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Efficacy of EUS-guided celiac plexus neurolysis compared with medication alone for unresectable pancreatic cancer in the oxycodone/fentanyl era: a prospective randomized control study

Published:January 14, 2020DOI:https://doi.org/10.1016/j.gie.2020.01.011

      Background and aims

      The efficacy of celiac plexus neurolysis (CPN) with EUS guidance (EUS-CPN) has not been confirmed in the era of developed opioids. The aim of this study was to evaluate the efficacy of EUS-CPN for patients with pancreatic cancer–associated pain to compare medication using oxycodone and/or fentanyl with and without EUS-CPN.

      Methods

      In this randomized control study involving patients who underwent EUS-CPN and those who did not, pain, quality of life (QOL), and opioid consumption were compared. Standard medicinal treatment using oxycodone and/or fentanyl was performed for both groups. The primary endpoint was defined as the pain evaluated by using a visual analog scale (VAS) rated from a 0 to 10, 4 weeks after the baseline.

      Results

      For 48 registered patients, the outcomes of 24 patients in the EUS-CPN group and 22 patients in the control group were analyzed. EUS-CPN was successfully performed and did not induce severe procedure-related adverse events for all patients in the EUS-CPN group. Although the average pain VAS scores for both groups significantly decreased in comparison with baseline, scores were not statistically different between the groups at week 4 (1.3 ± 1.3 for the EUS-CPN group vs 2.3 ± 2.3 for the control group, P = .10). There was no statistical difference or tendency in favor of EUS-CPN at evaluation points of weeks 1, 2, 8, and 12. Moreover, the average VAS scores for QOL and the average opioid consumption between the groups were not different at all evaluation points.

      Conclusions

      EUS-CPN for patients with pancreatic cancer–associated pain did not appear to improve pain, QOL, or opioid consumption compared with those who did not undergo EUS-CPN and medicated with oxycodone/fentanyl. Although EUS-CPN can be an option, it was not found to have a large enough impact to be routinely performed for all patients with pain. (Clinical trial registration number: UMIN 000037172.)

      Abbreviations:

      CI (confidence interval), CPN (celiac plexus neurolysis), EUS-CPN (EUS-guided CPN), QOL (quality of life), SMA (superior mesenteric artery), UICC (Union for International Cancer Control), VAS (visual analog scale)
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      References

