Digestive Diseases and Sciences

, Volume 54, Issue 11, pp 2330–2337

EUS-Guided Celiac Plexus Neurolysis for Pain due to Chronic Pancreatitis or Pancreatic Cancer Pain: A Meta-Analysis and Systematic Review

  • Srinivas R. Puli
  • Jyotsna B. K. Reddy
  • Matthew L. Bechtold
  • Mainor R. Antillon
  • William R. Brugge
Review

Abstract

The objective of this study was to evaluate the efficacy of EUS-guided CPN for pain relief in patients with chronic pancreatitis and pancreatic cancer. An initial search identified 1,439 reference articles, of which 130 relevant articles were selected and reviewed. Data was extracted from 8 studies (N = 283) for EUS-guided CPN for pain due to pancreatic cancer and nine studies for chronic pancreatitis (N = 376) which met the inclusion criteria. With EUS-guided CPN, the pooled proportion of patients with pancreatic cancer that showed pain relief was 80.12% (95% CI = 74.47–85.22). In patients with pain due to chronic pancreatitis, EUS-guided CPN provided pain relief in 59.45% (95% CI = 54.51–64.30). In conclusion, EUS-guided CPN offers a safe alternative technique for pain relief in patients with chronic pancreatitis or pancreatic cancer. In patients with pain due to chronic pancreatitis, better techniques or injected materials are needed to improve the response.

Keywords

Endoscopic ultrasound Celiac plexus neurolysis Pancreatic cancer Chronic pancreatitis Meta-analysis Systematic review 

