intervention and the rate of minor and major complications. RESULTS: The pooled pain measurement scales at pre-intervention and 1- or 2-, 7-, 30-, 60-, 90-, and 180-day post-intervention was 6.72 (95% confidence interval [CI], 4.77-9.46, I2 = 98%), 2.31 (95% CI 2.31-4.44, I2 = 92%), 2.84 (95% CI 1.39-5.79, I2 = 95%), 3.36 (95% CI 1.66-6.77, I2 = 98%), 3.19 (95% CI 1.44-7.08, I2 = 59%), 3.87 (95% CI 1.88-7.97, I2 = 0%), and 3.40 (95% CI 3.02-3.83, I2 = not applicable), respectively. The pooled minor complication rates of diarrhea, hypotension, nausea or vomiting, and pain associated with the procedure were 18% (95% CI 8-37%, I2 = 45%), 16% (95% CI 2-58%, I2 = 76%), 6% (95% CI 2-16%, I2 = 1%), and 7% (95% CI 2-21%, I2 = 17%), respectively. There was no major complication in the included studies. CONCLUSION: CT-guided single CPN can be performed safely and provides immediate analgesic efficacy although the amount of heterogeneity is characterized as large. Further investigation of its long-term analgesic efficacy is required.

Comparison Between Two Volumes of 70% Alcohol in Single Injection Ultrasound-Guided Celiac Plexus Neurolysis: A Randomized Controlled Trial.

BACKGROUND: Pain due to inoperable upper abdominal malignancies is a challenging condition that needs a multimodal analgesic regimen to be managed properly. Celiac plexus alcohol neurolysis was proved to be effective in relieving such type of pain; however, there is no consistent data about the optimal volume to be used to maintain the balance between the neurolytic effect and the destructive effect of alcohol. OBJECTIVES: We aim to compare the analgesic effect of 2 different volumes of alcohol to improve the outcome of interventional management. STUDY DESIGN: This was a randomized controlled double-blinded interventional clinical trial. SETTING: Single university hospital. METHODS: Thirty-two patients who suffered from abdominal pain due to unresectable abdominal malignancies were randomly allocated to receive in a single injection ultrasound-guided celiac plexus neurolysis (CPN) with injection of either 20 mL 70% alcohol (CPN20 group) or 40 mL 70% alcohol (CPN40 group). The primary outcome was the post-procedure pain score, while the secondary outcomes included the post-procedure total daily opioid consumption and quality of life (QOL). RESULTS: There was no statistically significant difference between both groups regarding visual analog scale (VAS) scores at all time points (P-value > 0.05); however, comparisons in each group revealed significantly reduced VAS scores at all time points following the intervention when compared to the baseline. Daily morphine equivalent consumption doses showed statistically significant differences between the baseline and each time point in both groups (P value < 0.05), with no significant difference between both groups at each time point (P value > 0.05). There was no statistically significant difference between the study groups regarding all domains in quality of life assessment at all time points (P value > 0.05). The scores of most time points in all domains were different significantly when compared to the baseline readings in both groups, with a tendency to decline over time in both groups approaching the baseline values. LIMITATIONS: This was a single-center study with a relatively small sample size. Further prospective, multicenter, randomized, and controlled studies with a larger sample size are required to confirm the effects in this study. CONCLUSIONS: During ultrasound-guided CPN for patients with inoperable upper abdominal cancers who failed medical management, a volume of 20 mL is as effective as 40 mL of 70% alcohol regarding pain control, opioid consumption, quality of life, and procedure-related complications.

Systematic review and meta-analysis of celiac plexus neurolysis for abdominal pain associated with unresectable pancreatic cancer.

INTRODUCTION: Celiac plexus neurolysis (CPN) has been developed as adjunctive therapy to medical management (MM) of abdominal pain associated with unresectable pancreatic cancer. We aimed to conduct a systematic review and meta-analysis to obtain updated and more accurate evidence on the efficacy of additional types of CPN, including endoscopic ultrasound-guided CPN (EUS-CPN). METHODS: On March 16, 2021, we performed searches of PubMed, Web of Science, and CENTRAL for original randomized controlled trials (RCTs). We defined the primary outcome as a standardized pain intensity score with a range of 0-10, and evaluated the mean difference between the CPN + MM and MM groups at 4, 8, and 12 weeks after the initiation of treatment. We used a random-effects model to synthesize the mean differences across RCTs. RESULTS: We selected 10 RCTs involving 646 individuals. The synthesized mean difference in the pain intensity score between the CPN + MM and MM groups was -0.58 (95% confidence interval [CI]: -1.09 to -0.07) (p = 0.034) in favor of CPN + MM at 4 weeks, -0.46 (95%CI: -1.00 to 0.08) (p = 0.081) at 8 weeks, and - 1.35 (95%CI: -3.61 to 0.92) (p = 0.17) at 12 weeks. CONCLUSIONS: This updated meta-analysis of CPN demonstrates its efficacy for managing abdominal pain at 4 weeks. Although there are various limitations, when abdominal pain in patients with unresectable pancreatic cancer is poorly controlled with MM alone, CPN should be an option even if the duration of effect is short-lived, taking into account the absence of serious adverse events.

