Kaufman, M., Singh, G., Das, S., Concha-Parra, R., Erber, J., Micames, C., & Gress, F. (2010). Efficacy of endoscopic ultrasound-guided celiac plexus block and celiac plexus neurolysis for managing abdominal pain associated with chronic pancreatitis and pancreatic cancer. Journal of Clinical Gastroenterology, 44(2), 127–134.

To evaluate the efficacy of endoscopic ultrasound-guided (EUS) celiac plexus block (CPB) and celiac plexus neurolysis (CPN) in alleviating chronic abdominal pain due to chronic pancreatitis (CP) or pancreatic cancer

• Databases searched were MEDLINE, PubMed, and EMBASE. Date range searched was January 1966–December 2007.
• Search keywords were endoscopic ultrasound, EUS, celiac plexus block, celiac plexus neurolysis, chronic pancreatitis, pancreatic cancer, and CP.
• Studies were included if
  • The reports were published in English.
  • Patients were at least 18 years old and had unremitting chronic abdominal pain due to CP or unresectable pancreatic cancer.
  • Patients needed narcotic analgesics for pain control.
  • The studies had enrolled at least 10 patients who had undergone EUS CPB or CPN.
• Authors did not cite exclusion criteria.

The initial search retrieved 588 articles. Authors selected nine studies for analysis (six of CP pain, three of pain due to pancreatic cancer). The report provides no data regarding quality rating. Of the six studies of CP, three were full articles and three were abstracts. Of the three studies of pancreatic cancer, one was an abstract. Across most studies, methods and procedures were similar. Because current expert consensus precludes the use of absolute alcohol in CPN of patients with CP, due to the potential for inducing fibrosis and limiting future surgical options, authors excluded from the meta-analysis partial data from one study. In this study investigators had used bupivacaine and alcohol in 5 of 19 patients.

• The sample was composed of 340 patients.
• Authors did not report sample range.
• Of all patients, 221 patients had CP and 119 had pancreatic cancer.

EUS CPB for CP was associated with a reduction of abdominal pain in 51% of patients but not with consistent elimination of the need for narcotic analgesics. However, in one study 47% of patients withdrew from narcotics. EUS CPB in CP patients offered temporary relief, up to 48 weeks, in some studies, but short-term pain relief may not indicate long-term effect. EUS CPN for pancreatic cancer pain was associated with a 73% reduction in pain. However, two of three studies reported that narcotic use did not change significantly post-CPN. Analysis of the patients with pancreatic cancer pain showed that the location of the tumor and the timing of EUS CPN were significant factors in the efficacy of the treatment and in pain and narcotics use.

• The number of studies analyzed was small. This could have had some effect on heterogeneity and publication bias.
• Authors did not provide details regarding pain etiology applicable to studies of CPB in CP.
• The studies did not track changes in quality of life.
• Physiologic evaluation for narcotic addiction was not part of the exclusion criteria in any of the studies. Addiction could have contributed to the lack of response in the CPB subgroup.
• Presentation of meta-analysis results is unclear.

Evidence suggests that EUS CPB is somewhat effective in managing the pain of appropriately selected patients. The evidence is not strong, however, and most effects appear to be temporary. EUS CPB is not an effective single method of pain control; EUS CPB may be useful only as a method of achieving temporary relief from acute flares.