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Musunuri B, Shetty S. Role of Endoscopic Ultrasound in the Management of Pancreatic Cancer. Indian J Surg Oncol 2024; 15:269-274. [PMID: 38818002 PMCID: PMC11133287 DOI: 10.1007/s13193-023-01859-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 11/29/2023] [Indexed: 06/01/2024] Open
Abstract
Pancreatic cancer is one of the common causes of cancer-associated mortality with a dismal overall prognosis which has remained virtually unchanged over decades. In the present era, the management of patients with pancreatic cancer involves a multi-disciplinary team of radiologists, gastroenterologists, surgical oncologists, medical oncologists, radiation oncologists and other specialists. The advancement of interventional endoscopy has made a significant impact in the management of pancreatic cancers. Since the inception of endoscopic ultrasound, it has evolved over the last few decades in the management of pancreatic malignancies and its role in staging and tissue acquisition is well established. There is an emerging role of endoscopic ultrasound in the treatment and palliation of unresectable pancreatic cancer. The aim of this article is to review the role of endoscopic ultrasound in diagnostic and therapeutic interventions in the current era.
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Affiliation(s)
- Balaji Musunuri
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka India
| | - Shiran Shetty
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka India
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2
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Xu R, Zhang K, Ge N, Sun S. EUS-guided interventional therapies for pancreatic diseases. Front Med (Lausanne) 2024; 10:1329676. [PMID: 38259846 PMCID: PMC10801084 DOI: 10.3389/fmed.2023.1329676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 12/26/2023] [Indexed: 01/24/2024] Open
Abstract
Endoscopic ultrasound (EUS) is an integrated diagnostic technique merging endoscope and ultrasound to examine the digestive system. EUS has emerged as a primary diagnostic method for pancreatic diseases due to its distinctive benefits. Over the past four decades, EUS has undergone a transformation, shifting its role from primarily diagnostic to increasingly therapeutic. Additionally, in recent years, EUS has emerged as an increasingly prominent adjunctive or alternative approach to conventional surgical interventions. This review provides a comprehensive analysis of current technological approaches in the treatment of pancreatic diseases. The dynamic interplay with diverse therapeutic approaches has reinvigorated EUS and shaped its trajectory in the management of pancreatic diseases.
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Affiliation(s)
| | | | | | - Siyu Sun
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
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3
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Tavangar A, Samarasena JB. Endoscopic Ultrasound-Guided Pain Management. Gastrointest Endosc Clin N Am 2024; 34:179-187. [PMID: 37973228 DOI: 10.1016/j.giec.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
The diagnosis and management of pancreatic cancer has become a standard role for the endoscopic oncologist. Pancreatic cancer can produce disabling abdominal pain, and the medical management of this pain is often challenging. Endoscopic ultrasound-guided celiac plexus neurolysis and celiac ganglia neurolysis serve as an alternative or adjunct for pain control in these patients. There remains a great deal of practice variability with regard to techniques and approaches. This article summarizes the latest scientific evidence and highlights contemporary best practice advice for these procedures.
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Affiliation(s)
- Amirali Tavangar
- Division of Gastroenterology and Hepatology, Digestive Health Institute, University of California Irvine, Orange, CA, USA
| | - Jason B Samarasena
- Division of Gastroenterology and Hepatology, Digestive Health Institute, University of California Irvine, Orange, CA, USA.
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4
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Han S, Papachristou GI. Therapeutic Endoscopic Ultrasound for Complications of Pancreatic Cancer. Cancers (Basel) 2023; 16:29. [PMID: 38201458 PMCID: PMC10778123 DOI: 10.3390/cancers16010029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 12/18/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Progression of pancreatic adenocarcinoma can result in disease complications such as biliary obstruction and gastric outlet obstruction. The recent advances in endoscopic ultrasound (EUS) have transformed EUS from a purely diagnostic technology to a therapeutic modality, particularly with the development of lumen-apposing metal stents. In terms of biliary drainage, EUS-guided choledochoduodenostomy and EUS-guided hepaticogastrostomy offer safe and effective techniques when conventional transpapillary stent placement via ERCP fails or is not possible. If these modalities are not feasible, EUS-guided gallbladder drainage offers yet another salvage technique when the cystic duct is non-involved by the cancer. Lastly, EUS-guided gastroenterostomy allows for an effective bypass treatment for cases of gastric outlet obstruction that enables patients to resume eating within several days. Future randomized studies comparing these techniques to current standard-of-care options are warranted to firmly establish therapeutic EUS procedures within the treatment algorithm for this challenging disease.
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Affiliation(s)
| | - Georgios I. Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA;
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5
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Del Chiaro M, Sugawara T, Karam SD, Messersmith WA. Advances in the management of pancreatic cancer. BMJ 2023; 383:e073995. [PMID: 38164628 DOI: 10.1136/bmj-2022-073995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Pancreatic cancer remains among the malignancies with the worst outcomes. Survival has been improving, but at a slower rate than other cancers. Multimodal treatment, including chemotherapy, surgical resection, and radiotherapy, has been under investigation for many years. Because of the anatomical characteristics of the pancreas, more emphasis on treatment selection has been placed on local extension into major vessels. Recently, the development of more effective treatment regimens has opened up new treatment strategies, but urgent research questions have also become apparent. This review outlines the current management of pancreatic cancer, and the recent advances in its treatment. The review discusses future treatment pathways aimed at integrating novel findings of translational and clinical research.
