pISSN 2636-0004eISSN 2636-0012
pISSN 2636-0004Guidelines on EUS-CPN
| Statement | EFSUMB (2016) | AEG (2018) | |
|---|---|---|---|
| Indication | EUS-guided CPN combined with standard analgesic treatment is superior to analgesic treatment alone in reducing pain in patients with pancreatic and upper gastrointestinal cancer. | EUS-guided CPN is recommended in patients suffering from pain due to unresectable upper abdominal cancer, particularly for pancreatic cancer. | |
| For chronic pancreatitis, percutaneous CPB has inferior efficacy compared with EUS-guided CPB, and therefore it is not recommended for use in clinical practice. | We recommend against EUS-CPN for the treatment of chronic pancreatitis pain. | EUS-guided CPN for treatment of pain arising from chronic pancreatitis is not recommended. | |
| Efficacy | EUS-guided CPB induces moderate pain improvement compared to analgesic drugs only. | Without availability of direct comparison between techniques, EUS-CPN appears equal or more effective in controlling pain. | The EUS-guided approach is recommended over percutaneous image-guided techniques for celiac plexus ablation. |
| Technique | Antibiotic prophylaxis should be considered before EUS-guided CPB when steroids are used. | Prophylactic antibiotics are suggested to be given when bupivacaine with steroids is used for EUS-CPB. | |
| The injection technique (central vs. bilateral) has no significant influence on the efficacy and safety of EUS-guided CPN and CPB. | Bilateral EUS-CPN (with needle advancement caudally, beyond the level of the celiac axis) is superior, but technical feasibility and operator comfort justify central injection as an acceptable option. | Celiac broad plexus neurolysis may be associated with improved efficacy but routine use is not recommended. | |
| 10–20 mL of absolute ethanol is recommended for EUS-CPN and the volume may be reduced in EUS-CGN. | |||
| Phenol may be used instead of alcohol for EUS-guided CPN in patients with alcohol intolerance due to aldehyde dehydrogenase deficiency, but the comparative efficacy and safety of the two agents is uncertain. | |||
| In order to perform EUS-CGN, the celiac ganglia can be identified between the aorta and the left adrenal gland in most patients. Otherwise, they may be located cephalad to the origin of the celiac axis in others. | |||
| In patients with painful non-resectable pancreatic and upper gastrointestinal cancer, EUS-guided CPN should be considered early in the course of the disease. | When on-site cytopathology is available, patients with painful inoperable pancreas cancer should undergo EUS-CPN at time of diagnosis (early). | Early EUS-CPN at the time of EUS-guided fine needle aspiration (FNA) is recommended as it reduces pain and may moderate opioid consumption compared with best medical therapy. | |
| In patients with visible ganglia, EUS-guided CGN should be preferred to conventional EUS-guided CPN as it provides greater pain relief. | There is no clear evidence that CGN is more superior to bilateral or broad plexus EUS-CPN (with needle advancement caudal to the base of the celiac axis). Therefore, EUS-guided CGN is not necessary. | EUS-guided CGN is recommended over single or bilateral injections around the celiac artery for improved pain relief. | |
| When the ganglion cannot be identified, EUS-CPN is performed by single or bilateral injections but evidence is contradictory on which approach is superior. | |||
| Complications | The safety profile of EUS-guided CPN and CPB is favorable. However, due to some serious adverse events that have been reported with EUS-guided CPN, its use in patients with benign conditions should be considered with caution | Although the evidence for efficacy outweighs the risks, the small incidence of serious adverse events should be disclosed to the patient. | The complications of EUS-CPN and CGN are generally minor and do not need specific treatment. |
| Repeated injections for chronic pancreatitis should be avoided to prevent development of major complications. | |||
| Training | Training in EUS-guided celiac plexus ablation is recommended in endoscopists experienced in EUS and EUS-FNA. |
EUS, endoscopic ultrasonography; CPN, celiac plexus neurolysis; EFSUMB, European Federation of Societies for Ultrasound in Medicine and Biology; AEG, Asian EUS Group; CPN, celiac plexus neurolysis; CPB, celiac plexus block; CGN, celiac ganglia neurolysis.