Endoscopic ultrasonography-guided celiac plexus neurolysis in patients with unresectable pancreatic cancer: An update

Abstract

Pancreatic cancer produces disabling abdominal pain, and the pain medical management for pancreatic cancer is often challenging because it mainly relies on the use of narcotics (major opioids). However, opioids often provide suboptimal pain relief, and the use of opioids can lead to patient tolerance and several side effects that considerably reduce the quality of life of pancreatic cancer patients. Endosonography-guided celiac plexus neurolysis (EUS-CPN) is an alternative for pain control in patients with nonsurgical pancreatic cancer; EUS-CPN consists of the injection of alcohol and a local anesthetic into the area of the celiac plexus to achieve chemical ablation of the nerve tissue. EUS-CPN via the transgastric approach is a safer and more accessible technique than the percutaneous approach. We have reviewed most of the studies that evaluate the efficacy of EUS-CPN and that have compared the different approaches that have been performed by endosonographers. The efficacy of EUS-CPN varies from 50% to 94% in the different studies, and EUS-CPN has a pain relief duration of 4–8 wk. Several factors are involved in its efficacy, such as the onset of pain, previous use of chemotherapy, presence of metastatic disease, EUS-CPN technique, type of needle or neurolytic agent used, etc. According to this review, injection into the ganglia may be the best technique, and a good visualization of the ganglia is the best predictor for a good EUS-CPN response, although more studies are needed. However, any of the 4 different techniques could be used to perform EUS-CPN effectively with no differences in terms of complications between the techniques, but more studies are needed. The effect of EUS-CPN on pain improvement, patient survival and patient quality of life should be evaluated in well-designed randomized clinical trials. Further research also needs to be performed to clarify the best time frame in performing a EUS-CPN.

Keywords: Pancreatic cancer, Endosonography, Celiac plexus neurolysis, Opioids, Echoendoscopy

Core Tip: In this review, we analyzed the efficacy of the celiac plexus neurolysis through echoendoscopy (EUS-CPN) technique in patients with unresectable pancreatic cancer. The use of opioids for pain control are associated with numerous side effects that reduce the quality of life of pancreatic cancer patients, and the use of EUS-CPN is a safe and effective approach to pain management and allows for the reduction in the opioid doses used. There are different techniques to perform a EUS-CPN, all of which are described in this article. However, there are concerns about the efficacy of EUS-CPN (since it produces a reduction in pain for a short time), the ideal time to perform this technique is unknown, and it is also unknown whether this technique has any influence on patient survival and quality of life.