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

OBJECTIVES: 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. METHODS: 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 1 week after the procedure to evaluate its effectiveness and the extent of pain relief. RESULTS: 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 72 days. 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. CONCLUSIONS: 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. CLINICAL TRIAL NUMBER: UMIN000031228.

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 EUS-guided 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.

Role of therapeutic endoscopic ultrasound in gastrointestinal malignancy- current evidence and future directions.

Endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to an advanced therapeutic modality. With the advent of better technologies and accessories, EUS has found ground in the management of gastrointestinal (GI) malignancies, not only for diagnosis but also for therapeutic purposes. EUS can tackle a host of conditions, including hepato-pancreatico-biliary malignancies. Advances and experience in various EUS-guided biliary drainage techniques have enabled the endosonologist to tackle biliary obstruction when conventional techniques of endoscopic retrograde cholangiopancreatography (ERCP) and/or percutaneous transhepatic biliary drainage (PTBD) fails. More and more emerging data not only establishes the safety of EUS-BD but also demonstrates superior efficacy over PTBD and sometimes even ERCP. Malignant gastric outlet obstruction can now be safely managed with EUS-guided gastroenterostomy. Starting from pain management in malignant tumors through celiac plexus neurolysis to various tumor ablative therapies, EUS has forged ahead over percutaneous treatment or surgical options in the management of GI malignancies. Additional data is now coming up on the prospects of EUS-guided immunotherapy and biological therapy for tumor management. The future of EUS therapeutics in the field of GI malignancies is bright. With increasing evidence, this modality becoming a key player in management of a host of complex clinical conditions arising out of GI malignancies is in the offing. This review focuses on elucidating the role of therapeutic EUS in the management of GI malignancies, a synopsis of various techniques, data on its safety and efficacy as well as future advancements in this domain.

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 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.

Celiac plexus neurolysis for abdominal cancers: going beyond pancreatic cancer pain.

INTRODUCTION: Celiac plexus neurolysis (CPN) has been verified for mitigating pancreatic cancer pain. However, information regarding CPN's use beyond this remains limited. OBJECTIVES: Identify which cancers benefit from CPN, which symptoms improve, and when symptoms improve. METHODS: Retrospective analysis was conducted on 173 patients who received CPN for pain caused by various malignancies. Mean symptom changes on the MD Anderson Symptom Inventory (MDASI) from baseline to 2 weeks, 1 month, and 2 months after CPN were analyzed overall and then by cancer type: pancreatic (all stages and stages III-IV), hepatobiliary, and nonpancreatic, nonhepatobiliary gastrointestinal (NPNH-gastrointestinal). RESULTS: Eighty-two pancreatic, 43 NPNH-gastrointestinal, 14 hepatobiliary, and 34 patients with other cancers met inclusion criteria. Statistically significant changes included decrease in the pain score at 1 month by 1.01 points for all cancers, 1.65 points for all pancreatic cancers, and 1.88 points for late-stage pancreatic cancers. At 2 months, pain decreased by 1.50 points for all cancers, 1.68 points for all pancreatic cancers, 2.37 points for late-stage pancreatic cancers, and 1.50 points in NPNH-gastrointestinal cancers. At 2 months, quality of life improved by 1.07 points for all cancers and 1.53 points for all pancreatic cancers. Sleep improved at 2 months for all cancers by 0.73 points and 1.60 points in late-stage pancreatic cancers. At 2 months, pancreatic cancer patients improved in general activity by 0.93 points, walking by 1.00 points, and working by 1.12 points. CONCLUSION: Celiac plexus neurolysis can decrease cancer symptom burden beyond pain including quality of life and sleep for pancreatic and nonpancreatic cancers, as well as general activity for pancreatic cancers.

EUS-guided celiac plexus neurolysis for pain in pancreatic cancer patients - a meta-analysis and systematic review.