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Affiliation(s)
- Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- University of Colorado Cancer Center, University of Colorado School of Medicine, Aurora, CO, USA
| | - Toshitaka Sugawara
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Sana D Karam
- University of Colorado Cancer Center, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Wells A Messersmith
- University of Colorado Cancer Center, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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6
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Rizzo GEM, Carrozza L, Rancatore G, Binda C, Fabbri C, Anderloni A, Tarantino I. The Role of Endoscopy in the Palliation of Pancreatico-Biliary Cancers: Biliary Drainage, Management of Gastrointestinal Obstruction, and Role in Relief of Oncologic Pain. Cancers (Basel) 2023; 15:5367. [PMID: 38001627 PMCID: PMC10670525 DOI: 10.3390/cancers15225367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/20/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
Therapeutic endoscopy permits many and various treatments for cancer palliation in patients with bilio-pancreatic cancers, enabling different options, supporting patients during their route to oncologic treatments, and trying to improve their quality of life. Therefore, both endoscopic and endoscopic ultrasound (EUS)-guided techniques are performed in this scenario. We performed a literature review focusing on the role of endoscopy in the palliation of those advanced pancreatic and biliary cancers developing malignant biliary obstruction (MBO), gastric outlet obstruction (GOO), and pain unresponsive to medical therapies. Therefore, we explored and focused on the clinical outcomes of endoscopic procedures in this scenario. In fact, the endoscopic treatment is based on achieving biliary drainage in the case of MBO through endoscopic retrograde cholangiopancreatography (ERCP) or EUS-guided biliary drainage (EUS-BD), while GOO is endoscopically treated through the deployment of an enteral stent or the creation of EUS-guided gastro-entero-anastomosis (EUS-GEA). Furthermore, untreatable chronic abdominal pain is a major issue in patients unresponsive to high doses of painkillers, so EUS-guided celiac plexus neurolysis (CPN) or celiac ganglia neurolysis (CGN) helps to reduce dosage and have better pain control. Therefore, therapeutic endoscopy in the palliative setting is an effective and safe approach for managing most of the clinical manifestations of advanced biliopancreatic tumors.
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Affiliation(s)
- Giacomo Emanuele Maria Rizzo
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
- Ph.D. Program, Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, 90133 Palermo, Italy
| | - Lucio Carrozza
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
| | - Gabriele Rancatore
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, 48100 Forlì-Cesena, Italy; (C.B.); (C.F.)
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, 48100 Forlì-Cesena, Italy; (C.B.); (C.F.)
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy;
| | - Ilaria Tarantino
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
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7
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Koulouris A, Baio G, Clark A, Alexandre L. Opioid burden in patients with inoperable pancreatic adenocarcinoma and the development of a multivariable risk prediction model for opioid use: A retrospective cohort study. Pancreatology 2023; 23:818-828. [PMID: 37741797 DOI: 10.1016/j.pan.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/26/2023] [Accepted: 08/26/2023] [Indexed: 09/25/2023]
Abstract
INTRODUCTION Risk prediction models to guide patient selection for early pre-emptive endoscopic ultrasound guided coeliac plexus neurolysis are lacking. This study aimed to determine in patients with inoperable pancreatic cancer: (1) opioid burden, (2) the relationship between opioid use and all-cause mortality, (3) risk factors for opioid use, and (4) develop and internally validate a risk prediction model for opioid use at three months. METHODS This was a single-centre retrospective cohort study of patients with confirmed pancreatic cancer. Cox proportional hazard regression estimated the association between opioid use at baseline and all-cause mortality. Logistic regression estimated the associations between clinical and radiological variables with opioid use by three months. Two risk prediction models were developed for opioid use (clinical and clinical-radiological). Model discrimination and calibration was assessed. RESULTS In total, 383 patients with inoperable pancreatic cancer were included. Prevalence of pain ranged between 37% and 47% at three monthly intervals in the first year of diagnosis. Opioid use at baseline was associated with poorer survival. Age, pain at presentation, performance status, tumour distance from the right ganglion, the anterior-posterior and the latero-lateral tumour dimensions were independent risk factors for the opioid use at three months. The Area Under Curve (AUC) for the clinical and clinical-radiological models was 0.81 and 0.84, respectively. Models were well calibrated. CONCLUSIONS Opioid use is prevalent in patients with pancreatic cancer, associated with poor prognosis, and can be predicted based on clinical and radiological variables. External validation of this predictive model is required.
