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Endoscopic ultrasound-guided celiac plexus and ganglia interventions

Michael J Levy, MD
Maurits J Wiersema, MD
Section Editor
Douglas A Howell, MD, FASGE, FACG
Deputy Editor
Anne C Travis, MD, MSc, FACG, AGAF


Pancreatic cancer and chronic pancreatitis are commonly associated with intense and often refractory pain [1,2]. Non-narcotic medical therapies are often inadequate, and opioids commonly induce nausea, constipation, and other side effects [3,4]. Non-pharmacologic therapies are commonly administered with the aim of improving pain control and quality of life, while reducing the risk of drug-induced side effects. Such therapies include celiac plexus neurolysis (CPN) with injection of alcohol in patients with pancreatic cancer or celiac plexus block (CPB) using steroids in patients with chronic pancreatitis.

This topic review will provide an overview of CPN and CPB in the management of pain occurring secondary to pancreatic cancer and chronic pancreatitis, respectively, while focusing on endosonographic methods. It will also briefly review other applications of endoscopic ultrasound guided neurolysis, as well as emerging data concerning direct celiac ganglia neurolysis (CGN) and block (CGB), the most recently introduced technical variation of the standard technique.

The clinical manifestations and diagnosis of pancreatic cancer, chronic pancreatitis, and an overview of palliative treatments for pancreatic cancer are discussed separately. (See "Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer" and "Clinical manifestations and diagnosis of chronic pancreatitis in adults" and "Supportive care of the patient with locally advanced or metastatic exocrine pancreatic cancer".)


Although the terms "celiac plexus" and "splanchnic nerves" are often used interchangeably, they are anatomically distinct structures [5-7]. The splanchnic nerves are located above and posterior to the diaphragm and anterior most often to the 12th thoracic vertebra. The celiac plexus is located below and anterior to the diaphragm and surrounds the origin of the celiac trunk. The celiac plexus is comprised of a dense network of ganglia and interconnecting fibers. Celiac ganglia are typically located between T12 and L2 and, in most patients, two to five ganglia are present [5]. The celiac plexus transmits the sensation of pain for the pancreas [8]. The nerves that supply the pancreas [9] receive nociceptive stimulation and then transmit this pain information to the celiac plexus [10]. Stimuli reach the thalamus and cortex of the brain and this information is perceived as pain. Descending inhibitory mechanisms may also modulate the ascending pain information.


Technique — CPN and CPB can be performed percutaneously, surgically, or under endosonographic guidance [11-13]. The retrocrural or classic approach involves injection of the solution so that diffusion occurs over the splanchnic nerves [14]. Modifications have been created in an attempt to improve the accuracy of needle placement and pain relief, while reducing procedure-related complications. These techniques differ with respect to the route of needle insertion, use of radiologic guidance versus a blind procedure, and chemical composition of the injectate. The anterocrural or "true" CPN results in injection anterior to the diaphragm thereby diffusing over the celiac ganglia.


