EUS in the Management of Pancreaticobiliary Cancers
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Transcript of EUS in the Management of Pancreaticobiliary Cancers
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EUS in the Management of Pancreaticobiliary Cancers
Frank Gress, MDProfessor of Medicine and Chief
Division of Gastroenterology and HepatologyState University of New YorkDownstate Medical Center
Brooklyn, NY
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• "EUS for the Diagnosis, Staging FNA and Celiac Neurolysis of Pancreatic Cancer”
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Pancreatic Adenocarcinoma
• The fourth leading cause of cancer-related death in the U.S.
• At diagnosis only ~15% of patients are candidates for curative surgery
• Five-year survival following a Whipple procedure was only 25% for node-negative tumors and 10% for node-positive tumors
Ahmad et al. Long term survival after pancreatic resection for pancreatic adenocarcinoma. The American Journal of Gastroenterol 2001;96(9):2609-15
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Pancreatic Cancer
• Late presentation, aggressive nature and lack of effective therapies all contribute to the poor prognosis
• Early detection is crucial to improve the overall prognosis
• Accurate Staging is vital for selecting the subset of patients who have potentially resectable tumors
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Common Indications for EUS
GI Tumor Staging
Esophageal Cancer Gastric Cancer Rectal Cancer Ampullary Cancer Pancreatic Cancer
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Cancer Staging
EUS Staging Accuracy Compared to PathIndication n T stage N stageEsophageal CA 739 85% 79%Gastric CA 1163 78% 73%Pancreatic CA 155 90% 78%Ampullary CA 94 86% 72%Rectal CA 19 84% 84%
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Clinical Applications for EUS
Pancreatic and Biliary Disease Tumor Staging Localization of Endocrine Tumors Detecting Choledocholithiasis Detecting Chronic Pancreatitis
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EUS Indications for StagingEUS Indications for Staging
• Pancreatic MassesPancreatic Masses– AdenocarcinomaAdenocarcinoma– Other malignancies/metastasesOther malignancies/metastases
• Bile duct cancer (cholangiocarcinoma)Bile duct cancer (cholangiocarcinoma)
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Clinical Applications for EUS
Current IndicationsPancreatic and Biliary Malignancies 1) Tumor staging primarily based on ability
to assess for vascular invasion2) Localization of Endocrine Tumors3) Ability to sample lesions for diagnosis
with >85% accuracy
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Pancreatic Tumor Staging
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EUS Stations for Staging Pancreatic Tumors
Transducer Major Structures Location identified with EUS
Gastric Body Confluence, Body/Tail of Pancreas, PD, Celiac Axis, Splenic vessels, SMA
Gastric Antrum Gallbladder,Liver,PancreasDuodenum
Bulb Head of Pancreas, CBD, PD 2nd Portion Head of Pancreas, SMA/SMV, Aorta, PD, Ampulla, Liver
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EUS Staging of Pancreatic Cancer
TNM Classification
T Staging is based on tumor size, depth of invasion and infiltration into major vessels
N Staging assesses for nodal involvement
M Staging denotes the absence/presence distant metastasis (EUS can detect hepatic metastasis)
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T2 Pancreatic Mass
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T3 Pancreatic Adenocarcinoma
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T3 Pancreatic Tumor
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Pancreatic Mass
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EUS Detection Rates of Pancreatic Tumors
Sensitivity (%) Specificity (%) PPV(%) NPV(%) Accuracy (%)
Rosch, 1991 99 100 100 97 76
Snady, 1992 85 80 89 73 83
Yasuda, 1993 - - - - 100
Muller, 1994 94 100 - - 96
Gress, 1997 93 100 - - -
Baron, 1997 95 88 95 88 -
Legmann, 1998 100 93 - - -
Akahoshi, 1998 89 97 94 93 94
Totals 95 94 95 88 90
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Pancreatic Cancer Staging by EUS
Pooled Data
• T staging accuracy ranges from 78 to 94% • T staging accuracy is higher in patients with
advanced lesions (T3 and T4)• Vascular invasion accuracy was 82 to 93%• N staging accuracy ranges from 64 to 82%
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Diagnosis by EUS
• EUS provides improved imaging of small tumors not seen with other imaging modalities
• The detection of pancreatic tumors < 3 cm in diameter was higher for EUS:
EUS (100%) TUS (57%) CT (68%) Rosch, et al. Endoscopic ultrasound in small pancreatic tumors.