Abbreviations

CP

Chronic pancreatitis

CPN

Celiac plexus neurolysis

EUS

Endoscopic ultrasound

References

  1. 1.
    Ammann RW, Muellhaupt B. The natural history of pain in alcoholic chronic pancreatitis. Gastroenterology. 1999;116(5):1132–1140. doi:10.1016/S0016-5085(99)70016-8.CrossRefPubMedGoogle Scholar
  2. 2.
    Bornman PC, Marks IN, Girdwood AW, Berberat PO, Gulbinas A, Büchler MW. Pathogenesis of pain in chronic pancreatitis: ongoing enigma. World J Surg. 2003;27(11):1175–1182. doi:10.1007/s00268-003-7235-x.CrossRefPubMedGoogle Scholar
  3. 3.
    Ebbehøj N, Svendsen LB, Madsen P. Pancreatic tissue pressure: techniques and pathophysiological aspects. Scand J Gastroenterol. 1984;19(8):1066–1068.PubMedGoogle Scholar
  4. 4.
    Ebbehøj N, Borly L, Bülow J, Henriksen JH, Heyeraas KJ, Rasmussen SG. Evaluation of pancreatic tissue fluid pressure measurements intraoperatively and by sonographically guided fine-needle puncture. Scand J Gastroenterol. 1990;25(11):1097–1102. doi:10.3109/00365529008998540.CrossRefPubMedGoogle Scholar
  5. 5.
    Keith RG, Keshavjee SH, Kerenyi NR. Neuropathology of chronic pancreatitis in humans. Can J Surg. 1985;28(3):207–211.PubMedGoogle Scholar
  6. 6.
    Bockman DE, Buchler M, Malfertheiner P, Beger HG. Analysis of nerves in chronic pancreatitis. Gastroenterology. 1988;94(6):1459–1469.PubMedGoogle Scholar
  7. 7.
    Pace MC, Mazzariello L, Passavanti MB, Sansone P, Barbarisi M, Aurilio C. Neurobiology of pain. J Cell Physiol. 2006;209(1):8–12. doi:10.1002/jcp.20693.CrossRefPubMedGoogle Scholar
  8. 8.
    Warshaw AL, Banks PA, Fernández-Del Castillo C. AGA technical review: treatment of pain in chronic pancreatitis. Gastroenterology. 1998;115(3):765–776. doi:10.1016/S0016-5085(98)70157-X.CrossRefPubMedGoogle Scholar
  9. 9.
    Andrén-Sandberg A, Hoem D, Gislason H. Pain management in chronic pancreatitis. Eur J Gastroenterol Hepatol. 2002;14(9):957–970. doi:10.1097/00042737-200209000-00006.CrossRefPubMedGoogle Scholar
  10. 10.
    Wilder-Smith CH, Hill L, Osler W, O’Keefe S. Effect of tramadol and morphine on pain and gastrointestinal motor function in patients with chronic pancreatitis. Dig Dis Sci. 1999;44(6):1107–1116. doi:10.1023/A:1026607703352.CrossRefPubMedGoogle Scholar
  11. 11.
    Halgreen H, Pedersen NT, Worning H. Symptomatic effect of pancreatic enzyme therapy in patients with chronic pancreatitis. Scand J Gastroenterol. 1986;21(1):104–108. doi:10.3109/00365528609034631.CrossRefPubMedGoogle Scholar
  12. 12.
    Malesci A, Gaia E, Fioretta A, et al. No effect of long-term treatment with pancreatic extract on recurrent abdominal pain in patients with chronic pancreatitis. Scand J Gastroenterol. 1995;30(4):392–398. doi:10.3109/00365529509093296.CrossRefPubMedGoogle Scholar
  13. 13.
    Uden S, Bilton D, Nathan L, Hunt LP, Main C, Braganza JM. Antioxidant therapy for recurrent pancreatitis: placebo-controlled trial. Aliment Pharmacol Ther. 1990;4(4):357–371.PubMedCrossRefGoogle Scholar
  14. 14.
    Rösch T, Daniel S, Scholz M, et al. European Society of Gastrointestinal Endoscopy Research Group. Endoscopic treatment of chronic pancreatitis: a multicenter study of 1000 patients with long-term follow-up. Endoscopy. 2002;34(10):765–771. doi:10.1055/s-2002-34256.CrossRefPubMedGoogle Scholar
  15. 15.
    Wilcox CM, Varadarajulu S. Endoscopic therapy for chronic pancreatitis: an evidence-based review. Curr Gastroenterol Rep. 2006;8(2):104–110. doi:10.1007/s11894-006-0005-9.CrossRefPubMedGoogle Scholar
  16. 16.
    Tham TC, Lichtenstein DR, Vandervoort J, et al. Pancreatic duct stents for “obstructive type” pain in pancreatic malignancy. Am J Gastroenterol. 2000;95(4):956–960.PubMedGoogle Scholar
  17. 17.
    Guda NM, Partington S, Freeman ML. Extracorporeal shock wave lithotripsy in the management of chronic calcific pancreatitis: a meta-analysis. JOP. 2005;6(1):6–12.PubMedGoogle Scholar
  18. 18.
    Ohara H, Hoshino M, Hayakawa T, et al. Single application extracorporeal shock wave lithotripsy is the first choice for patients with pancreatic duct stones. Am J Gastroenterol. 1996;91(7):1388–1394.PubMedGoogle Scholar
  19. 19.
    Dumonceau JM, Costamagna G, Tringali A, et al. Treatment for painful calcified chronic pancreatitis: extracorporeal shock wave lithotripsy versus endoscopic treatment: a randomised controlled trial. Gut. 2007;56(4):545–552. doi:10.1136/gut.2006.096883.CrossRefPubMedGoogle Scholar