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Literature review current through: Sep 2016. | This topic last updated: Dec 12, 2013.
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  1. Ventafridda GV, Caraceni AT, Sbanotto AM, et al. Pain treatment in cancer of the pancreas. Eur J Surg Oncol 1990; 16:1.
  2. Lankisch PG. Natural course of chronic pancreatitis. Pancreatology 2001; 1:3.
  3. Ventafridda V, Tamburini M, Caraceni A, et al. A validation study of the WHO method for cancer pain relief. Cancer 1987; 59:850.
  4. Yeager MP, Colacchio TA, Yu CT, et al. Morphine inhibits spontaneous and cytokine-enhanced natural killer cell cytotoxicity in volunteers. Anesthesiology 1995; 83:500.
  5. Ward EM, Rorie DK, Nauss LA, Bahn RC. The celiac ganglia in man: normal anatomic variations. Anesth Analg 1979; 58:461.
  6. Ischia S, Ischia A, Polati E, Finco G. Three posterior percutaneous celiac plexus block techniques. A prospective, randomized study in 61 patients with pancreatic cancer pain. Anesthesiology 1992; 76:534.
  7. Brown DL, Moore DC. The use of neurolytic celiac plexus block for pancreatic cancer: anatomy and technique. J Pain Symptom Manage 1988; 3:206.
  8. Plancarte R, Velasquez R, Patt R. Neurolytic blocks of the sympathetic axis. In: Pain, Lippincott, Philadelphia 1993. p.377.
  9. Nagakawa T, Mori K, Nakano T, et al. Perineural invasion of carcinoma of the pancreas and biliary tract. Br J Surg 1993; 80:619.
  10. Gebhardt GF. Visceral pain mechanisms. In: Current and emerging issues in cancer pain, Chapman CR, Foley KM (Eds), Raven Press, New York 1993. p.99.
  11. Yan BM, Myers RP. Neurolytic celiac plexus block for pain control in unresectable pancreatic cancer. Am J Gastroenterol 2007; 102:430.
  12. Wang PJ, Shang MY, Qian Z, et al. CT-guided percutaneous neurolytic celiac plexus block technique. Abdom Imaging 2006; 31:710.
  13. Carroll I. Celiac plexus block for visceral pain. Curr Pain Headache Rep 2006; 10:20.
  14. Kappis M. Erfahrungen mit local anasthesie bie bauchoperationen. Vehr Dtsch Gesellsch Chir 1914; 43:87.
  15. Eisenberg E, Carr DB, Chalmers TC. Neurolytic celiac plexus block for treatment of cancer pain: a meta-analysis. Anesth Analg 1995; 80:290.
  16. Arcidiacono PG, Calori G, Carrara S, et al. Celiac plexus block for pancreatic cancer pain in adults. Cochrane Database Syst Rev 2011; :CD007519.
  17. Lillemoe KD, Cameron JL, Kaufman HS, et al. Chemical splanchnicectomy in patients with unresectable pancreatic cancer. A prospective randomized trial. Ann Surg 1993; 217:447.
  18. 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; 291:1092.
  19. Polati E, Finco G, Gottin L, et al. Prospective randomized double-blind trial of neurolytic coeliac plexus block in patients with pancreatic cancer. Br J Surg 1998; 85:199.
  20. Kawamata M, Ishitani K, Ishikawa K, et al. Comparison between celiac plexus block and morphine treatment on quality of life in patients with pancreatic cancer pain. Pain 1996; 64:597.
  21. Allen PJ, Chou J, Janakos M, et al. Prospective evaluation of laparoscopic celiac plexus block in patients with unresectable pancreatic adenocarcinoma. Ann Surg Oncol 2011; 18:636.
  22. Sahai AV, Lemelin V, Lam E, Paquin SC. Central vs. bilateral endoscopic ultrasound-guided celiac plexus block or neurolysis: a comparative study of short-term effectiveness. Am J Gastroenterol 2009; 104:326.
  23. Gress F, Schmitt C, Sherman S, et al. A prospective randomized comparison of endoscopic ultrasound- and computed tomography-guided celiac plexus block for managing chronic pancreatitis pain. Am J Gastroenterol 1999; 94:900.
  24. Gress F, Schmitt C, Sherman S, et al. Endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience. Am J Gastroenterol 2001; 96:409.
