Neoplasms

Symptoms and General Pathology

All Conditions

Digestive System Diseases

Gland and Hormone Related Diseases

Nutritional and Metabolic Diseases

Skin and Connective Tissue Diseases

Nervous System Diseases

Rare Diseases

Neoplasm Metastasis

Pancreatic Neoplasms

Pain

Abdominal Pain

Celiac Disease

Ganglion Cysts

Synovial Cyst

Neurologic Manifestations

Signs and Symptoms, Digestive

Pancreatic Cancer

Central Nervous System Depressants

All Drugs and Chemicals

Anti-Infective Agents

Levobupivacaine

Ethanol

Anesthetics

Anesthetics, Local

Endoscopic ultrasound guided celiac ganglion neurolysis would be performed

Percutaneous celiac plexus neurolysis would be performed

EUS-CGN would be performed with a linear video echoendoscope (Olympus UM 2000; Olympus Co Ltd, Japan). The celiac ganglia are visualized under linear EUS and the injection would be applied directly into the ganglia. It is represented by small 2 to 3 mm hypoechoic nodules with hyperechoic foci in the center or a single elongated hypoechoic structure. IIf the ganglia are not identified by EUS, then injection would be performed as bilateral injections at the celiac vessel trunk. All procedures would be performed by a two experienced endosonographer.

EUS-guided celiac ganglion neurolysis

Percutaneous fluoroscopy-guided CPN would be performed in the operation theatre with the transcural technique. A 22-gauge, 17 cm-long spinal needle (B-D Quincke Type Point, Becton Dickinson \&Co., NJ 07417, USA) would be inserted and advanced just caudal to the margin of 12th rib and cephalad to the transverse process of L1 toward the anterolateral surface of the L1 vertebral body. Final needle position would be confirmed by radiographic contrast, layering over anterior surface of aorta. 10mL of levobupivacaine (0.25%), followed by 10mL of absolute alcohol would be injected on both sides using separate punctures.

Percutaneous celiac plexus neurolysis

Olympus UM 2000

B-D Quincke Type Point

Patients suffering from pancreatic cancer are associated with a poor prognosis and survival of less than one year is expected in inoperable tumours. Management of these patients would be towards palliation of symptoms. Severe pain occurs in 50 to 70% of the patients and this "intractable" pain is often difficult to treat. Different pharmacological agents have been used in the past to control this pain and these include non-steroidal anti-inflammatory drugs and narcotic agents. However, patients' responses are often variable and difficult to predict. Furthermore, these agents are associated with their own adverse effects and may further impair quality of life.

Celiac plexus neurolysis (CPN) was first described in 1919, since then, different approaches of performing the procedure have been described. The standard technique involves a percutaneous approach but CPN can also be performed by an intra-operative approach with open or laparoscopic means. Results from meta-analysis have shown that CPN was associated with superior pain relief as compared to analgesic therapy alone and reduces the need for opioids analgesics in patients with inoperable pancreatic cancer. Furthermore, CPN causes fewer adverse effects than opioid analgesics and it is the preferred method of improving pain relief in these patients.

Recently, endoscopic ultrasonography (EUS) - guided CPN has become popular. The approach is safe and effective and was shown to be associated with long lasting pain relieve in patients suffering from chronic pancreatitis or pancreatic cancer. Serious complications are uncommon and are less than 2% in these series. Transient diarrhoea and hypotension are common after CPN and is seen up to 30% to 40% of the patients, regardless of whether the procedure is being done by the EUS or percutaneous approach. The EUS approach offers several theoretical advantages over the percutaneous option. Most notably is the visualization of the celiac ganglia situated anterior to the aorta, allowing direct injection of the ganglia with alcohol resulting in celiac ganglion neurolysis (CGN). This increases the accuracy of CPN and may result in improved pain control. Furthermore, it could reduce complications associated with the percutaneous approach that includes lower extremity paresthesia and paralysis.

Hence, the aim of the study is to compare the efficacy and safety of endoscopic ultrasound (EUS)-guided celiac ganglion neurolysis (CGN) versus percutaneous celiac plexus neurolysis (CPN) in reducing cancer pain in patients suffering from inoperable cancer. With direct visualization and injection of the celiac ganglion, the investigators hypothesis that EUS-guided CGN is more advantageous on improving pain relief and decreasing the need for opioid analgesics in patients with inoperable cancer as compared to percutaneous CPN.

EUS-guided CGN for Inoperable Cancer

A Randomized Controlled Trial on Endoscopic Ultrasound-guided Celiac Ganglion Neurolysis Versus Percutaneous Celiac Plexus Neurolysis in Patients With Inoperable Cancer

Pain scores at 2 weeks after the procedure will be measured using the visual analogue scale

Amounts of opioid medications required at assessment interval

Patients would be monitored for presence of adverse events after CGN or CPN. Transient diarrhea and hypotension are common manifestations of the sympathetic blockade and may be seen in up to 38 and 44 percent of the patients. Severe adverse effects after percutaneous CPN include neurologic complications (l%) such as lower extremity weakness and paresthesia, epidural anesthesia, and lumbar puncture. Non-neurological adverse effects (1%) including pneumothorax, shoulder, chest and pleuritic pain, hiccoughing, and hematuria have also been reported.

QOL would be assessed using the FACT-Hep Chinese module

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
EUS-guided CGN for Inoperable Cancer	NCT02356640	Intractable Abd...	EUS-guided celi... Percutaneous ce... Olympus UM 2000 B-D Quincke Typ... Levobupivacaine	18 Years -	Chinese University of Hong Kong
EUS-guided CGN for Inoperable Cancer	NCT02356640	Intractable Abd...	EUS-guided celi... Percutaneous ce... Olympus UM 2000 B-D Quincke Typ... Levobupivacaine	18 Years -	Chinese University of Hong Kong
EUS-guided CGN for Inoperable Cancer	NCT02356640	Intractable Abd...	EUS-guided celi... Percutaneous ce... Olympus UM 2000 B-D Quincke Typ... Levobupivacaine	18 Years -	Chinese University of Hong Kong

Spots Global Cancer Trial Database for intractable abdominal pain secondary to inoperable malignancy