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Affiliation(s)
- Andreas Koulouris
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, NR4 7TJ, United Kingdom; Norfolk and Norwich University Hospital, Norwich, Colney Lane, NR4 7UY, United Kingdom.
| | - Gabriella Baio
- Norfolk and Norwich University Hospital, Norwich, Colney Lane, NR4 7UY, United Kingdom
| | - Allan Clark
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, NR4 7TJ, United Kingdom
| | - Leo Alexandre
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, NR4 7TJ, United Kingdom; Norfolk and Norwich University Hospital, Norwich, Colney Lane, NR4 7UY, United Kingdom
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8
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Okita M, Otani K, Matsui S. Efficacy of Endoscopic Ultrasound-guided Celiac Plexus Neurolysis for Abdominal Pain in Patients With Unresectable Pancreatic Cancer: Network Meta-analysis of Randomized Controlled Trials. J Clin Gastroenterol 2023; 57:1054-1062. [PMID: 36227001 DOI: 10.1097/mcg.0000000000001773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 05/10/2022] [Indexed: 12/10/2022]
Abstract
GOALS We conducted a systematic review and network meta-analysis to investigate the effect of endoscopic ultrasound-guided celiac plexus neurolysis added to medical management (EUS-CPN+MM) compared with MM, percutaneous CPN (P-CPN)+MM, or intraoperative CPN (I-CPN)+MM for abdominal pain associated with unresectable pancreatic cancer. BACKGROUND Many approaches to CPN have been proposed since 1919. EUS-CPN, which is less invasive and safer than traditional procedures, has been preferred recently, but the superiority of EUS-CPN+MM has not been fully investigated. STUDY We performed searches of PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) on March 16, 2021. We conducted the network meta-analysis using a frequentist weighted least-squares approach. We used a random-effects model to synthesize the primary outcome, defined as the mean difference between treatment groups in standardized pain intensity scores at 4 and 12 weeks. RESULTS We selected 10 RCTs involving 662 individuals. At 4 weeks, the estimated mean difference between the EUS-CPN+MM and MM groups was -1.30 (95% CI: -2.19 to -0.41) in favor of EUS-CPN+MM, and that between the EUS-CPN+MM and P-CPN+MM groups was -0.88 (95% CI: -1.82 to 0.06). At 12 weeks, the estimated mean difference between the EUS-CPN+MM and MM groups was -2.58 (95% CI: -3.68 to -1.48), and that between the EUS-CPN+MM and P-CPN+MM groups was -2.44 (95% CI: -4.03 to -0.84), both in favor of EUS-CPN+MM. CONCLUSIONS The combination of EUS-CPN+MM was effective at 4 and 12 weeks, although the risk of bias in synthesized studies was generally high, necessitating careful interpretation.
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Affiliation(s)
- Muneyori Okita
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Japan
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9
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Pacheco-Feijoó GM, Amado-Tineo JP, Plancarte-Sánchez R, Valdivia CC, López-Millán JM. Efficacy and Safety of Celiac Plexus Neurolysis in the Treatment of Chronic Pain Secondary to Oncological Pathology of the Upper Hemiabdomen: A Systematic Review and Meta-Analysis. Indian J Palliat Care 2023; 29:394-406. [PMID: 38058484 PMCID: PMC10696325 DOI: 10.25259/ijpc_203_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 08/29/2023] [Indexed: 12/08/2023] Open
Abstract
Objectives The management of chronic pain among patients with abdominal cancer is complex; against that, the neurolysis of the celiac plexus (CPN) is the best technique at the moment to determine the efficacy and safety in the treatment of chronic pain secondary to oncological pathology of the upper abdomen. Material and Methods This was a systematic review of controlled clinical trials between 2000 and 2021, in the sources MEDLINE/PubMed, Cochrane, Scopus, Web of Science, and Google Scholar. Three independent evaluators analysed the results of the bibliographical research. The quality of the studies was assessed with the Jadad scale and the mean difference (95% confidence interval) and heterogeneity of the studies (I2) were calculated with Review Manager 5.3. Results Seven hundred and forty-four publications were identified, including 13 studies in the qualitative synthesis and three studies in the quantitative synthesis. No difference was found in the decrease in pain intensity between 1 and 12 weeks after the intervention, comparing the experimental group with the control (P > 0.05). The adverse effects related to neurolysis were not serious and transitory, mentioning the most frequent adverse effects and reporting a percentage between 21% and 67% (with 17% for echoendoscopic neurolysis and 49% for percutaneous neurolysis). Conclusion Celiac plexus neurolysis for the treatment of severe chronic pain secondary to oncological pathology in the upper hemiabdomen produces similar pain relief as conventional pharmacological analgesic treatment. It is a safe analgesic technique since the complications are mild and transitory.
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Affiliation(s)
| | - Jose Percy Amado-Tineo
- Department of Medicine, School of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | | | | | - José M. López-Millán
- Department of Anesthesiology-Critical Care and Pain Medicine, Virgen Macarena University Hospital, Seville, Spain
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10
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On W, Ahmed W, Everett S, Huggett M, Paranandi B. Utility of interventional endoscopic ultrasound in pancreatic cancer. Front Oncol 2023; 13:1252824. [PMID: 37781196 PMCID: PMC10540845 DOI: 10.3389/fonc.2023.1252824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/30/2023] [Indexed: 10/03/2023] Open
Abstract
Endoscopic ultrasound (EUS) has an important role in the management algorithm of patients with pancreatic ductal adenocarcinoma (PDAC), typically for its diagnostic utilities. The past two decades have seen a rapid expansion of the therapeutic capabilities of EUS. Interventional EUS is now one of the more exciting developments within the field of endoscopy. The local effects of PDAC tend to be in anatomical areas which are difficult to target and endoscopy has cemented itself as a key role in managing the clinical sequelae of PDAC. Interventional EUS is increasingly utilized in situations whereby conventional endoscopy is either impossible to perform or unsuccessful. It also adds a different dimension to the host of oncological and surgical treatments for patients with PDAC. In this review, we aim to summarize the various ways in which interventional EUS could benefit patients with PDAC and aim to provide a balanced commentary on the current evidence of interventional EUS in the literature.