        • Caraceni A.
        • Prtenoy R.K.
        Pain management in patients with pancreatic carcinoma.
        Cancer. 1996; 78: 639-653
        • World Health Organization
        Cancer pain relief.
        2nd ed. WHO, Geneva, Switzerland2006
        • Arcidiacono P.G.
        • Calori G.
        • Carrara S.
        • et al.
        Celiac plexus block for pancreatic cancer pain in adults.
        Cochrane Database Syst Rev. 2011; 16: CD007519
        • Nagels W.
        • Pease N.
        • Bekkering G.
        • et al.
        Celiac plexus neurolysis for abdominal cancer pain: a systematic review.
        Pain Med. 2013; 14: 1140-1163
        • Wiersema M.J.
        • Wiersema L.M.
        Endosonography-guided celiac plexus neurolysis.
        Gastrointest Endosc. 1996; 44: 656-662
        • Iwata K.
        • Yasuda I.
        • Enya M.
        • et al.
        Predictive factors for pain relief after endoscopic ultrasound-guided celiac plexus neurolysis.
        Dig Endosc. 2011; 23: 140-145
        • Teoh A.Y.B.
        • Dhir V.
        • Kida M.
        • et al.
        Consensus guidelines on the optimal management in interventional EUS procedures: results from the Asian EUS group RAND/UCLA expert panel.
        Gut. 2018; 67: 1209-1228
        • Asaki S.
        Efficacy of endoscopic pure ethanol injection method for gastrointestinal ulcer bleeding.
        World J Surg. 2000; 24: 294-298
        • Asaki S.
        • Nishimura T.
        • Sato A.
        • et al.
        Efficacy of absolute ethanol injection method for stress ulcer bleeding after major surgeries.
        Tohoku J Exp Med. 1989; 159: 221-225
        • Kataoka S.
        • Ohchi H.
        • Toyonaga T.
        • et al.
        Perforation of the stomach following endoscopic injection hemostasis: case report and review of the literature [in Japanese with English abstract].
        Gastroenterol Endosc. 1998; 40: 33-39
        • Kawamata M.
        • Ishitani K.
        • Ishikawa K.
        • et al.
        Comparison between celiac plexus block and morphine treatment on quality of life in patients with pancreatic cancer pain.
        Pain. 1996; 64: 597-602
        • Sakamoto H.
        • Kitano M.
        • Kamata K.
        • et al.
        EUS-guided broad plexus neurolysis over the superior mesenteric artery using a 25-gauge needle.
        Am J Gastroenterol. 2010; 105: 2599-2606
        • Gunaratnam N.T.
        • Sarma A.V.
        • Norton I.D.
        • et al.
        A prospective study of EUS-guided celiac plexus neurolysis for pancreatic cancer pain.
        Gastrointest Endosc. 2001; 54: 316-324
        • Lillemoe K.D.
        • Cameron J.L.
        • Kaufman H.S.
        • et al.
        Chemical splanchnicectomy in patients with unresectable pancreatic cancer. A prospective randomized trial.
        Ann Surg. 1993; 217: 447-455
        • Wong G.Y.
        • Schroeder D.R.
        • Carns P.E.
        • et al.
        Effect of neurolytic celiac plexus block on pain relief, quality of life, and survival in patients with unresectable pancreatic cancer: a randomized controlled trial.
        JAMA. 2004; 291: 1092-1099
        • Zhang C.L.
        • Zhang T.J.
        • Guo Y.N.
        • et al.
        Effect of neurolytic celiac plexus block guided by computerized tomography on pancreatic cancer pain.
        Dig Dis Sci. 2008; 53: 856-860
        • Kappis M.
        Erfahrungen mit localanasthesie bie bauchoperationen [in German].
        Verh Dtsch Gesellsch Chir. 1914; 43: 87-89
        • Haaga J.R.
        • Kori S.H.
        • Eastwood D.W.
        • et al.
        Improved technique for CT-guided celiac ganglia block.
        AJR Am J Roentgenol. 1984; 142: 1201-1204
        • Mercadante S.
        Celiac plexus block versus analgesics in pancreatic cancer pain.
        Pain. 1993; 52: 187-192
        • Polati E.
        • Finco G.
        • Gottin L.
        • et al.
        Prospective randomized double-blind trial of neurolytic coeliac plexus block in patients with pancreatic cancer.
        Br J Surg. 1998; 85: 199-201
        • Doi S.
        • Yasuda I.
        • Kawakami H.
        • et al.
        Endoscopic ultrasound-guided celiac ganglia neurolysis vs. celiac plexus neurolysis: a randomized multicenter trial.
        Endoscopy. 2013; 45: 362-369
        • Levy M.J.
        • Topazian M.D.
        • Wiersema M.J.
        • et al.