Z Gastroenterol 1991;29:110-5.
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Diagnosis by EUS
• The detection of pancreatic tumors < 2cm in diameter was higher for EUS:
EUS (100%) ERCP (57%) TUS (29%) CT (29%) Angiography (14%)
Yasuda K, et al. The diagnosis of pancreatic cancer by endoscopic ultrasonography. Gastrointest Endosc 1998;34:1.
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EUS Staging
Lower T and N staging accuracy has also been described:
• 89 patients with pancreatic cancer had EUS staging compared to surgery
• Overall accuracy for T staging was 69% and for N staging was 54%
• Only 46% of tumors designated by EUS as resectable actually were at laparotomy
Ahmad,et al Gastrointest Endo 2000;52:46
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Pancreatic CancerPancreatic Cancer
• Best modality for small lesionsBest modality for small lesions• Diagnostic imaging and fine needle Diagnostic imaging and fine needle
aspiration during single procedureaspiration during single procedure• Evaluate for chronic pancreatitis if Evaluate for chronic pancreatitis if
not tumor foundnot tumor found• All pancreatic cancer has a dismal All pancreatic cancer has a dismal
prognosisprognosis
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Liver Metastasis
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Liver
• EUS provides excellent imaging of the liver particularly the left lobe of the liver and some portions of the right lobe
• The left lobe is best seen from the gastric body and fundus
• The right lobe is best imaged from the antrum and duodenum
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Clinical Utility of EUS FNA for Diagnosing Liver lesions
Sensitivity of EUS-FNA for the diagnosis of malignancy ranged from 82 to 94%
When compared with benign lesions, EUS features predictive of malignant hepatic masses were the presence of regular outer margins (60% vs 27%; p = 0.02) and the detection of two or more lesions (38% vs 9%; p = 0.03).
[DeWitt J et al. Am J Gastroenterol. 2003 Sep;98(9):1976-81]
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EUS IndicationsEUS IndicationsCancer StagingCancer Staging
• AmpullaryAmpullaryMost accurate locoregional stagingMost accurate locoregional staging
• RectalRectalMost accurate locoregional stagingMost accurate locoregional staging
• Other e.g. duodenal tumors, Other e.g. duodenal tumors, adenomasadenomas
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T1 Ampullary TumorT1 Ampullary Tumor
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Limitations of EUS
• Factors influencing EUS staging accuracy:– Experience level of endosonographer– Imaging artifacts/Normal variants/Chronic
Pancreatitis– Distinguishing vascular compression from
tumor infiltration can be difficult in larger tumors
– Accuracy for detecting invasion into the SMA and SMV is lower than that for PV or SV
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EUS versus Helical CT
Contrast enhanced helical CT has been compared to EUS for detecting pancreatic tumors, predicting resectability and determining vascular invasion
Leggmann, et al; 1998 Midwinter, et al; 1999 Mertz, et al; 2000Tierney, et al; 2002
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EUS versus Helical CT
Pooled Data Accuracy
4 Studies n=164 EUS CTDetecting pancreatic tumors 97% 73%
Predicting resectability 91% 83%
Determining vascular invasion 91% 64%
Hunt GC, et al. Gastrointest Endosc 2002;55:232.
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EUS versus Helical CT
Several features of the individual studies may account for the disparity in the conclusions:
- Differences in Gold Standard - Differences in Helical CT Technique - Number of patients with advanced disease
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EUS versus Multidetector CT
• Prospective study comparing EUS and Multidetector CT for detecting and staging pancreatic cancer
120 patients with known pancreatic cancer
EUS was: 98% sensitive for tumor detection (86% for CT)
67% for tumor staging accuracy (41% for CT) 44% for nodal staging accuracy (47% for CT)
DeWitt J, et al. Comparison of EUS and Multidetector CT for detecting and staging pancreatic cancer. Annals of Internal Med 2004;141:753-63
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EUS versus Helical CT
Conclusions
• EUS and Helical CT are complementary for staging pancreatic cancer.