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Affiliation(s)
- Wei On
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
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11
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Basiliya K, Pang P, Honing J, di Pietro M, Varghese S, Gbegli E, Corbett G, Carroll NR, Godfrey EM. What can the Interventional Endoscopist Offer in the Management of Upper Gastrointestinal Malignancies? Clin Oncol (R Coll Radiol) 2023:S0936-6555(23)00183-8. [PMID: 37253647 DOI: 10.1016/j.clon.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/10/2023] [Accepted: 05/10/2023] [Indexed: 06/01/2023]
Abstract
The therapeutic possibilities of endoscopy have rapidly increased in the last decades and now allow organ-sparing treatment of early upper gastrointestinal malignancy as well as an increasing number of options for symptom palliation. This review contains an overview of the interventional endoscopic procedures in upper gastrointestinal malignancies. It describes endoscopic treatment of early oesophageal and gastric cancers, and the palliative options in managing dysphagia and gastric outlet obstruction. It also provides an overview of the therapeutic possibilities of biliary endoscopy, such as retrograde stenting and radiofrequency biliary ablation. Endoscopic ultrasound-guided therapeutic options are discussed, including biliary drainage, gastrojejunostomy and coeliac axis block. To aid in clinical decision making, the procedures are described in the context of their indication, efficacy, risks and limitations.
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Affiliation(s)
- K Basiliya
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK.
| | - P Pang
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - J Honing
- Early Cancer Institute, University of Cambridge, Cambridge, UK
| | - M di Pietro
- Early Cancer Institute, University of Cambridge, Cambridge, UK
| | - S Varghese
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - E Gbegli
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - G Corbett
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - N R Carroll
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - E M Godfrey
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
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12
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Wadhwa V, Patel N, Grover D, Ali FS, Thosani N. Interventional gastroenterology in oncology. CA Cancer J Clin 2022; 73:286-319. [PMID: 36495087 DOI: 10.3322/caac.21766] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 10/12/2022] [Accepted: 10/17/2022] [Indexed: 12/14/2022] Open
Abstract
Cancer is one of the foremost health problems worldwide and is among the leading causes of death in the United States. Gastrointestinal tract cancers account for almost one third of the cancer-related mortality globally, making it one of the deadliest groups of cancers. Early diagnosis and prompt management are key to preventing cancer-related morbidity and mortality. With advancements in technology and endoscopic techniques, endoscopy has become the core in diagnosis and management of gastrointestinal tract cancers. In this extensive review, the authors discuss the role endoscopy plays in early detection, diagnosis, and management of esophageal, gastric, colorectal, pancreatic, ampullary, biliary tract, and small intestinal cancers.
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Affiliation(s)
- Vaibhav Wadhwa
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology Hepatology and Nutrition, University of Texas Health Science Center, McGovern Medical School, Houston, Texas, USA
| | - Nicole Patel
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology Hepatology and Nutrition, University of Texas Health Science Center, McGovern Medical School, Houston, Texas, USA
| | - Dheera Grover
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology Hepatology and Nutrition, University of Texas Health Science Center, McGovern Medical School, Houston, Texas, USA
| | - Faisal S Ali
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology Hepatology and Nutrition, University of Texas Health Science Center, McGovern Medical School, Houston, Texas, USA
| | - Nirav Thosani
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology Hepatology and Nutrition, University of Texas Health Science Center, McGovern Medical School, Houston, Texas, USA
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13
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Arcidiacono PG, Santo E. Introduction. Best Pract Res Clin Gastroenterol 2022; 60-61:101813. [PMID: 36577538 DOI: 10.1016/j.bpg.2022.101813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 11/21/2022] [Indexed: 12/30/2022]
Abstract
Endoscopic ultrasound (EUS) was born from the combination of a high-frequency ultrasound probe with an endoscope to assess in detail the walls of the upper and lower gastrointestinal tract and surrounding organs and structures. The subsequent possibility of EUS-guided tissue acquisition has rapidly established the irreplaceable role of EUS in the management of a wide range of benign and malignant gastrointestinal diseases. The actual diagnostic armamentarium involving fine-Doppler, elastography, and contrast enhancement has significantly improved its diagnostic yield, which could be even more refined by newer ways of interrogating data and images, such as artificial intelligence. Technological development (e.g., new echendoscopes, larger operative channels, special-design needles, lumen apposing metal stents, and dedicated biliary stents) and the clinical need for new, more effective, and less-invasive procedures has rapidly evolved EUS from a purely diagnostic tool to a therapeutic modality, that is making increasingly outdated some surgical or radiological procedures that have hitherto been considered standard of care.
