Endoscopic ultrasound-guided celiac ganglia neurolysis vs. celiac plexus neurolysis: a randomized multicenter trial

Background and study aims: No prospective comparison of endoscopic ultrasonography-guided direct celiac ganglia neurolysis (EUS – CGN) vs. EUS-guided celiac plexus neurolysis (EUS – CPN) has been reported. The aim of the current study was to compare the effectiveness of EUS – CGN and EUS – CPN in providing pain relief from upper abdominal cancer pain in a multicenter randomized controlled trial.

Patients and methods: Patients with upper abdominal cancer pain were randomly assigned to treatment using either EUS – CGN or EUS – CPN. Evaluation was performed at Day 7 postoperatively using a pain scale of 0 to 10. Patients for whom pain decreased to ≤ 3 were considered to have a positive response, and those experiencing a decrease in pain to ≤ 1 were considered to be completely responsive. Comparison between the two groups was performed using intention-to-treat analysis. The primary endpoint was the difference in treatment response rates between EUS – CGN and EUS – CPN at postoperative Day 7. Secondary endpoints included differences in complete response rates, pain scores, duration of pain relief, and incidence of adverse effects.

Results: A total of 34 patients were assigned to each group. Visualization of ganglia was possible in 30 cases (88 %) in the EUS – CGN group. The positive response rate was significantly higher in the EUS – CGN group (73.5 %) than in the EUS – CPN group (45.5 %; P = 0.026). The complete response rate was also significantly higher in the EUS – CGN group (50.0 %) than in the EUS – CPN group (18.2 %; P = 0.010). There was no difference in adverse events or duration of pain relief between the two groups.

Conclusions: EUS – CGN is significantly superior to conventional EUS – CPN in cancer pain relief.

Clinical trial registration: http://www.umin.ac.jp/ctr/index.htm (ID: UMIN-000002536)

• References

• 1 Ventafridda V, Tamburini M, Caraceni A et al. A validation study of the WHO method for cancer pain relief. Cancer 1987; 59: 850-856
• 2 Kappis M. Erfahrungen mit localanasthesie bie bauchoperationen. Verh Dtsch Gesellsch Chir 1914; 43: 87-89
• 3 Haaga JR, Kori SH, Eastwood DW et al. Improved technique for CT-guided celiac ganglia block. AJR Am J Roentgenol 1984; 142: 1201-1204
• 4 Eisenberg E, Carr DB, Chalmers TC. Neurolytic celiac plexus block for treatment of cancer pain: a meta-analysis. Anesth Analg 1995; 80: 290-295
• 5 Faigel DO, Veloso KM, Long WB et al. Endosonography-guided celiac plexus injection for abdominal pain due to chronic pancreatitis. Am J Gastroenterol 1996; 91: 1675
• 6 Wiersema MJ, Wiersema LM. Endosonography-guided celiac plexus neurolysis. Gastrointest Endosc 1996; 44: 656-662
• 7 Gunaratnam NT, Sarma AV, Norton ID et al. A prospective study of EUS-guided celiac plexus neurolysis for pancreatic cancer pain. Gastrointest Endosc 2001; 54: 316-324
• 8 Levy M, Rajan E, Keeney G et al. Neural ganglia visualized by endoscopic ultrasound. Am J Gastroenterol 2006; 101: 1787-1791
• 9 Gleeson FC, Levy MJ, Papachristou GI et al. Frequency of visualization of presumed celiac ganglia by endoscopic ultrasound. Endoscopy 2007; 39: 620-624
• 10 Gerke H, Silva Jr RG, Shamoun D et al. EUS characteristics of celiac ganglia with cytologic and histologic confirmation. Gastrointest Endosc 2006; 64: 35-39
• 11 Levy MJ, Topazian MD, Wiersema MJ et al. Initial evaluation of the efficacy and safety of endoscopic ultrasound-guided direct ganglia neurolysis and block. Am J Gastroenterol 2008; 103: 98-103
• 12 Oken MM, Creech RH, Tormey DC et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 1982; 5: 649-655
• 13 Puli SR, Reddy JB, Bechtold ML et al. EUS-guided celiac plexus neurolysis for pain due to chronic pancreatitis or pancreatic cancer pain: a meta-analysis and systematic review. Dig Dis Sci 2009; 54: 2330-2337
• 14 Sahai AV, Lemelin V, Lam E et al. Central vs. bilateral endoscopic ultrasound-guided celiac plexus block or neurolysis: a comparative study of short-term effectiveness. Am J Gastroenterol 2009; 104: 326-329
• 15 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
• 16 Harada N, Wiersema MJ, Wiersema LM. Endosonography-guided celiac plexus neurolysis. Gastrointest Endosc Clin N Am 1997; 7: 237-245
• 17 Tran QN, Urayama S, Meyers FJ. Endoscopic ultrasound-guided celiac plexus neurolysis for pancreatic cancer pain: a single-institution experience and review of the literature. J Support Oncol 2006; 4: 460-462 ; discussion 463-464
• 18 De Cicco M, Matovic M, Bortolussi R et al. Celiac plexus block: injectate spread and pain relief in patients with regional anatomic distortions. Anesthesiology 2001; 94: 561-565
• 19 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
• 20 Ascunce G, Ribeiro A, Reis I 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
• 21 Harada S, Misawa S, Agarwal DP et al. Liver alcohol dehydrogenase and aldehyde dehydrogenase in the Japanese: isozyme variation and its possible role in alcohol intoxication. Am J Hum Genet 1980; 32: 8-15