• EUS is a more accurate modality for T staging
and predicting vascular invasion and CT is better for detecting distant metastasis.
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EUS and Cancer DiagnosisEUS and Cancer Diagnosis
• Controversial whether pre-operative Controversial whether pre-operative diagnosis is necessarydiagnosis is necessary
• Direct to resection when clinical Direct to resection when clinical suspicion is highsuspicion is high
vs.vs.• Pre-operative tissue diagnosisPre-operative tissue diagnosis
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Role of EUS inRecurrent Cancer after Whipple
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EUS-FNA of Pancreatic Lesions
Not all pancreatic masses are cancer Differential Diagnosis• Adenocarcinoma• Neuroendocrine tumor• Lymphoma• Chronic pancreatitis
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Normal PancreasNormal Pancreas
EG-3630UREG-3630UR
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Normal PancreasNormal Pancreas
EG-3630UREG-3630URGF-UM130GF-UM130
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Pancreatic CancerPancreatic Cancer
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Islet Cell TumorIslet Cell Tumor
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Chronic PancreatitisChronic Pancreatitis
EG-3630UREG-3630UR
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EUS-guided Fine Needle Aspiration
• Percutaneous or CT-guided biopsy has been the traditional approach for establishing the diagnosis of pancreatic cancer
• EUS FNA was introduced ~10 years ago
• The main advantage of EUS guided FNA biopsy is its ability to obtain tissue sampling of any suspicious mass found during EUS evaluation.
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Fine Needle AspirationFine Needle Aspiration
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EUS FNA Needles
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Diagnostic Characteristics of EUS FNA for Pancreatic Mass Lesions
n Sensitivity (%) Specificity (%) Accuracy (%)
Giovannini [Endoscopy 1995;27(2)] 43 75 100 79
Cahn [AJS 1996;172(5)] 50 88 100 87
Bhutani [Endoscopy;1997;29(9)] 47 64 100 72
Chang [GIE;1997;45(5)] 44 92 100 95
Erickson [AFP 1997;55(6)] 28 -- -- 96
Faigel [JClinOnc1997;15(4)] 45 72 100 75
Gress [GIE1997;45(3)] 121 80 100 85
Wiersema [Gastro 1997;112(4)] 124 87 100 88
Binmoeller [GIE1998;47(2)] 58 76 100 92
560 81% 100% 86%
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RESULTS OF EUS-GUIDED FNA BIOPSY IN PATIENTS WITH OR WITHOUT PANCREATIC
CANCEREUS- Guided Patients with Patients without LikelihoodFNA BX Pancreatic CA Pancreatic CA Ratio (95% (CI)
Positive results 57/61 (93.%) 0/41 (0) All values 9.7+
Negative results 3/61 (4.9%) 34/41 (83%) 0.05 (0.02-0.15)
Inconclusive or 1/61 (1.6%) 7/41 (17.%) 0.096 (0.012-0.75)
nondiagnostic
(Gress F, et.al. Ann Int Med 2001; 134(6):459-464)
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EUS-Guided FNA
Reported Complications:
• Infection (cysts >>solid mass)• Pancreatitis (<1- 2%)• Bleeding
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EUS-Guided FNA
Reported Complications:InfectionBleedingPancreatitis (2-4%)
100 patients having EUS FNA of pancreas [Gress, et al GIE 2003] - 2/100 developed clinical pancreatitis - Transient Elevations in enzymes occur
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Pancreatic Mass
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Neuroendocrine Tumor
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Advantages over CT-guided Biopsy
• Ability to sample lesions (including lymph nodes) too small to be identified by TUS, CT or MRI
• Minimizing the risk of needle track seeding
• Ability to obtain accurate local staging
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Diagnostic Characteristics of EUS FNA for Pancreatic Mass Lesions
n Sensitivity (%) Specificity (%) Accuracy (%)
Giovannini [Endoscopy 1995;27(2)] 43 75 100 79
Cahn [AJS 1996;172(5)] 50 88 100 87
Bhutani [Endoscopy;1997;29(9)] 47 64 100 72
Chang [GIE;1997;45(5)] 44 92 100 95
Erickson [AFP 1997;55(6)] 28 -- -- 96
Faigel [JClinOnc1997;15(4)] 45 72 100 75
Gress [GIE1997;45(3)] 121 80 100 85
Wiersema [Gastro 1997;112(4)] 124 87 100 88
Binmoeller [GIE1998;47(2)] 58 76 100 92
560 81% 100% 86%
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Diagnosis by EUS FNA
• 102 patients with suspected pancreatic cancer with negative CT-guided FNA and/or ERCP sampling underwent EUS-FNA
• EUS-FNA was positive in 57 patients (56%)• 4 patients who had a negative EUS-FNA
subsequently were found to have pancreatic cancer
Gress F, et al. Endoscopic ultrasonography-guided fine needle aspiration biopsy of suspected pancreatic cancer. Ann Intern Med. 2001;134:459-64.
