CT-Guided Celiac Ganglion Block for Neurogenic Gastrointestinal Dysmotility.

PURPOSE: To determine whether celiac ganglion block can serve as a diagnostic test for dysautonomia as the cause of gastrointestinal dysmotility-related symptoms. MATERIALS AND METHODS: This was an institutional review board-approved, prospective, single-arm, registered study, from January 2020 to May 2021, and included patients aged 14-85 years with gastrointestinal symptoms of food intolerance, abdominal pain, or angina. Patients with nonneurogenic causes (ie, chronic cholecystitis, peptic ulcer disease, gastroesophageal reflux, and malabsorption syndrome) were excluded. All 15 patients underwent computed tomography-guided celiac ganglion block with 100 mg of liposomal bupivacaine. Patients filled out the dysautonomia-validated questionnaire Composite Autonomic Symptom Score 31 (COMPASS-31) before and after intervention. Differences (before vs after) were compared with the exact permutation method. RESULTS: Fifteen women (median age, 17 years; range, 14-41 years) were included. Average COMPASS-31 score improved significantly, from baseline 11 (SD ± 2.8) to 4 (SD ± 1.9) (improvement, 7 points ± 2.8; P < .001). All patients reported significant reduction in abdominal angina. Fourteen of the 15 patients (93%) reported complete resolution, and 14 of 15 (93%) reported a significant reduction in non-postprandial abdominal pain (P < .01). Only 1 patient reported no improvement. Eight of those 14 patients (57%) reported complete resolution of abdominal pain. There was a significant improvement in functional scores (vomiting, P = .01; constipation frequency, P = .02; constipation severity, P < .01; and nausea, P < .01). The rate of minor and major adverse events was 13% and 0%, respectively, per the Society of Interventional Radiology adverse event classification. CONCLUSIONS: Celiac ganglion block is a safe diagnostic tool for confirming dysautonomia as the underlying condition in patients with gastrointestinal dysmotility-related symptoms. It could provide early diagnosis, lead to definitive treatment (ganglionectomy) earlier, or obviate unnecessary surgery.

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.

EUS-CGN versus EUS-CPN in pancreatic cancer: A qualitative systematic review.

BACKGROUND: Comparison between endosonographic ultrasonography (EUS)-guided celiac ganglia neurolysis (CGN) and EUS-guided celiac plexus neurolysis (CPN) in pain management for pancreatic cancer has engendered controversy. To analyze the effectiveness and safety of EUS-CGN and figure out whether EUS-CGN is better than EUS-CPN, a qualitative systematic review was conducted. METHODS: Studies were searched from Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE up to April 2020. We only included studies with full-text and in English and assessed study quality with Newcastle-Ottawa Scale or Cochrane risk-of-bias tool. We recorded details of study design, participants, procedure performed, protocol of follow-up, pain response, quality of life, survival, and adverse events. The study was conducted under Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement 2009. RESULTS: Five studies involving 319 patients were included. Short-term pain response rates ranged from 65.0% to 88.46% in EUS-CGN group and most studies reported its superiority over EUS-CPN. As for adverse events, the incidence of transient hypotension and gastrointestinal symptoms seemed comparable, while results of initial pain exacerbation varied among studies. Besides, EUS-CGN might provide a shorter survival. CONCLUSION: EUS-CGN can be safely performed while it may shorten survival. In terms of short-term pain response, EUS-CGN is better than EUS-CPN while no conclusion of long-term pain control can be drawn.

Is the level of diffusion restriction in celiac and cervico-thoracic sympathetic ganglia helpful in their proper recognition on PSMA ligand PET/MR?

AIM: To check if diffusion weighted imaging (DWI) might be helpful in proper recognition of celiac (CG) and cervicothoracic (CTG) sympathetic ganglia on the whole-body multimodal PSMA-ligand PET/MR imaging, in the view of their common misleading avidity on PET potentially suggestive of malignant lesions, including metastatic lymph nodes. METHODS: The thickness and the level of diffusion restriction was assessed qualitatively and quantitatively in 406 sympathetic ganglia (189 CTG in 101 males and 217 CG in 116 males) on DWI maps (b-value 0 and 800 s/mm2) and apparent diffusion coefficient (ADC) maps (mean ADC) of the whole-body PET/MR 68Ga-PSMA-11 PET/MR. To form a reference group of a matching ganglia size, the smallest lymph node was chosen from each patient with metastases and underwent the same procedure. RESULTS: Very low and low level of diffusion restriction was noted in the majority of sympathetic ganglia (81.0 % CTG, 67.3 % CG, and 73.6 % of all). In the majority (91.7 %) of metastatic lymph nodes the level of diffusion restriction was moderate to high.The mean ADC values in sympathetic ganglia were statistically significantly higher in CTG, CG and all ganglia than in metastatic lymph nodes (p < 0.001; the effect size was large). CONCLUSIONS: Sympathetic celiac and cervicothoracic ganglia present very low and low level of diffusion restriction in visual DWI assessment, and significantly higher than metastatic lymph nodes mean ADC values in the majority of cases, which may serve as additional factors aiding differential diagnosis on multimodal PSMA-ligand PET/MR imaging.Therefore, PSMA-ligand PET/MR appears potentially superior to PSMA-ligand PET/CT in proper identification of sympathetic ganglia.