  20. 20.
    Puestow CB, Gillesby WJ. Retrograde surgical drainage of pancreas for chronic relapsing pancreatitis. AMA Arch Surg. 1958;76(6):898–907.PubMedGoogle Scholar
  21. 21.
    Partington PF, Rochelle RE. Modified Puestow procedure for retrograde drainage of the pancreatic duct. Ann Surg. 1960;152:1037–1043.CrossRefPubMedGoogle Scholar
  22. 22.
    Beger HG, Krautzberger W, Bittner R, Büchler M, Limmer J. Duodenum-preserving resection of the head of the pancreas in patients with severe chronic pancreatitis. Surgery. 1985;97(4):467–473.PubMedGoogle Scholar
  23. 23.
    Frey CF, Smith GJ. Description and rationale of a new operation for chronic pancreatitis. Pancreas. 1987;2(6):701–707. doi:10.1097/00006676-198711000-00014.CrossRefPubMedGoogle Scholar
  24. 24.
    Büchler MW, Friess H, Müller MW, Wheatley AM, Beger HG. Randomized trial of duodenum-preserving pancreatic head resection versus pylorus-preserving Whipple in chronic pancreatitis. Am J Surg. 1995;169(1):65–69. doi:10.1016/S0002-9610(99)80111-1.CrossRefPubMedGoogle Scholar
  25. 25.
    Izbicki JR, Bloechle C, Broering DC, Knoefel WT, Kuechler T, Broelsch CE. Extended drainage versus resection in surgery for chronic pancreatitis: a prospective randomized trial comparing the longitudinal pancreaticojejunostomy combined with local pancreatic head excision with the pylorus-preserving pancreatoduodenectomy. Ann Surg. 1998;228(6):771–779. doi:10.1097/00000658-199812000-00008.CrossRefPubMedGoogle Scholar
  26. 26.
    Bradley EL 3rd, Bem J. Nerve blocks and neuroablative surgery for chronic pancreatitis. World J Surg. 2003;27(11):1241–1248. doi:10.1007/s00268-003-7244-9.CrossRefPubMedGoogle Scholar
  27. 27.
    Lillemoe KD, Cameron JL, Kaufman HS, Yeo CJ, Pitt HA, Sauter PK. Chemical splanchnicectomy in patients with unresectable pancreatic cancer. A prospective randomized trial. Ann Surg. 1993;217(5):447–455. doi:10.1097/00000658-199305010-00004.CrossRefPubMedGoogle Scholar
  28. 28.
    Wong GY, Schroeder DR, Carns PE, et al. Effect of neurolytic celiac plexus block on pain relief, quality of life, and survival in patients with unresectable pancreatic cancer: a randomized controlled trial. JAMA. 2004;291(9):1092–1099. doi:10.1001/jama.291.9.1092.CrossRefPubMedGoogle Scholar
  29. 29.
    Moher D, Cook DJ, Eastwood S, et al. Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Lancet. 1999;354:1896–1900. doi:10.1016/S0140-6736(99)04149-5.CrossRefPubMedGoogle Scholar
  30. 30.
    Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology. A proposal for reporting. JAMA. 2002;283:2008–2012. doi:10.1001/jama.283.15.2008.CrossRefGoogle Scholar
  31. 31.
    Brennan P, Silman A. Statistical methods for assessing observer variability in clinical measures. BMJ. 1992;304:1491–1494.CrossRefPubMedGoogle Scholar
  32. 32.
    Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996;17:1–12. doi:10.1016/0197-2456(95)00134-4.CrossRefPubMedGoogle Scholar
  33. 33.
    Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of observational studies in epidemiology (MOOSE) group. JAMA. 2000;283(15):2008–2012. doi:10.1001/jama.283.15.2008.CrossRefPubMedGoogle Scholar
  34. 34.
    Stuart A, Ord JK. Kendall’s Advanced Theory of Statistics. 6th ed. London: Edward Arnold; 1994.Google Scholar
  35. 35.
    DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7:177–188. doi:10.1016/0197-2456(86)90046-2.CrossRefPubMedGoogle Scholar
  36. 36.
    Deeks JJ. Systematic reviews of evaluations of diagnostic and screening tests. In: Egger M, Smith GD, Altman DG, eds. Systematic Reviews in Health Care. Meta-Analysis in Context. London: BMJ Books; 2001.Google Scholar
  37. 37.
    Harbord RM, Egger M, Sterne JAC. A modified test for small-study effects in meta-analyses of controlled trials with binary endpoints. Stat Med. 2005;25(20):3443–3457. doi:10.1002/sim.2380.CrossRefGoogle Scholar
  38. 38.
    Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics. 1994;50:1088–1101. doi:10.2307/2533446.CrossRefPubMedGoogle Scholar
  39. 39.
    Sterne JAC, Egger M, Davey-Smith G. Investigating and dealing with publication and other biases in meta-analysis. BMJ. 2001;323:101–105. doi:10.1136/bmj.323.7304.101.CrossRefPubMedGoogle Scholar
  40. 40.
    Sterne JAC, Egger M. Funnel plots for detecting bias in meta-analysis: guidelines on choice of axis. J Clin Epidemiol. 2001;54:1046–1055. doi:10.1016/S0895-4356(01)00377-8.CrossRefPubMedGoogle Scholar