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Affiliation(s)
- Paolo Giorgio Arcidiacono
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.
| | - Erwin Santo
- Invasive Endoscopy Unit, The Gastroenterology Institute, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
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14
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Wyse JM, Sahai AV. EUS-guided celiac plexus neurolysis for pancreas cancer - Finally established or still under review? Best Pract Res Clin Gastroenterol 2022; 60-61:101809. [PMID: 36577532 DOI: 10.1016/j.bpg.2022.101809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 11/10/2022] [Indexed: 11/23/2022]
Abstract
Patients with pancreas cancer must deal frequently with intractable and refractory pain. Endoscopic ultrasound guided-celiac plexus neurolysis (EUS-CPN) has been the most studied and used therapeutic technique aimed to destroy the pain fibres that allow the pancreas to communicate with the central nervous system. A neurolytic agent, most commonly ethanol, is optimally spread around the celiac axis in order to reduce pain and mitigate narcotic requirements. This can be performed early to prevent the spiral of pain and medication use, or more historically as salvage therapy. Different techniques to best administer the ethanol for effective EUS-CPN are still being debated. New EUS-guided injection techniques with radiofrequency, radioactive, and/or chemotherapeutic agents need more study.
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Affiliation(s)
- Jonathan M Wyse
- Division of Gastroenterology, Jewish General Hospital, McGill University, Montreal, Canada.
| | - Anand V Sahai
- Division of Gastroenterology, Center Hospitalier de l'Université de Montréal, Montreal, Canada
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15
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Matsumoto T, Yoshimatsu R, Osaki M, Miyatake K, Yamanishi T, Yamagami T. Computed tomography-guided single celiac plexus neurolysis analgesic efficacy and safety: a systematic review and meta-analysis. ABDOMINAL RADIOLOGY (NEW YORK) 2022; 47:3892-3906. [PMID: 36087117 DOI: 10.1007/s00261-022-03670-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 08/26/2022] [Accepted: 08/27/2022] [Indexed: 01/18/2023]
Abstract
PURPOSE To perform a systematic review and meta-analysis of published studies to evaluate the analgesic efficacy and safety of computed tomography (CT)-guided single celiac plexus neurolysis (CPN) with the injection of a neurolytic agent into the celiac plexus in one session (CT-guided single CPN). METHODS PubMed, the Cochrane Library, and Ichushi-Web were searched for English or Japanese articles published up to February 2022, which reported findings about patients who underwent CT-guided single CPN. The outcome measures assessed in the systematic review and meta-analysis were the pain measurement scales from 0 to 10 before and after the intervention and the rate of minor and major complications. RESULTS The pooled pain measurement scales at pre-intervention and 1- or 2-, 7-, 30-, 60-, 90-, and 180-day post-intervention was 6.72 (95% confidence interval [CI], 4.77-9.46, I2 = 98%), 2.31 (95% CI 2.31-4.44, I2 = 92%), 2.84 (95% CI 1.39-5.79, I2 = 95%), 3.36 (95% CI 1.66-6.77, I2 = 98%), 3.19 (95% CI 1.44-7.08, I2 = 59%), 3.87 (95% CI 1.88-7.97, I2 = 0%), and 3.40 (95% CI 3.02-3.83, I2 = not applicable), respectively. The pooled minor complication rates of diarrhea, hypotension, nausea or vomiting, and pain associated with the procedure were 18% (95% CI 8-37%, I2 = 45%), 16% (95% CI 2-58%, I2 = 76%), 6% (95% CI 2-16%, I2 = 1%), and 7% (95% CI 2-21%, I2 = 17%), respectively. There was no major complication in the included studies. CONCLUSION CT-guided single CPN can be performed safely and provides immediate analgesic efficacy although the amount of heterogeneity is characterized as large. Further investigation of its long-term analgesic efficacy is required.
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Affiliation(s)
- Tomohiro Matsumoto
- Department of Diagnostic and Interventional Radiology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan.
| | - Rika Yoshimatsu
- Department of Diagnostic and Interventional Radiology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Marina Osaki
- Department of Diagnostic and Interventional Radiology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Kana Miyatake
- Department of Diagnostic and Interventional Radiology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Tomoaki Yamanishi
- Department of Diagnostic and Interventional Radiology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Takuji Yamagami
- Department of Diagnostic and Interventional Radiology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
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16
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Okita M, Otani K, Gibo N, Matsui S. Systematic review and meta-analysis of celiac plexus neurolysis for abdominal pain associated with unresectable pancreatic cancer. Pain Pract 2022; 22:652-661. [PMID: 35748531 DOI: 10.1111/papr.13143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 04/08/2022] [Accepted: 05/09/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Celiac plexus neurolysis (CPN) has been developed as adjunctive therapy to medical management (MM) of abdominal pain associated with unresectable pancreatic cancer. We aimed to conduct a systematic review and meta-analysis to obtain updated and more accurate evidence on the efficacy of additional types of CPN, including endoscopic ultrasound-guided CPN (EUS-CPN). METHODS On March 16, 2021, we performed searches of PubMed, Web of Science, and CENTRAL for original randomized controlled trials (RCTs). We defined the primary outcome as a standardized pain intensity score with a range of 0-10, and evaluated the mean difference between the CPN + MM and MM groups at 4, 8, and 12 weeks after the initiation of treatment. We used a random-effects model to synthesize the mean differences across RCTs. RESULTS We selected 10 RCTs involving 646 individuals. The synthesized mean difference in the pain intensity score between the CPN + MM and MM groups was -0.58 (95% confidence interval [CI]: -1.09 to -0.07) (p = 0.034) in favor of CPN + MM at 4 weeks, -0.46 (95%CI: -1.00 to 0.08) (p = 0.081) at 8 weeks, and - 1.35 (95%CI: -3.61 to 0.92) (p = 0.17) at 12 weeks. CONCLUSIONS This updated meta-analysis of CPN demonstrates its efficacy for managing abdominal pain at 4 weeks. Although there are various limitations, when abdominal pain in patients with unresectable pancreatic cancer is poorly controlled with MM alone, CPN should be an option even if the duration of effect is short-lived, taking into account the absence of serious adverse events.