The "question-mark" MR anatomy of the cervico-thoracic ganglia complex: can it help to avoid mistaking it for a malignant lesion on 68Ga-PSMA-11 PET/MR?

Background Detectable uptake of 68Ga-PSMA-ligands in sympathetic ganglia may potentially lead to mistaking them for malignant lesions. Our aim was to investigate the anatomy of cervico-thoracic-ganglia-complex (CTG-C) in the MR part of multimodal 68Ga-PSMA-11 PET/MR imaging, in view of PET factors hindering its proper identification. Patients and methods In 106 patients, 212 sites of the CTG-C were retrospectively reviewed to assess the radiotracer uptake (SUVmax), size, shape, position, symmetry of location and visual uptake intensity. Asymmetry of PSMA-ligand uptake and increased uptake were regarded as risk factors of malignancy. Results In 66.0% left (L) and 53.8% right (R) CTG-C we noticed configurations, resembling the shape of an exclamation-mark, a question-mark, or its part (called "typical"). Tumor-like CTG-C shapes (oval, binodular or longitudinal) were detected in 28.3% L-CTG-C and in 40.6% R-CTG-C. When visual assessment of PET suggested malignancy, the recognition of "typical" shape of underlying CTG-C on MR generated a rise in the accuracy of their proper identification (from 34.4% to 75%, χ2(1) = 70.4; p < 0.001). Recognizing the shape of the CTG-C as "typical" in MR allowed us to classify as "not-suspicious" 61.9% of all CTG-C which were treated as "suspicious" after sole PET assessment. Conclusions The characteristic shape of cervico-thoracic-ganglia-complex (resembling a question-mark, or its part) helps in proper recognition of CTG-C on multimodal whole-body 68Ga-PSMA-ligand PET/MR imaging, when detectable uptake might lead to considering pathology.

18F-Fluciclovine Uptake in Celiac Ganglia: A Pitfall in Prostate Cancer PET Imaging.

We present 4 cases of patients who underwent F-fluciclovine PET for prostate cancer demonstrating physiologic uptake in the celiac ganglia, which could be mistaken for metastatic lymphadenopathy if the celiac ganglia have a nodular configuration and uptake higher than bone marrow. Uptake in celiac, cervical, and sacral ganglia has been reported previously as an important pitfall in Ga-PSMA-HBED-CC PET for prostate cancer. In our patients, only celiac ganglion uptake was visualized. Advances in PET scanner technology may cause physiologic uptake of F-fluciclovine in celiac ganglia to become more visually distinguishable from muscular uptake in adjacent diaphragmatic crura.

Accuracy of Endoscopic Ultrasound Imaging in Distinguishing Celiac Ganglia From Celiac Lymph Nodes.

BACKGROUND & AIMS: Endoscopic ultrasound (EUS) allows visualization of celiac lymph nodes (CLNs) and celiac ganglia (CG). Reliably distinguishing these structures is important for tumor staging and CG ablative therapies. We aimed to evaluate the accuracy of EUS in distinguishing CLNs from CG using a strict cytopathology reference standard. We also determined the rate of detection of CLN and CG by conventional cross-sectional imaging. METHODS: From EUS and cytopathology databases, we identified all patients who underwent EUS-FNA of a presumed CLN or CG from October 1, 2004, through March 1, 2017, and compared the findings with those from cytology (reference standard). Indeterminate cytology results were re-reviewed. EUS imaging (ie, index test) results were compared with those from the reference standard. An expert radiologist re-reviewed computed tomography and magnetic resonance images from 100 lesions, from 94 randomly selected patients with a reference standard, to determine the rates of CLN and CG detection. RESULTS: A total of 504 patients (mean age, 63.4 ± 13.2 years; 292 men) underwent a median of 7 EUS-FNA passes (range, 1-13) for a total of 566 lesions perceived to be either a CLN or CG; the cytology reference standard was available for 521 lesions (92.1%). When we excluded indeterminate cytology results, the EUS accurately identified 281/286 CLNs (98.3%) and 166/186 CGs (89.2%), for an overall accuracy of 447/472 (94.7%). EUS-FNA distinguished CG from CLNs with a 93.3% sensitivity, 93.7% specificity, a positive predictive value of 96.2%, and a negative predictive value of 89.2%. Of 100 lesions in 94 patients randomly selected for a second expert radiology review, computed tomography and magnetic resonance imaging detected 59/67 CLNs (88.1%) and 13/33 CG (39.4%). CONCLUSION: EUS accurately distinguishes CLNs from CG. EUS might therefore be used to increase the accuracy of tumor staging, to select tumor stage-appropriate therapy, and to guide CG-ablative therapies.