Background: Endoscopic ultrasound guided celiac plexus neurolysis (EUS- CPN) has been reported to be an effective way to help with pain in pancreatic cancer patient. The aim of our updated meta-analysis is to assess the efficacy of pain relief in patients with pancreatic cancer who underwent EUS guided neurolysis. Methods: Pooled proportions were calculated using both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity among studies was tested using Cochran's Q test based upon inverse variance weights.  Results: Initial search identified 176 reference articles, of which 34 were selected and reviewed in detail. Sixteen studies that met the inclusion criteria were included in this analysis. The mean age of patients undergoing neurolysis was 56.31 ± 19.72 years. Number of males, N = 563 (57.4%), was higher than the number of females, N = 417 (42.5%). The pooled proportion of patients who showed pain relief with EUS-guided neurolysis was 71% (95% CI = 68-74). Bias calculated using Begg-Mazumdar was not significant (p = 0.8). In a subgroup analysis, when comparing the central and bilateral techniques, the pooled proportion of patients with pain relief was 66% (95% CI = 61-71) and 57% (95% CI = 48-67), respectively. Conclusions: Our results show that EUS guided CPN could provide relief in as much as 70% of patients with central neurolysis technique having some edge over peripheral neurolysis. Further larger scale randomized controlled trials may further help to elaborate the efficacy of central vs peripheral neurolysis.

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.

Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) technique and analgesic efficacy in patients with pancreatic cancer: A systematic review and meta-analysis.

BACKGROUND: Endoscopic Ultrasound-guided Celiac Plexus Neurolysis (EUS-CPN) for the treatment of abdominal pain in pancreatic cancer can be administered in three different ways, depending on the site of needle insertion: central injection (CI), bilateral injection (BI) and celiac ganglia neurolysis (CGN). This meta-analysis aimed to (1) estimate the overall efficacy of the EUS-CPN; (2) compare the efficacy of each of the three techniques; and (3) investigate demographic and disease characteristics as potential predictors of treatment response. METHODS: We searched MEDLINE and EMBASE for studies that reported the proportion of treatment responders to EUS-CPN overall, and according to the technique used. We performed a random effects meta-analysis of proportions, and meta-regression was used to estimate the association between technique and clinical characteristics on treatment response. The safety profile was reviewed through narrative synthesis. RESULTS: Overall response rate to EUS-CPN was 68% (95% CI 61%-74%) at week two and 53% (95% CI 45%-62%) at week four. There was no evidence of a significant difference in the response rates between the three techniques. Demographics and disease characteristics were not associated with treatment response. Serious complications have been reported for BI and CGN but not for CI. Moderate to high risk of bias was observed. DISCUSSION: EUS-CPN is a useful adjunct to opioids in the management of pain. There is no evidence of a difference in the efficacy among the three techniques, however, CI is the only one for which serious complications have not been reported. Future research should focus on the appropriate timing of EUS-CPN (early versus on demand) and randomised comparison to establish the comparative efficacy of each technique.

Value of Adding Dexmedetomidine in Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis for Treatment of Pancreatic Cancer-Associated Pain.

BACKGROUND: Abdominal and back pain is present in up to 80% of patients with pancreatic cancer and represents a significant cause of morbidity. Celiac plexus neurolysis (CPN) demonstrated good results in relief of pain of upper abdominal malignancy. Dexmedetomidine is alpha-2 adrenoceptor highly selective agonist approved for procedural sedation use. PATIENTS AND METHODS: Fifty patients divided in two groups with locally advanced pancreatic cancer-associated abdominal pain underwent endoscopic ultrasound (EUS)-guided CPN using bupivacaine 0.5% alone with alcohol for the first group and bupivacaine 0.5% plus dexmedetomidine in the second. Patients scored their pain according to the Numeric Rating Scale (NRS-11) before, 2, 4, 6, 8, 12, 16, and 24 week after the procedure. RESULTS: The study has included 50 patient in two groups. There was no significant difference between the two groups as regards medical, laboratory, or tumor characters. The median pain score decreases from 8.32 ± 0.75 before the procedure to 3.75 ± 3.72 24 week after the procedure in group 1 and from 8.08 ± 0.86 before to 1.67 ± 2.3 24 week after the procedure in group 2. However, there was no significant difference between the two groups in the median pain score during the first 4 weeks. There was no statistically significant difference between the two groups as regards the median survival time. CONCLUSION: The addition of dexmedetomidine to bupivacaine 0.5% in EUS-CPN demonstrated beneficial effects as regards the degree and duration of pain relieve with negligible effect on the patient survival.

EUS and ERCP: A rationale categorization of a productive partnership.

ERCP and EUS are complementary techniques in the management of biliary and pancreatic diseases. Combination of these two techniques can reach different levels of complexity with increasing rates of adverse events. In this article we propose a categorization of the relationship between EUS and ERCP based on whether EUS indicates, complements, facilitates or replaces ERCP. It has implications for the complexity of the technique, the training of the endoscopist and the necessary hospital resources. This classification can also be useful in planning endoscopist training and patient management.