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Affiliation(s)
- Muneyori Okita
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuki Otani
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Noriaki Gibo
- Department of Gastroenterology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shigeyuki Matsui
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
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17
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Nakano R, Shiomi H, Ota S, Iijima H. Endoscopic ultrasound-guided celiac plexus neurolysis for managing abdominal pain related with advanced cancer. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2022. [DOI: 10.18528/ijgii220026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Ryota Nakano
- Division of Gastroenterology and Hepato-Biliary-Pancreatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Japan
| | - Hideyuki Shiomi
- Division of Gastroenterology and Hepato-Biliary-Pancreatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Japan
| | - Shogo Ota
- Division of Gastroenterology and Hepato-Biliary-Pancreatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Japan
| | - Hiroko Iijima
- Division of Gastroenterology and Hepato-Biliary-Pancreatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Japan
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18
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Yau CC, Leeds J. Managing inoperable pancreatic cancer: the role of the pancreaticobiliary physician. Frontline Gastroenterol 2022; 13:e88-e93. [PMID: 35812020 PMCID: PMC9234734 DOI: 10.1136/flgastro-2022-102124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/21/2022] [Indexed: 02/04/2023] Open
Abstract
Despite our understanding of pancreatic cancer (PC), the majority of patients with this disease are incurable. Both the incidence and mortality rates for PC have increased over the last decade. At diagnosis, the majority of patients have locally advanced PC, less than 20% of patients are eligible for potentially curative resection and approximately one-third have metastatic disease. The combination of frequent advanced presentation, low resection rates and poor responses to chemotherapy make PC one of the most lethal tumours. The treatment goals are to maintain local control, manage tumour-related morbidities and improve quality of life. Patients with inoperable PC are likely to experience significant symptoms associated with their tumour, including pancreatic insufficiency, nutritional deficiencies, pain, biliary obstruction, gastric outlet obstruction and diabetes. As a result, guidance on the management of patients with inoperable PC is critical. PC is commonly referred centrally to specialist centres particularly for surgery; however, the majority do not undergo surgical intervention and thus the importance of pancreaticobiliary physicians and endoscopists. This review will focus on the non-operative management of patients with unresectable pancreatic adenocarcinoma and review some of the issues that centralisation has contributed to.
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Affiliation(s)
- Chia Chuin Yau
- Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - John Leeds
- Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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19
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Abstract
Pancreatobiliary malignancies have poor prognosis, and many patients are inoperable at the time of diagnosis. When surgical resection is impossible, systemic chemotherapy or radiotherapy is traditionally conducted with trial of immunotherapy or gene therapy lately. With the rapid development of endoscopic instruments and accessories in recent years, not only endoscopic early detection, characterization, and staging but also endoscopic palliative management of the pancreatobiliary malignancies is expanding the horizons. Endoscopic management is often preferred due to similar efficacy to surgical management with less morbidity. Here, we review the methodology and treatment outcome of various endoscopic management strategies in pancreatobiliary malignancies including endoscopic complication management, local palliative therapy, endoscopy-assisted therapy, and pain control utilizing endoscopic retrograde cholangiopancreatography or endoscopic ultrasound.
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20
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Kerdsirichairat T, Shin EJ. Endoscopic ultrasound guided interventions in the management of pancreatic cancer. World J Gastrointest Endosc 2022; 14:191-204. [PMID: 35634485 PMCID: PMC9048490 DOI: 10.4253/wjge.v14.i4.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/09/2021] [Accepted: 03/27/2022] [Indexed: 02/06/2023] Open
Abstract
There has been a growing interest in developing endoscopic ultrasound (EUS)-guided interventions for pancreatic cancer, some of which have become standard of care. There are two main factors that drive these advancements to facilitate treatment of patients with pancreatic cancer, ranging from direct locoregional therapy to palliation of symptoms related to inoperable pancreatic cancer. Firstly, an upper EUS has the capability to access the entire pancreas–lesions in the pancreatic head and uncinate process can be accessed from the duodenum, and lesions in the pancreatic body and tail can be accessed from the stomach. Secondly, there has been a robust development of devices that allow through-the-needle interventions, such as placement of fiducial markers, brachytherapy, intratumoral injection, gastroenterostomy creation, and ablation. While these techniques are rapidly emerging, data from a multicenter randomized controlled trial for some procedures are awaited prior to their adoption in clinical settings.