        Initial evaluation of the efficacy and safety of endoscopic ultrasound-guided ganglia neurolysis and block.
        Am J Gastroenterol. 2008; 103: 98-103
        • Ascunce G.
        • Ribeiro A.
        • Reis A.
        • et al.
        EUS visualization and direct celiac ganglia neurolysis predicts better pain relief in patients with pancreatic malignancy (with video).
        Gastrointest Endosc. 2011; 73: 267-274
        • Obstein K.L.
        • Martins F.P.
        • Fernandez-Esparrach G.
        • et al.
        Endoscopic-ultrasound-guided celiac plexus neurolysis using a reverse phase polymer.
        World J Gastroenterol. 2010; 16: 728-731
        • Ishiwatari H.
        • Hayashi T.
        • Yoshida M.
        • et al.
        EUS-guided celiac plexus neurolysis by using highly viscous phenol-glycerol as a neurolytic agent (with video).
        Gastrointest Endosc. 2015; 81: 479-483
        • Wyse J.M.
        • Carone M.
        • Paquin S.C.
        • et al.
        Randomized, double-blind, controlled trial of early endoscopic ultrasound-guided celiac plexus neurolysis to prevent pain progression in patients with newly diagnosed, painful, inoperable pancreatic cancer.
        J Clin Oncol. 2011; 29: 3541-3546
        • Levy M.J.
        • Gleeson F.C.
        • Topazian M.D.
        • et al.
        Combined celiac ganglia and plexus neurolysis shortens survival, without benefit, vs plexus neurolysis alone.
        Clin Gastroenterol Hepatol. 2019; 17: 728-738
        • Minaga K.
        • Takenaka M.
        • Kamata K.
        • et al.
        Alleviating pancreatic cancer-associated pain using endoscopic ultrasound-guided neurolysis.
        Cancers. 2018; 10: E50
        • Mittal M.K.
        • Rabinstein A.A.
        • Wijdicks E.F.
        Acute spinal cord infarction following endoscopic ultrasound-guided celiac plexus neurolysis.
        Neurology. 2012; 78: e57-e59
        • Fujii L.
        • Clain J.E.
        • Morris J.M.
        • et al.
        Anterior spinal cord infarction with permanent paralysis following endoscopic ultrasound celiac plexus neurolysis.
        Endoscopy. 2012; 44: E265-E266
        • Minaga K.
        • Kitano M.
        • Imai H.
        • et al.
        Acute spinal cord infarction after EUS-guided celiac plexus neurolysis.
        Gastrointest Endosc. 2016; 83: 1039-1040
        • Köker I.H.
        • Aralasmak A.
        • Ünver N.
        • et al.
        Spinal cord ischemia after endoscopic ultrasound-guided celiac plexus neurolysis: case report and review of the literature.
        Scand J Gastroenterol. 2017; 52: 1158-1161
        • Muscatiello N.
        • Panella C.
        • Pietrini L.
        • et al.
        Complication of endoscopic ultrasound-guided celiac plexus neurolysis.
        Endoscopy. 2006; 38: 858
        • Gimeno-Garcia A.Z.
        • Elwassief A.
        • Paquin S.C.
        • et al.
        Fatal complication after endoscopic ultrasound-guide celiac plexus neurolysis.
        Endoscopy. 2012; 44: E267
        • Jang H.Y.
        • Cha S.W.
        • Lee B.H.
        • et al.
        Hepatic and splenic infarction and bowel ischemia following endoscopic ultrasound-guided celiac plexus neurolysis.
        Clin Endosc. 2013; 46: 306-309
        • Mulhall A.M.
        • Rashkin M.C.
        • Pina E.M.
        Bilateral diaphragmatic paralysis: a rare complication related to endoscopic ultrasound-guided celiac plexus neurolysis.
        Ann Am Thorac Soc. 2016; 13: 1660-1662
        • Fujii-Lau L.L.
        • Bamlet W.R.
        • Eldrige J.S.
        • et al.
        Impact of celiac neurolysis on survival in patients with pancreatic cancer.
        Gastrointest Endosc. 2015; 82: 46-56
        • Japan Pancreas Society
        Classification of pancreatic carcinoma.
        4th ed. 2017 (Available at:)

      Linked Article

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          We read with great interest the research by Kanno et al,1 in which the authors assessed the effectiveness of celiac plexus neurolysis (CPN) with EUS guidance (EUS-CPN) for patients with pancreatic cancer–associated pain to compare medication using oxycodone and/or fentanyl with and without EUS-CPN. The final result indicated that compared with patients who did not undergo EUS-CPN and who were medicated with oxycodone/fentanyl, EUS-CPN did not seem to improve pain, quality of life, and opioid dosage.
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