  41. 41.
    Wiersema MJ, Wiersema LM. Endosonography-guided celiac plexus neurolysis. Gastrointest Endosc. 1996;44(6):656–662. doi:10.1016/S0016-5107(96)70047-0.CrossRefPubMedGoogle Scholar
  42. 42.
    Tran QN, Urayama S, Meyers FJ. Endoscopic ultrasound-guided celiac plexus neurolysis for pancreatic cancer pain: a single-institution experience and review of the literature. J Support Oncol. 2006;4(9):460–462.PubMedGoogle Scholar
  43. 43.
    Usatii M, Paquin SC, Dagenais M, et al. Preliminary results of a randomized, double blind, controlled trial of early EUS-guided celiac plexus neurolysis (EUS-Cpn) versus conventional management for pain in patients with inoperable pancreatic cancer. Gastrointest Endosc. 2008;67(5):M1438. doi:10.1016/j.gie.2008.03.1025.CrossRefGoogle Scholar
  44. 44.
    Gunaratnam NT, Sarma AV, Norton ID, Wiersema MJ. A prospective study of EUS-guided celiac plexus neurolysis for pancreatic cancer pain. Gastrointest Endosc. 2001;54(3):316–324. doi:10.1067/mge.2001.117515.CrossRefPubMedGoogle Scholar
  45. 45.
    Levy MJ, Topazian MD, Wiersema MJ, et al. Initial evaluation of the efficacy and safety of endoscopic ultrasound-guided direct ganglia neurolysis and block. Am J Gastroenterol. 2008;103(1):98–103.PubMedGoogle Scholar
  46. 46.
    LeBlanc JK, Dewitt J, McHenry L, Sherman S, Imperiale T, Collins E. A prospective evaluation of EUS-guided celiac plexus block in patients with chronic pancreatitis and pancreas cancer. Gastrointest Endosc. 2004;59(5):236. doi:10.1016/S0016-5107(04)01063-6.CrossRefGoogle Scholar
  47. 47.
    Catalano MF, Ahmed U, Chauhan SS, Patel SN, Geenen JE. Celiac plexus neurolysis (CPN) in the treatment of refractory pain of pancreatic cancer (PCA): site specific response to therapy. Gastrointest Endosc. 2005;61(5):AB273. doi:10.1016/S0016-5107(05)01417-3.CrossRefGoogle Scholar
  48. 48.
    O’Toole TM, Shire NJ, Chauhan SS, Schmulewitz N. Predictors of response to EUS-guided celiac plexus blockade for abdominal pain in patients with chronic pancreatitis. Gastrointest Endosc. 2007;65(5):AB209. doi:10.1016/j.gie.2007.03.422.CrossRefGoogle Scholar
  49. 49.
    LeBlanc J, De Witt 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(5):M1488. doi:10.1016/j.gie.2008.03.560.CrossRefGoogle Scholar
  50. 50.
    Lemelin V, Lam E, Sahai A. A prospective trial of central versus bilateral celiac plexus bloc/neurolysis in 160 patients: bilateral injection is safe and is more effective. Gastrointest Endosc. 2005;61(5):AB77. doi:10.1016/S0016-5107(05)00591-2.CrossRefGoogle Scholar
  51. 51.
    Gress F, Schmitt C, Sherman S, Ikenberry S, Lehman G. A prospective randomized comparison of endoscopic ultrasound- and computed tomography-guided celiac plexus block for managing chronic pancreatitis pain. Am J Gastroenterol. 1999;94(4):900–905. doi:10.1111/j.1572-0241.1999.01042.x.CrossRefPubMedGoogle Scholar
  52. 52.
    Gress F, Schmitt C, Sherman S, Ciaccia D, Ikenberry S, Lehman G. Endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience. Am J Gastroenterol. 2001;96(2):409–416. doi:10.1111/j.1572-0241.2001.03551.x.CrossRefPubMedGoogle Scholar
  53. 53.
    Mahajan RJ, Nowell W, Hira K, Oaks K, Adams LJ. Patients’ perspective on endoscopic ultrasound (EUS) guided celiac plexus pain block (CPB) in treatment of unremitting pain of chronic pancreatitis (CP). Am J Gastroenterol. 2002;97(9-suppl 1):S59–S60.Google Scholar
  54. 54.
    Gress F, Ciaccia D, Sherman S, Lehman G. Multi-center evaluation of endoscopic ultrasound (EUS)-guided celiac plexus neurolysis (CPN) for treating abdominal pain associated with chronic pancreatitis (CP). Gastroenterology. 1998;114(15-suppl 1):A463.Google Scholar
  55. 55.
    Eisenberg E, Carr DB, Chalmers TC. Neurolytic celiac plexus block for treatment of cancer pain: a meta-analysis. Anesth Analg. 1995;80:290–295. doi:10.1097/00000539-199502000-00015.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Srinivas R. Puli
    • 1
  • Jyotsna B. K. Reddy
    • 1
  • Matthew L. Bechtold
    • 1
  • Mainor R. Antillon
    • 1
  • William R. Brugge
    • 2
  1. 1.Division of Gastroenterology and Hepatology, CE443 Clinical Support & EducationUniversity of Missouri-ColumbiaColumbiaUSA
  2. 2.GI UnitMassachusetts General HospitalBostonUSA

Personalised recommendations