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Affiliation(s)
| | - Eun Ji Shin
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD 21287, United States
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21
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Ye L, Schorn S, Pergolini I, Safak O, Demir E, Istvanffy R, Friess H, Ceyhan GO, Demir IE. The Effect of Celiac Neurolysis and Splanchnicectomy on Survival in Unresectable Pancreatic Cancer: A Systematic Review and Meta-Analysis. Dig Surg 2021; 39:51-59. [PMID: 34903684 DOI: 10.1159/000520456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/14/2021] [Indexed: 12/10/2022]
Abstract
BACKGROUND Intractable pancreatic pain is one of the most common symptoms of patients with pancreatic ductal adenocarcinoma (PDAC). Celiac neurolysis (CN) and splanchnicectomy were already described as effective methods to manage abdominal pain in unresectable PDAC, but their impact on overall survival (OS) has not yet been established. OBJECTIVE We aimed to investigate the impact of CN and splanchnicectomy on the survival of patients with unresectable pancreatic cancer. METHODS A systematic review of PubMed and Cochrane Library according to predefined searching terms was conducted in March 2020. Hazard ratios (HR) of OS data were calculated using the Mantel-Haenszel model for random effects or fixed effects. RESULT Four randomized-controlled trials (RCTs) and 2 non-RCTs with a total of 2,507 patients were identified. The overall pooled HR did not reveal any relevant effect of CN and splanchnicectomy on OS (HR: 1.03; 95% CI: 0.81-1.32), which was also underlined by the sensitivity analysis of RCTs (HR: 1.0; 95% CI: 0.72-1.39) and non-RCTs (HR: 1.07; 95% CI: 0.71-1.63). However, subgroup analyses depending on tumor stage revealed that CN or splanchnicectomy was associated with a worsened OS in AJCC (American Joint Committee on Cancer) stage III patients with unresectable PDAC (HR: 1.22; 95% CI: 1.03-1.45), but nor for AJCC stage IV patients (HR: 1.27; 95% CI: 0.9-1.80). CONCLUSION Although only few data are currently available, this systematic review with meta-analysis showed that in unresectable PDAC, CN or splanchnicectomy is associated with a worsened survival in stage III PDAC patients, with no effect on stage IV PDAC patients. These data call for caution in the usage of CN or splanchnicectomy in stage III PDAC and for further studies addressing this observation.
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Affiliation(s)
- Linhan Ye
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany,
| | - Stephan Schorn
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Ilaria Pergolini
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Okan Safak
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Elke Demir
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Rouzanna Istvanffy
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site, Munich, Germany.,CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
| | - Helmut Friess
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site, Munich, Germany.,CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
| | - Güralp O Ceyhan
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Ihsan Ekin Demir
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site, Munich, Germany.,CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany.,Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey.,Else Kröner Clinician Scientist Professor for "Translational Pancreatic Surgery", Munich, Germany
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22
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Pérez-Aguado G, de la Mata DMA, Valenciano CML, Sainz IFU. Endoscopic ultrasonography-guided celiac plexus neurolysis in patients with unresectable pancreatic cancer: An update. World J Gastrointest Endosc 2021; 13:460-472. [PMID: 34733407 PMCID: PMC8546561 DOI: 10.4253/wjge.v13.i10.460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/27/2021] [Accepted: 09/08/2021] [Indexed: 02/06/2023] Open
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.
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Affiliation(s)
- Guillermo Pérez-Aguado
- Department of Gastroenterology, Complejo Hospitalario Insular Materno Infantil de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas 35016, Spain
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23
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Uc A, Andersen DK, Apkarian AV, Bellin MD, Colloca L, Drewes AM, Dunbar EK, Forsmark CE, Goodman MT, Kapural L, Koob GF, Palermo TM, Pandol SJ, Pasricha P, Phillips AE, Piomelli D, Saloman JL, Schwarzenberg SJ, Singh VK, Sowa G, Strouse T, Treisman GJ, Windsor JA, Yadav D. Pancreatic Pain-Knowledge Gaps and Research Opportunities in Children and Adults: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop. Pancreas 2021; 50:906-915. [PMID: 34643606 PMCID: PMC10273134 DOI: 10.1097/mpa.0000000000001899] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ABSTRACT A workshop was sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases to focus on research gaps and opportunities in pancreatic pain. The event was held on July 21, 2021, and structured into 4 sessions: (1) pathophysiology; (2) biomarkers, mediators, and pharmacology of pain; (3) pain assessment; and (4) pain treatment challenges and opportunities. The current state of knowledge was reviewed; many knowledge gaps and research needs were identified that require further investigation. Common themes included the need to better understand the underlying mechanisms of pain in pancreatic diseases, the relationship of visceral neural pathways and central pain centers, the role of behavioral factors and disorders on the perception of pain, and differences in pain perception and processes in children when compared with adults. In addition, the role of genetic risk factors for pain and the mechanisms and role of placebos in pain treatment were discussed. Methods of pain assessment including quantitative sensory testing were examined, as well as the process of central sensitization of pain. Finally, newer approaches to pain management including cognitive behavioral therapy, nerve stimulation, experimental (nonopioid) drugs, and cannabinoid compounds were covered.
