Case Study: Endoscopic Ultrasound (EUS) Guided-Celiac Plexus Neurolysis (CPN)
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Author: Mohamad A. Eloubeidi, M.D., M.H.S., F.A.C.P., F.A.C.G. FASGE
Associate Professor of Medicine and Pathology Director, Endoscopic Ultrasound Program Co-Director Pancreatico-biliary Center
Institution: University of Alabama at Birmingham
Department of Medicine
Division of Gastroenterology/Hepatology
Statement of COI: Dr. Eloubeidi reports no conflicts of interests relating to this video presentation
A 62 year old lady with pancreatic cancer was diagnosed two weeks ago at our center by EUS-guided FNA. We started her on Loretab but unfortunately it did not help her pain. During her last examination by EUS and by CT scan of the abdomen there is clear evidence of involvement of the celiac artery and therefore she is not amenable for surgical resection. We counseled her regarding the need for celiac plexus neurolysis (CPN) and she's here today to undergo CPN. Many studies published to date suggest that EUS-guided CPN is really helpful in the setting of pancreatic cancer pain and leads to success in about 70-80% of the patients. It is a safe procedure performed on outpatient basis under conscious sedation. We have given our patient a low dose of Demerol, and Verset, and we used low dose Ketamine as an adjunct to sedation. Typically we insert the echo endoscope to the level of the celiac artery where the injection is performed at its base. The echo endoscope is inserted in the patient esophagus. It was a smooth intubation. When the echoendoscope is at about 35 cm from the incisors we switch to ultrasound. The landmark we look for is really the descending aorta at about 35-40 centimeters from the incisors. The descending aorta is a tubular organ as you see here with color Doppler ultrasound. Once you identify the aorta you push forward with the echo endoscope until you find the first branching artery and that's the celiac artery.
To confirm further it would be nice to demonstrate the superior mesenteric artery as you can see in this image back to back. This way you are sure you are performing the celiac neurolysis in the right area. Also for confirmatory purposes we perform color Doppler sonography to identify further the celiac artery and to be sure that there are no intervening vessels in the way. The arrow actually is a good location and estimation of where I need my needle to be to initiate the injection. I am currently using the CPN needle it's a 20 gauge needle. I think the advantages are clear with using it. In comparison to the 22 gauge needle I think we can do a quicker and faster injection. I think I crossed the wall of the stomach here and then we're going to aspirate to ensure we don't have any blood return. We are performing the injection, again it's all at the tip of the arrow- you see the needle in place. That actually created a nice cushion for us to inject the alcohol. Now here we better be sure of the needle placement since the alcohol will create a hyperechoic shadow that will block the view as you see in this image. As you see the injections really quick with this fenestrated needle we used 6ccs of bupivacaine and we injected 20 ccs of absolute alcohol in this area. We withdraw the needle from the scope and at this time the procedure is terminated.
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Mohamad A. Eloubeidi, MD Associate Professor of Medicine and Pathology University of Alabama at Birmingham |
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Citation: Eloubeidi, MA (Oct 19 2009). Case Study: Endoscopic Ultrasound (EUS) Guided-Celiac Plexus Neurolysis (CPN). The DAVE Project. Retrieved Feb, 8, 2010, from http://daveproject.org/viewfilms.cfm?film_id=881 Times viewed since Feb 2006: 1186 |
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