Although endoscopic ultrasound-guided celiac neurolysis (EUS-CN) and percutaneous celiac neurolysis (PCN) are utilized to manage intractable pain in pancreatic cancer patients, no direct comparison has been made between the two methods. We compared the efficacy and safety of EUS-CN and PCN in managing intractable pain in such patients. Sixty pancreatic cancer patients with intractable pain were randomly assigned to EUS-CN (n = 30) or PCN (n = 30). The primary outcomes were pain reduction in numerical rating scale (NRS) and opioid requirement reduction. Secondary outcomes were: successful pain response (NRS decrease ≥50% or ≥3-point reduction from baseline); quality of life; patient satisfaction; adverse events; and survival rate at 3 months postintervention. Both groups reported sustained decreases in pain scores up to 3 months postintervention (mean reductions in abdominal pain: 0.9 (95% confidence interval (CI): −0.8 to 4.2) and 1.7 (95% CI: −0.3 to 2.1); back pain: 1.3 (95% CI: −0.9 to 3.4) and 2.5 (95% CI: −0.2 to 5.2) in EUS-CN, and PCN groups, respectively). The differences in mean pain scores between the two groups at baseline and 3 months were −0.5 (p = 0.46) and −1.4 (p = 0.11) for abdominal pain and 0.1 (p = 0.85) and −0.9 (p = 0.31) for back pain in favor of PCN. No significant differences were noted in opioid requirement reduction and other outcomes. EUS-CN and PCN were similarly effective and safe in managing intractable pain in pancreatic cancer patients. Either methods may be used depending on the resources and expertise of each institution.
Background and objectiveThoracic epidural analgesia can significantly reduce acute postoperative pain. However, thoracic epidural catheter placement is challenging. Although real-time ultrasound (US)-guided thoracic epidural catheter placement has been recently introduced, data regarding the accuracy and technical description are limited. Therefore, this prospective observational study aimed to assess the success rate and describe the technical considerations of real-time US-guided low thoracic epidural catheter placement.Methods38 patients in the prone position were prospectively studied. After the target interlaminar space between T9 and T12 was identified, the needle was advanced under real-time US guidance and was stopped just short of the posterior complex. Further advancement of the needle was accomplished without US guidance using loss-of-resistance techniques to normal saline until the epidural space was accessed. Procedure-related variables such as time to mark space, needling time, number of needle passes, number of skin punctures, and the first-pass success rate were measured. The primary outcome was the success rate of real-time US-guided thoracic epidural catheter placement, which was evaluated using fluoroscopy. In addition, the position of the catheter, contrast dispersion, and complications were evaluated.ResultsThis study included 38 patients. The T10–T11 interlaminar space was the most location for epidural access. During the procedure, the mean time for marking the overlying skin for the procedure was 49.5±13.8 s and the median needling time was 49 s. The median number of needle passes was 1.0 (1.0–1.0). All patients underwent one skin puncture for the procedure. The first-pass and second-pass success rates were 76.3% and 18.4%, respectively. Fluoroscopic evaluation revealed that the catheter tips were all positioned in the epidural space and were usually located between T9 and T10 (84.2%). The cranial and caudal contrast dispersion were observed up to 5.4±1.6 and 2.6±1.0 vertebral body levels, respectively. No procedure-related complications occurred.ConclusionReal-time US guidance appears to be a feasible option for facilitating thoracic epidural insertion. Whether or not this technique improves the procedural success and quality compared with landmark-based techniques will require additional study.Trial registration numberNCT03890640.
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