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Affiliation(s)
- Aliye Uc
- From the Division of Gastroenterology, Hepatology, Pancreatology and Nutrition, Stead Family Department of Pediatrics, The University of Iowa, Iowa City, IA
| | - Dana K Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - A Vania Apkarian
- Departments of Physiology, Anesthesiology, Physical Medicine and Rehabilitation, and Center for Translational Pain Research, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Melena D Bellin
- Departments of Pediatrics and Surgery, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | | | - Asbjørn M Drewes
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Christopher E Forsmark
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Florida, Gainesville, FL
| | - Marc T Goodman
- Cancer Prevention and Control Program, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - George F Koob
- National Institute on Alcohol Abuse and Alcoholism and Intramural Research Program, National Institute on Drug, National Institutes of Health, Bethesda, MD
| | | | - Stephen J Pandol
- Division of Gastroenterology, Department of Medicine, Cedars Sinai Medical Center, Los Angeles, CA
| | - Pankaj Pasricha
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anna E Phillips
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine
| | - Daniele Piomelli
- Departments of Anatomy and Neurobiology, Biological Chemistry, and Pharmacology, University of California, Irvine School of Medicine, Irvine, CA
| | - Jami L Saloman
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine
| | - Sarah Jane Schwarzenberg
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gwendolyn Sowa
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Thomas Strouse
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Glenn J Treisman
- Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine
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24
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Abstract
Pain is the main symptom of pancreatic cancer (pancreatic ductal adenocarcinoma, PDAC). Pain in pancreatic cancer may be visceral, somatic or neuropathic in origin. Pain is produced by tissue damage, inflammation, ductal obstruction and infiltration. Visceral nociceptive signals caused by damage to the upper abdominal viscera are carried along sympathetic fibers, which travel to the celiac plexus nerves and ganglia, which are found at the T12-L2 vertebral levels, anterolateral to the aorta near the celiac trunk. From here, the signals are transmitted through the splanchnic nerves to the T5-T12 dorsal root ganglia and then on to the higher centers of the central nervous system. Somatic and neuropathic pain may arise from tumor extension into the surrounding peritoneum, retroperitoneum and bones and, in the latter case, into the nerves, such as the lumbosacral plexus. It should also be noted that other types of pain might arise because of therapeutic interventions, such as post-chemoradiation syndromes, which cause mucositis and enteritis. Management with non-steroidal anti-inflammatory agents and narcotics was the mainstay of therapy. In recent years, celiac plexus blocks and neurolysis, as well as intrathecal therapies have been used to control severe pain, at times resulting in a decreased need for drugs, avoiding their unwanted side effects. Pain may impair the patient’s quality of life, negatively affecting patient outcome and resulting in increased psychological stress. Even after recognizing the negative effect of cancer pain on patient overall health, studies have shown that cancer pain is still undertreated. This review focuses on neuropathic pain, which is difficult to handle; thus, the most recent literature was reviewed in order to diagnose neuropathic pain and its management.
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25
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Asif AA, Walayat SK, Bechtold ML, Revanur V, Puli SR. EUS-guided celiac plexus neurolysis for pain in pancreatic cancer patients - a meta-analysis and systematic review. J Community Hosp Intern Med Perspect 2021; 11:536-542. [PMID: 34211665 PMCID: PMC8221153 DOI: 10.1080/20009666.2021.1929049] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Endoscopic ultrasound guided celiac plexus neurolysis (EUS- CPN) has been reported to be an effective way to help with pain in pancreatic cancer patient. The aim of our updated meta-analysis is to assess the efficacy of pain relief in patients with pancreatic cancer who underwent EUS guided neurolysis. Methods: Pooled proportions were calculated using both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity among studies was tested using Cochran’s Q test based upon inverse variance weights. Results: Initial search identified 176 reference articles, of which 34 were selected and reviewed in detail. Sixteen studies that met the inclusion criteria were included in this analysis. The mean age of patients undergoing neurolysis was 56.31 ± 19.72 years. Number of males, N = 563 (57.4%), was higher than the number of females, N = 417 (42.5%). The pooled proportion of patients who showed pain relief with EUS-guided neurolysis was 71% (95% CI = 68–74). Bias calculated using Begg–Mazumdar was not significant (p = 0.8). In a subgroup analysis, when comparing the central and bilateral techniques, the pooled proportion of patients with pain relief was 66% (95% CI = 61–71) and 57% (95% CI = 48–67), respectively. Conclusions: Our results show that EUS guided CPN could provide relief in as much as 70% of patients with central neurolysis technique having some edge over peripheral neurolysis. Further larger scale randomized controlled trials may further help to elaborate the efficacy of central vs peripheral neurolysis.
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Affiliation(s)
- Abuzar A Asif
- Department of Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Saqib K Walayat
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Matthew L Bechtold
- Division of Gastroenterology and Hepatology, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Vakya Revanur
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Srinivas R Puli
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
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