Complication rates of EUS-guided celiac plexus blockade and neurolysis: results of a large case series

Background and study aims: Complication rates for EUS-guided celiac plexus blockade (CPB) and celiac plexus neurolysis (CPN) have been largely derived from studies utilizing percutaneous or surgical techniques, with few studies specifically examining rates for EUS-guided CPB and CPN. This study aims to further describe the complication rates of EUS-guided CPB and CPN.

Patients and methods: In a retrospective analysis of a prospectively collected EUS database, tracking patients and complications for a single endosonographer at a tertiary-care teaching hospital, data for consecutive patients between August 2003 and March 2008 undergoing either EUS-guided CPB or CPN were analyzed for indications, methods, and complications. Excellent follow-up data were available for all patients.

Results: 189 EUS-CPB and 31 EUS-CPN procedures were done in 128 and 30 patients, respectively (60 men, 98 women). Indications for blockades included chronic pancreatitis (122), relapsing pancreatitis with chronic pain (28), upper abdominal pain of suspected pancreatic origin (37), and suspected (yet unproven) pancreatic cancer with pain (2). Neurolyses were performed for refractory pain from cancer (21) or chronic pancreatitis (10). No prophylactic antibiotics were administered. Acid suppression was not withheld. Complications were defined as procedural side effects treated with anything beyond standard observation. Four complications were observed during clinical follow-up (three after CPB, one after CPN), giving an overall complication rate of 1.8 % (CPB 1.6 %, CPN 3.2 %). Complications included asymptomatic hypotension after neurolysis, retroperitoneal abscess after CPB, and severe self-limited postprocedural pain in two patients after CPB.

Conclusions: EUS-guided CPB and CPN are reasonably safe procedures with tolerable side-effect profiles and low overall complication rates.

References

• 1 Michaels A J, Draganov P V. Endoscopic ultrasonography guided celiac plexus neurolysis and celiac plexus block in the management of pain due to pancreatic cancer and chronic pancreatitis.  World J Gastroenterol. 2007;  13 3575-3580
• 2 Staats P S, Hekmat H, Sauter P. et al . The effects of alcohol celiac plexus block, pain, and mood on longevity in patients with unresectable pancreatic cancer: a double-blind, randomized, placebo-controlled study.  Pain Med. 2001;  2 28-34
• 3 Caraceni A, Portenoy R K. Pain management in patients with pancreatic carcinoma.  Cancer. 1996;  78 639-653
• 4 Lankisch P G. Natural course of chronic pancreatitis.  Pancreatology. 2001;  1 3-14
• 5 Kappis M. Erfahrungen mit localanasthesie bie bauchoperationen.  Vehr Dtsch Gesellsch Chir. 1914;  43 87-89
• 6 Mercadante S. Celiac plexus block versus analgesics in pancreatic cancer pain.  Pain. 1993;  52 187-192
• 7 Eisenberg E, Carr D B, Chalmers T C. Neurolytic celiac plexus block for treatment of cancer pain: a meta-analysis.  Anesth Analg. 1995;  80 290-295
• 8 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;  217 447-457
• 9 Wang P J, Shang M Y, Qian Z. et al . CT-guided percutaneous neurolytic celiac plexus block technique.  Abdom Imaging. 2006;  31 710-718
• 10 Wiersema M, Sandusky D, Carr R. et al . Endosonography guided celiac plexus neurolysis in patients with pain due to intra-abdominal malignancy [abstract].  Gastrointest Endosc. 1995;  41 315
• 11 Faigel D O, Veloso K M, Long W B. et al . Endosonography-guided celiac plexus injection for abdominal pain due to chronic pancreatitis.  Am J Gastroenterol. 1996;  91 1675
• 12 Wiersema M J, Wiersema L M. Endosonography-guided celiac plexus neurolysis.  Gastrointest Endosc. 1996;  44 656-662
• 13 Gress F, Ciaccia D, Kiel S. et al . Endoscopic ultrasound (EUS) guided celiac plexus block (CB) for management of pain due to chronic pancreatitis (CP): a large single center experience [abstract].  Gastrointest Endosc. 1997;  45 AB173
• 14 Gress F, Schmitt C, Sherman S. et al . A prospective randomized comparison of endoscopic ultrasound- and computed tomography-guided celiac plexus block for managing chronic pancreatitis pain.  Am J Gastroenterol. 1999;  94 900-905
• 15 Gunaratnam N T, Wong G Y, Wiersema M J. EUS-guided celiac plexus block for the management of pancreatic pain.  Gastrointest Endosc. 2000;  52 28-34
• 16 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
• 17 Gress F, Schmitt C, Sherman S. et al . Endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience.  Am J Gastroenterol. 2001;  96 409-416
• 18 Tran Q N, Urayama S, Meyers F J. 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, 464; discussion 463 – 464
• 19 Levy M J, Wiersema M J. Endoscopic ultrasound-guided pain control for intra-abdominal cancer.  Gastroenterol Clin N Am. 2006;  35 153-165
• 20 Levy M J, Topazian M D, Wiersema M J. 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
• 21 Leblanc J, Dewitt J, Calley C. et al . A prospective randomized trial of 1 versus 2 injections during a single EUS-guided celiac plexus block (CPB) procedure for chronic pancreatitis pain: final results.  Gastrointest Endosc. 2008;  67 AB224
• 22 Paz Z, Rosen A. The human celiac ganglion and its splanchnic nerves.  Acta Anat. 1989;  136 129-133
• 23 Ward E M, Rorie D K, Nauss L A. et al . The celiac ganglia in man: normal anatomic variations.  Anesth Analg. 1979;  58 461-465
• 24 Schmulewitz N, Hawes R. EUS-guided celiac plexus neurolysis – technique and indication.  Endoscopy. 2003;  35 49-53
• 25 Gafanovich I, Shir Y, Tsvang E. et al . Chronic diarrhea-induced by celiac plexus block?.  J Clin Gastroenterol. 1998;  26 300-302
• 26 Iftikhar S, Loftus Jr. E V. Gastroparesis after celiac plexus block.  Am J Gastroenterol. 1998;  93 2223-2225
• 27 Chan V W. Chronic diarrhea: an uncommon side effect of celiac plexus block.  Anesth Analg. 1996;  82 205-207
• 28 Davies D D. Incidence of major complications of neurolytic coeliac plexus block.  J R Soc Med. 1993;  86 264-266
• 29 Wong G Y, Brown D L. Transient paraplegia following alcohol celiac plexus block.  Reg Anesth Pain Med. 1995;  20 352-355
• 30 Hayakawa J, Kobayashi O, Murayama H. Paraplegia after intraoperative celiac plexus block.  Anesth Analg. 1997;  84 447-448
• 31 Adler D G, Jacobson B C, Davila R E. et al . ASGE guideline: complications of EUS. Gastrointest Endosc 2005; 61 : 8 – 12.  Erratum in: Gastrointest Endosc. 2005;  61 502
• 32 Malick J K, McGrath K M. Endoscopic ultrasound guided injection: a close look at celiac plexus block and celiac plexus neurolysis.  Gastrointest Nurs. 2003;  26 159-163
• 33 Pham C QD, Regal R E, Bostwick T R, Knauf K S. Acid suppressive therapy use in an inpatient internal medicine service.  Ann Pharmacother. 2006;  40 1261-1266