Elsevier

Gastrointestinal Endoscopy

Volume 76, Issue 5, November 2012, Pages 945-952
Gastrointestinal Endoscopy

Original article
Clinical endoscopy
EUS-guided celiac ganglion irradiation with iodine-125 seeds for pain control in pancreatic carcinoma: a prospective pilot study

https://doi.org/10.1016/j.gie.2012.05.032Get rights and content

Background

Celiac plexus neurolysis for the palliative reduction of pain in unresectable pancreatic carcinoma (PC) is safe but provides limited relief. In a previous study, we found that EUS-guided implantation of iodine-125 (125I) around the celiac ganglia is a safe procedure and can induce apoptosis of local neurons in a porcine model.

Objective

To evaluate the safety and efficacy of direct celiac ganglion irradiation with 125I seeds for the relief of moderate to severe pain secondary to unresectable PC.

Design

Prospective study.

Setting

Single, tertiary care referral center.

Patients

This study enrolled consecutive patients who had moderate to severe pain resulting from biopsy-proven unresectable PC.

Intervention

All patients underwent EUS-guided direct celiac ganglion irradiation with 125I seeds. Follow-up was conducted at least once weekly until death.

Main Outcome Measurements

Blood parameters, Visual Analog Scale (VAS) score, mean analgesic (MS Contin [morphine sulfate]) consumption, and complications were evaluated during follow-up.

Results

Twenty-three patients with unresectable PC underwent the procedure. The mean number of seeds implanted in the celiac ganglion per patient was 4 (range 2-6). Immediately after the procedure, pain relief and analgesic consumption showed no significant changes compared with preoperative values. Six patients (26%) reported pain exacerbation. Two weeks later, the VAS score and mean analgesic consumption were significantly less than preoperative values. No procedure-related deaths or major complications occurred.

Limitations

Uncontrolled study.

Conclusions

EUS-guided direct celiac ganglion irradiation with 125I seeds can reduce the VAS score and analgesic drug consumption in patients with unresectable PC.

Section snippets

Patients

Patients were eligible for EUS-guided direct celiac ganglion irradiation if they had moderate to severe narcotic-dependent pain resulting from biopsy-proven unresectable PC. Tumors were deemed unresectable if there was superior mesenteric artery or celiac encasement greater than 180 degrees, unreconstructable superior mesenteric vein/portal occlusion or metastases to lymph nodes beyond the field of resection.12 Patients were excluded from the study if they had (1) uncorrectable coagulopathy

Results

Twenty-seven patients were initially enrolled in the study from January 2009 to December 2011. Four patients underwent the standard CPN procedure because the celiac ganglia could not be clearly identified. The celiac ganglia could be seen and accessed in 85.2% (23/27) of patients. As a result, a total of 23 patients underwent direct ganglion implantation with 125I seeds. The patients (14 men and 9 women) were between 38 and 77 years of age, with an average age of 64 years. Of all patients

Discussion

Chemotherapy is the first-line treatment in the majority of PC patients at a palliative stage and has been observed to have the ability to reduce pain, but the analgesic effect is limited and weak.18 The standard approach to the management of cancer pain follows the WHO 3-step analgesic ladder, beginning with nonopioid analgesics, followed by weak opioids, and finally strong opioids as necessary.13 Virtually all PC patients require increasing doses of opioids. Inevitably, intolerable adverse

References (28)

  • A.L. Grahm et al.

    Prospective evaluation of pain in exocrine pancreatic cancer

    Digestion

    (1997)
  • O. Akhan et al.

    Long-term results of celiac ganglia block: correlation of grade of tumoral invasion and pain relief

    AJR Am J Roentgenol

    (2004)
  • A. Chak

    What is the evidence for EUS-guided celiac plexus block/neurolysis?

    Gastrointest Endosc

    (2009)
  • M.J. Levy et al.

    Initial evaluation of the efficacy and safety of endoscopic ultrasound-guided direct ganglia neurolysis and block

    Am J Gastroenterol

    (2008)
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    DISCLOSURE: The authors disclosed no financial relationships relevant to this publication.

    If you would like to chat with an author of this article, you may contact Dr Li at [email protected].

    See CME section; p. 1020.

    Drs Wang and Jin contributed equally to this article.

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