Celiac ganglia: can they be misinterpreted on multimodal 68Ga-PSMA-11 PET/MR?

OBJECTIVE: The objective of this study was to investigate the morphologic features and Ga-prostate-specific membrane antigen (PSMA)-11 avidity of celiac ganglia (CG) on multimodal PET/MRI. MATERIALS AND METHODS: Ga-PSMA-11 whole-body PET/MR examinations in 120 patients, referred for staging or follow-up of prostate cancer, were retrospectively reviewed to investigate the radiotracer uptake [maximum standardized uptake value (SUVmax)] and morphologic features (size, shape, location) of CG. Nodular, oval and longitudinal nodular, thick or with oval parts shapes of CG were regarded as mistakable with lymph nodes, whereas linear and longitudinal shapes were considered as not mistakable. RESULTS: On MR scans, CG were visible in 98% (117/120) on both sides and in two patients only on the left side. Mistakable CG shape was detected in 69% (83/120) of patients on both or at least one side. The left CG were thicker (4±1.4 mm; range: 1.5-7.5 mm) than the right ones (3±1.3 mm; range: 0.5-7 mm). Mean SUVmax was 2.51±1.17 (range: 0.02-5.48) in the left CG and 2.23±1.22 (range: 0.02-5.91) in the right CG. Increased Ga-PSMA-11 uptake, SUVmax at least 2, was detected in 75% (90/120), and both - erroneous shape and elevated Ga-PSMA-ligand uptake - was observed in 55% (66/120) of all patients on both sides or at least one side. CONCLUSION: Frequently observed, the nodular, oval and longitudinal (nodular, thick or with oval parts) shape of CG, especially of the thicker left CG, on MR scans may cause mistaking them for lymph nodes, even abnormal or metastatic. On whole-body PET/MRI, evident and sometimes high Ga-PSMA-11 uptake in CG increases the risk of a misinterpretation of them as metastases.

Outcome of Percutaneous Radiofrequency Thoracic Sympathectomy for Palmar Hyperhidrosis.

The impact of upper thoracic percutaneous sympathectomy with radiofrequency on the quality of life (QOL) of patients with palmar hyperhidrosis was evaluated. Thirty-six patients with palmar hyperhidrosis were selected for a prospective observational study. Treatment consisted of percutaneous radiofrequency thoracic sympathectomy of T3 and T4 ganglions in all cases. QOL questionnaires were applied preoperatively, on the 1st postoperative (PO) day, and on the 30th, 90th, 180th, and 360th PO days. Furthermore, compensatory hyperhidrosis (HDSSc) scale measures were used simultaneously, in order to evaluate the rate and frequency of this side effect. The QOL questionnaire evaluation showed preoperative values of 83.94 ±â€¯4.74 (meaning poor quality of life), decreasing to 24.61 ±â€¯2.86 on the 1st PO day, 25.14 ±â€¯3.12 on the 30th PO day, 31.28 ±â€¯4.42 on the 90th PO day, 32.97 ±â€¯4.54 on the 180th PO day, and 33.94 ±â€¯4.6 on the 360th PO day (all postoperative results with values below 35 were considered optimal). Compensatory hyperhidrosis (HDSSc) scale values were 1.14 ±â€¯0.35 on the 1st PO day, 1.42 ±â€¯0.55 on the 30th PO day, 1.83 ±â€¯0.85 on the 90th PO day, 1.92 ±â€¯0.91 on the 180th PO day, and 1.92 ±â€¯0.91 on the 360th PO day (meaning that hyperhidrosis was mainly unnoticed). Patients' subjective satisfaction was considered very good and the majority of patients would recommend the treatment procedure. Percutaneous radiofrequency thoracic sympathectomy had a positive impact on the quality of life of patients with palmar hyperhidrosis, compared to the surgical treatment, with a low rate and intensity of HDSSc and without other complications.