  25. Wiersema MJ, Wong GY, Croghan GA. Endoscopic technique with ultrasound imaging for neurolytic celiac plexus block. Reg Anesth Pain Med 2001; 26:159.
  26. Gleeson FC, Levy MJ, Papachristou GI, et al. Frequency of visualization of presumed celiac ganglia by endoscopic ultrasound. Endoscopy 2007; 39:620.
  27. Levy M, Rajan E, Keeney G, et al. Neural ganglia visualized by endoscopic ultrasound. Am J Gastroenterol 2006; 101:1787.
  28. Wiersema MJ, Wiersema LM. Endosonography-guided celiac plexus neurolysis. Gastrointest Endosc 1996; 44:656.
  29. Sakamoto H, Kitano M, Kamata K, et al. EUS-guided broad plexus neurolysis over the superior mesenteric artery using a 25-gauge needle. Am J Gastroenterol 2010; 105:2599.
  30. Gunaratnam NT, Sarma AV, Norton ID, Wiersema MJ. A prospective study of EUS-guided celiac plexus neurolysis for pancreatic cancer pain. Gastrointest Endosc 2001; 54:316.
  31. Puli SR, Reddy JB, Bechtold ML, et al. EUS-guided celiac plexus neurolysis for pain due to chronic pancreatitis or pancreatic cancer pain: a meta-analysis and systematic review. Dig Dis Sci 2009; 54:2330.
  32. Kaufman M, Singh G, Das S, et al. Efficacy of endoscopic ultrasound-guided celiac plexus block and celiac plexus neurolysis for managing abdominal pain associated with chronic pancreatitis and pancreatic cancer. J Clin Gastroenterol 2010; 44:127.
  33. Wyse JM, Carone M, Paquin SC, et al. Randomized, double-blind, controlled trial of early endoscopic ultrasound-guided celiac plexus neurolysis to prevent pain progression in patients with newly diagnosed, painful, inoperable pancreatic cancer. J Clin Oncol 2011; 29:3541.
  34. Iwata K, Yasuda I, Enya M, et al. Predictive factors for pain relief after endoscopic ultrasound-guided celiac plexus neurolysis. Dig Endosc 2011; 23:140.
  35. Levy MJ, Topazian M, Keeney G, et al. Preoperative diagnosis of extrapancreatic neural invasion in pancreatic cancer. Clin Gastroenterol Hepatol 2006; 4:1479.
  36. Gerke H, Silva RG Jr, Shamoun D, et al. EUS characteristics of celiac ganglia with cytologic and histologic confirmation. Gastrointest Endosc 2006; 64:35.
  37. Ha TI, Kim GH, Kang DH, et al. Detection of celiac ganglia with radial scanning endoscopic ultrasonography. Korean J Intern Med 2008; 23:5.
  38. 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; 103:98.
  39. Doi S, Yasuda I, Kawakami H, et al. Endoscopic ultrasound-guided celiac ganglia neurolysis vs. celiac plexus neurolysis: a randomized multicenter trial. Endoscopy 2013; 45:362.
  40. Ayub K. Endoscopic ultrasound-guided superior hypogastric plexus neurolysis: A new technique for the management of pelvic pain. Gastrointest Endosc 2001; 56:S143.
  41. O'Toole TM, Schmulewitz N. Complication rates of EUS-guided celiac plexus blockade and neurolysis: results of a large case series. Endoscopy 2009; 41:593.
  42. Hardy PA, Wells JC. Coeliac plexus block and cephalic spread of injectate. Ann R Coll Surg Engl 1989; 71:48.
  43. Mercadante S, Nicosia F. Celiac plexus block: a reappraisal. Reg Anesth Pain Med 1998; 23:37.
  44. Hayakawa J, Kobayashi O, Murayama H. Paraplegia after intraoperative celiac plexus block. Anesth Analg 1997; 84:447.
  45. De Conno F, Caraceni A, Aldrighetti L, et al. Paraplegia following coeliac plexus block. Pain 1993; 55:383.
  46. van Dongen RT, Crul BJ. Paraplegia following coeliac plexus block. Anaesthesia 1991; 46:862.
  47. Loeve US, Mortensen MB. Lethal necrosis and perforation of the stomach and the aorta after multiple EUS-guided celiac plexus neurolysis procedures in a patient with chronic pancreatitis. Gastrointest Endosc 2013; 77:151.