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Initial Evaluation of the Efficacy and Safety of Endoscopic Ultrasound-Guided Direct Ganglia Neurolysis and Block

Levy, Michael J., M.D.1; Topazian, Mark D., M.D.1; Wiersema, Maurits J., M.D.2; Clain, Jonathan E., M.D.1; Rajan, Elizabeth, M.D.1; Wang, Kenneth K., M.D.1; de la Mora, Jose G., M.D.1; Gleeson, Ferga C., M.D.1; Pearson, Randall K., M.D.1; Pelaez, Mario C., M.D.1; Petersen, Bret T., M.D.1; Vege, Santhi S., M.D.1; Chari, Suresh T., M.D.1

American Journal of Gastroenterology: January 2008 - Volume 103 - Issue 1 - p 98–103
ORIGINAL CONTRIBUTIONS: ENDOSCOPY
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BACKGROUND Celiac plexus neurolysis and block are considered safe but provide limited pain relief. Standard techniques target the region of the celiac plexus but do not attempt injections directly into celiac ganglia. The recent recognition that celiac ganglia can be visualized by endoscopic ultrasound (EUS) now allows direct injection into celiac ganglia for neurolysis (CGN) and block (CGB).

AIMS To determine the safety and initial efficacy (at 2–4 wk) of direct ganglia injection in patients with moderate to severe pain secondary to unresectable pancreatic carcinoma or chronic pancreatitis.

METHODS An EUS database was reviewed to identify patients undergoing CGN and CGB. Data were retrieved from the medical records and phone follow-up.

RESULTS Thirty-three patients underwent 36 direct celiac ganglia injections for unresectable pancreatic cancer (CGN N = 17, CGB N = 1) or chronic pancreatitis (CGN N = 5, CGB N = 13) with bupivacaine (0.25%) and alcohol (99%) for CGN, or Depo-Medrol (80 mg/2 cc) for CGB. Cancer patients reported pain relief in 16/17 (94%) when alcohol was injected and 0/1 (00%) when steroid was injected. For chronic pancreatitis, 4/5 (80%) who received alcohol reported pain relief versus 5/13 (38%) receiving steroids. Thirteen (34%) patients experienced initial pain exacerbation, which correlated with improved therapeutic response (P < 0.05). Transient hypotension and diarrhea developed in 12 and 6 patients, respectively.

CONCLUSIONS Initial experience suggests that EUS-guided direct celiac ganglion block or neurolysis is safe. Alcohol injection into ganglia appears to be effective in both cancer and chronic pancreatitis. Prospective trials are needed to confirm the efficacy of this new approach.

1Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota; and 2Indiana Medical Associates, Fort Wayne, Indiana

Reprint requests and correspondence: Michael J. Levy, M.D., Director of Endoscopic Ultrasound, Mayo Clinic, 200 First Street SW, Charlton 8, Rochester, MN 55905.

Received May 22, 2007; accepted August 3, 2007.

CONFLICT OF INTERESTGuarantor of the article: Michael J. Levy, M.D.

Specific author contributions: concept and design: Michael Levy, Mark Topazian, Maurits Wiersema, Jonathan Clain, Elizabeth Rajan, Suresh Chari; data acquisition: Michael Levy, Mark Topazian, Jonathan Clain, Elizabeth Rajan, Jose G. de la Mora, Mario Pelaez; data analysis and interpretation: Michael Levy, Mark Topazian, Maurits Wiersema, Jonathan Clain, Elizabeth Rajan, Kenneth Wang, Jose G. de la Mora, Ferga Gleeson, Randall Pearson, Mario Pelaez, Bret Petersen, Santhi Vege, Suresh Chari; manuscript drafting and critical revising: Michael Levy, Mark Topazian, Maurits Wiersema, Jonathan Clain, Elizabeth Rajan, Kenneth Wang, Jose G. de la Mora, Ferga Gleeson, Randall Pearson, Mario Pelaez, Bret Petersen, Santhi Vege, Suresh Chari.

Financial support: None.

Potential competing interests: None.

© The American College of Gastroenterology 2008. All Rights Reserved.
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