The reconstruction algorithm used for [68Ga]PSMA-HBED-CC PET/CT reconstruction significantly influences the number of detected lymph node metastases and coeliac ganglia.

PURPOSE: To investigate whether the numbers of lymph node metastases and coeliac ganglia delineated on [68Ga]PSMA-HBED-CC PET/CT scans differ among datasets generated using different reconstruction algorithms. METHODS: Data were constructed using the BLOB-OS-TF, BLOB-OS and 3D-RAMLA algorithms. All reconstructions were assessed by two nuclear medicine physicians for the number of pelvic/paraaortal lymph node metastases as well the number of coeliac ganglia. Standardized uptake values (SUV) were also calculated in different regions. RESULTS: At least one [68Ga]PSMA-HBED-CC PET/CT-positive pelvic or paraaortal lymph node metastasis was found in 49 and 35 patients using the BLOB-OS-TF algorithm, in 42 and 33 patients using the BLOB-OS algorithm, and in 41 and 31 patients using the 3D-RAMLA algorithm, respectively, and a positive ganglion was found in 92, 59 and 24 of 100 patients using the three algorithms, respectively. Quantitatively, the SUVmean and SUVmax were significantly higher with the BLOB-OS algorithm than with either the BLOB-OS-TF or the 3D-RAMLA algorithm in all measured regions (p < 0.001 for all comparisons). The differences between the SUVs with the BLOB-OS-TF- and 3D-RAMLA algorithms were not significant in the aorta (SUVmean, p = 0.93; SUVmax, p = 0.97) but were significant in all other regions (p < 0.001 in all cases). The SUVmean ganglion/gluteus ratio was significantly higher with the BLOB-OS-TF algorithm than with either the BLOB-OS or the 3D-RAMLA algorithm and was significantly higher with the BLOB-OS than with the 3D-RAMLA algorithm (p < 0.001 in all cases). CONCLUSION: The results of [68Ga]PSMA-HBED-CC PET/CT are affected by the reconstruction algorithm used. The highest number of lesions and physiological structures will be visualized using a modern algorithm employing time-of-flight information.

MR-guided perineural injection of the ganglion impar: technical considerations and feasibility.

OBJECTIVE: Perineural ganglion impar injections are used in the management of pelvic pain syndromes; however, there is no consensus regarding the optimal image guidance. Magnetic resonance imaging (MRI) provides high soft tissue contrast and the potential to directly visualize and target the ganglion. The purpose of this study was to assess the feasibility of MR-guided percutaneous perineural ganglion impar injections. MATERIALS AND METHODS: Six MR-guided ganglion impar injections were performed in six human cadavers. Procedures were performed with a clinical 1.5-Tesla MRI system through a far lateral transgluteus approach. Ganglion impar visibility, distance from the sacrococcygeal joint, number of intermittent MRI control steps required to place the needle, target error between the intended and final needle tip location, inadvertent punctures of non-targeted vulnerable structures, injectant distribution, and procedure time were determined. RESULTS: The ganglion impar was seen on MRI in 4/6 (66 %) of cases and located 0.8 mm cephalad to 16.3 mm caudad (average 1.2 mm caudad) to the midpoint of the sacrococcygeal joint. Needle placement required an average of three MRI control steps (range, 2-6). The average target error was 2.2 ± 2.1 mm. In 6/6 cases (100 %), there was appropriate periganglionic distribution and filling of the presacrococcygeal space. No punctures of non-targeted structures occurred. The median procedure time was 20 min (range, 12-29 min). CONCLUSION: Interventional MRI can visualize and directly target the ganglion impar for accurate needle placement and successful periganglionic injection with the additional benefit of no ionizing radiation exposure to patient and staff. Our results support clinical evaluation.

Depiction of celiac ganglia on positron emission tomography and computed tomography in patients with lung cancer.

OBJECTIVE: To differentiate imaging characteristics of celiac ganglia from metastatic lesion on positron emission tomography-computed tomography (PET-CT) in patients with lung cancer and correlate these findings to postmortem multidetector row computed tomography (MDCT). METHODS: One hundred twenty-nine patients were included. Imaging characteristics and fluorodeoxyglucose (FDG) avidity of the celiac ganglia were recorded. Postmortem MDCT of 20 subjects were reviewed. RESULTS: Celiac ganglia were identified unilaterally in 127 and bilaterally in 108 patients without abnormal FDG uptake. Postmortem images showed celiac ganglia in all cases with no significant difference compared to our patients. CONCLUSIONS: Familiarity with CT characteristics and FDG-avidity of celiac ganglia enable us to distinguish them from metastatic lesions in their vicinity.

