Wouter F W Kappelle1, Ronald L A W Bleys2, Albert J M van Wijck3, Peter D Siersema4, Frank P Vleggaar1. 1. Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands. 2. Department of Anatomy, University Medical Center Utrecht, Utrecht, The Netherlands. 3. Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands. 4. Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.
Abstract
BACKGROUND AND AIMS: There is little evidence that structures targeted during EUS-guided celiac ganglia neurolysis (EUS-CGN) are celiac ganglia and that selective ethanol injection into ganglia is feasible. We aimed to visualize celiac ganglia, confirm that these structures are ganglia, and visualize ethanol spread after EUS-CGN and EUS-guided celiac plexus neurolysis (EUS-CPN). METHODS: First, celiac ganglia were sought during 97 consecutive EUS procedures. Second, ganglia were identified in a prosected human cadaver by placing a linear echoendoscope next to the celiac trunk and removing the underlying tissue for histology. Finally, various EUS-CGN and EUS-CPN techniques were performed in human cadavers; EUS-CGN was performed with 1 mL ethanol in 1 ganglion, 1 mL per ganglion (both low volume), and 4 mL per ganglion (high volume). EUS-CPN was performed with a central (20 mL) and a bilateral (2*10 mL) approach. Transverse sections (75 μm) were obtained and photographed to allow visualization of the spread of ethanol. RESULTS: A total of 204 ganglia were detected in 83 patients. Mean (± standard deviation) size of the long axis was 8.1 mm (± 7.4 mm). Histology of the removed region in the cadaver showed only nerve cell bodies. After low-volume EUS-CGN in cadavers, ethanol spread well beyond the targeted ganglion. After high-volume EUS-CGN in cadavers, a larger ethanol spread was seen, which also reached unidentified ganglia; the spread was comparable to the spread after EUS-CPN. CONCLUSIONS: Specific EUS-CGN is not feasible because ethanol spreads well beyond the targeted ganglion. Unidentified celiac ganglia are better reached with high-volume EUS-CGN, and this would likely result in a more thorough neurolysis. High-volume EUS-CGN should be preferred to low-volume EUS-CGN.
BACKGROUND AND AIMS: There is little evidence that structures targeted during EUS-guided celiac ganglia neurolysis (EUS-CGN) are celiac ganglia and that selective ethanol injection into ganglia is feasible. We aimed to visualize celiac ganglia, confirm that these structures are ganglia, and visualize ethanol spread after EUS-CGN and EUS-guided celiac plexus neurolysis (EUS-CPN). METHODS: First, celiac ganglia were sought during 97 consecutive EUS procedures. Second, ganglia were identified in a prosected human cadaver by placing a linear echoendoscope next to the celiac trunk and removing the underlying tissue for histology. Finally, various EUS-CGN and EUS-CPN techniques were performed in human cadavers; EUS-CGN was performed with 1 mL ethanol in 1 ganglion, 1 mL per ganglion (both low volume), and 4 mL per ganglion (high volume). EUS-CPN was performed with a central (20 mL) and a bilateral (2*10 mL) approach. Transverse sections (75 μm) were obtained and photographed to allow visualization of the spread of ethanol. RESULTS: A total of 204 ganglia were detected in 83 patients. Mean (± standard deviation) size of the long axis was 8.1 mm (± 7.4 mm). Histology of the removed region in the cadaver showed only nerve cell bodies. After low-volume EUS-CGN in cadavers, ethanol spread well beyond the targeted ganglion. After high-volume EUS-CGN in cadavers, a larger ethanol spread was seen, which also reached unidentified ganglia; the spread was comparable to the spread after EUS-CPN. CONCLUSIONS: Specific EUS-CGN is not feasible because ethanol spreads well beyond the targeted ganglion. Unidentified celiac ganglia are better reached with high-volume EUS-CGN, and this would likely result in a more thorough neurolysis. High-volume EUS-CGN should be preferred to low-volume EUS-CGN.
Authors: Jonathan M Wyse; Robert Battat; Siyu Sun; Adrian Saftoiu; Ali A Siddiqui; Ang Tiing Leong; Brenda Lucia Arturo Arias; Carlo Fabbri; Douglas G Adler; Erwin Santo; Evangelos Kalaitzakis; Everson Artifon; Girish Mishra; Hussein Hassan Okasha; Jan Werner Poley; Jintao Guo; Juan J Vila; Linda S Lee; Malay Sharma; Manoop S Bhutani; Marc Giovannini; Masayuki Kitano; Mohamad Ali Eloubeidi; Mouen A Khashab; Nam Q Nguyen; Payal Saxena; Peter Vilmann; Pietro Fusaroli; Pramod Kumar Garg; Sammy Ho; Shuntaro Mukai; Silvia Carrara; Subbaramiah Sridhar; Sundeep Lakhtakia; Surinder S Rana; Vinay Dhir; Anand V Sahai Journal: Endosc Ultrasound Date: 2017 Nov-Dec Impact factor: 5.628