[Frequency of visualization of celiac ganglia by endoscopic ultrasound and its potential in assessing neural invasion in patients with pancreatic lesions]. / Frecuencia de visualización de ganglios celíacos por ultrasonido endoscópico y su potencial en la evaluación de invasión neural en pacientes con lesiones pancreáticas.

BACKGROUND: Celiac ganglia (CG) can be seen by endoscopic ultrasound; they play an important role in pain management and are a potential site for extrapancreatic tumor neural invasion. AIMS: To evaluate the frequency of CG visualization during endoscopic ultrasound examination and to evaluate the feasibility of this technique to identify extrapancreatic tumor neural invasion in patients with pancreatic lesions. METHODS: We retrospectively reviewed all endoscopic ultrasound studies performed between November 2007 and June 2010. Images of the celiac region were presented to an endosonographer, who reported the presence or absence of CG. RESULTS: We included 31 cases. CG were identified in 14 (45%) cases. Average size was 10mm (range 4-25mm) by±1mm (range 1-7mm). In 2 cases, fine needle aspiration biopsy was performed and reported nerve cell bodies; in one case malignant cells were seen. CONCLUSIONS: CG were identified in 45% of the cases. Fine needle aspiration biopsy can detect unanticipated extrapancreatic tumor neural invasion in pancreatic malignancies.

Endoscopic ultrasound fine needle aspiration biopsy of celiac ganglia.

OBJECTIVE: Celiac ganglia are normal anatomic structures located in the region of the celiac artery and can vary in size from 5 mm to 4.5 cm. These nodules can be visualized by endoscopic ultrasound (EUS) and be subject to fine needle aspiration (FNA) biopsy. They can be identified in patients with and without underlying pathology and present a challenge in accurate interpretation. STUDY DESIGN: The hospital database was retrospectively searched for patients who had undergone EUS FNA and where a diagnosis of 'ganglia' was rendered. Clinical and demographic data were collected and the cases reviewed for cytomorphologic features. RESULTS: Aspirate smears were generally hypocellular with variable cellularity between aspirate passes, showing dispersed single large epithelioid cells with cytoplasmic pigmentation, small groups of bland stroma and spindled cells, as well as 'grape-like' groups with peripheral epithelioid cells and central stroma with spindled elements. CONCLUSION: EUS cannot always definitively identify celiac lesions and the use of EUS FNA can help to accurately classify these cases. In patients with known or suspected malignancy, the accurate identification of celiac ganglia by EUS FNA can have important patient management implications. EUS FNA can identify celiac ganglia and show the distinctive features of large pigmented epithelioid ganglion cells and background neural elements.

EUS-guided celiac ganglion irradiation with iodine-125 seeds for pain control in pancreatic carcinoma: a prospective pilot study.

BACKGROUND: Celiac plexus neurolysis for the palliative reduction of pain in unresectable pancreatic carcinoma (PC) is safe but provides limited relief. In a previous study, we found that EUS-guided implantation of iodine-125 ((125)I) around the celiac ganglia is a safe procedure and can induce apoptosis of local neurons in a porcine model. OBJECTIVE: To evaluate the safety and efficacy of direct celiac ganglion irradiation with (125)I seeds for the relief of moderate to severe pain secondary to unresectable PC. DESIGN: Prospective study. SETTING: Single, tertiary care referral center. PATIENTS: This study enrolled consecutive patients who had moderate to severe pain resulting from biopsy-proven unresectable PC. INTERVENTION: All patients underwent EUS-guided direct celiac ganglion irradiation with (125)I seeds. Follow-up was conducted at least once weekly until death. MAIN OUTCOME MEASUREMENTS: Blood parameters, Visual Analog Scale (VAS) score, mean analgesic (MS Contin [morphine sulfate]) consumption, and complications were evaluated during follow-up. RESULTS: Twenty-three patients with unresectable PC underwent the procedure. The mean number of seeds implanted in the celiac ganglion per patient was 4 (range 2-6). Immediately after the procedure, pain relief and analgesic consumption showed no significant changes compared with preoperative values. Six patients (26%) reported pain exacerbation. Two weeks later, the VAS score and mean analgesic consumption were significantly less than preoperative values. No procedure-related deaths or major complications occurred. LIMITATIONS: Uncontrolled study. CONCLUSIONS: EUS-guided direct celiac ganglion irradiation with (125)I seeds can reduce the VAS score and analgesic drug consumption in patients with unresectable PC.