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Follow up Study of EUS FNA Accuracy in Suspected Pancreatic CA with prior
negative CT/ERCP biopsies (Harewood et al Am J Gastro 2002 97(6)
E U S F N Ah a d 9 0% se ns itiv i ty
fo r d e te ctin g m a lign an cyw ith a n o ve ra ll 84 % a ccu ra cy
58N e ga tiv e C T F N A
B iop sy
E U S F N Ah a d 9 4% se ns itiv i ty
fo r d e te ctin g m a lign an cyw ith a n o ve ra ll 92 % a ccu ra cy
36N e ga tive E R C PT issue S a m pling
1 85S u b je c ts w ith kn o w n o r susp ec ted
P a nc rea tic C a nc er
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Lymph Node FNALymph Node FNA
Hitachi EUB-6000Hitachi EUB-6000
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Diagnostic Characteristics of EUS FNA for
Peri-intestinal Lymph Nodes n Sensitivity (%) Specificity (%) Accuracy
(%)
Bhutani [GIE 1997;45(6)] 22 100 100 100
Chang [GIE 1997;45(5)] 14 83 100 88
Erickson [AFP 1997;55(6)] 14 100 100 100
Gress [GIE 1997;45(3) 56 - - 93
Wiersema [Gastro 1997;112(4)] 192 92 93 92
Binmoeller [GIE 1998;47(2)] 43 91 100 95
Reed [AIS 1999;67(2)] 57 72 97 86
398 90% 98% 93%
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Diagnosis by EUS FNA
• Molecular markers from EUS FNA can differentiate pancreatic neoplasia requiring surgery from benign conditions and chronic pancreatitis (Anderson, et al)
• EUS FNA of pancreatic duct fluid in the evaluation of pancreatic cancer (Davila, et al)
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Metastatic MelanomaMetastatic Melanoma
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Bile Duct CancerBile Duct CancerCholangiocarcinomaCholangiocarcinoma
• Difficult to see a mass with EUSDifficult to see a mass with EUS• Difficult pathological diagnosis to Difficult pathological diagnosis to
make pre-operativelymake pre-operatively• Sensitivity of EUS with FNA is low ~ Sensitivity of EUS with FNA is low ~
60%60%
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Staging Cholangiocarcinoma with EUS
• Staging cholangiocarcinomas with EUS
• Role of intraductal US
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EUS for Pancreatic Neoplasms
• Ductal adenocarcinoma– Diagnostic/Staging Accuracy– Negative Predictive Value
• Fine Needle Aspiration Biopsy• Neuroendocrine tumors• Miscellaneous: Lymphoma, Metastases• Cystic Neoplasms
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Normal Appearing Pancreas
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Negative Predictive Value of EUS for Pancreatic Carcinoma
Study Group
N NPV 95% CI
Kaufman 25 87% 60%-98%
Baron 32 88% 71%-96%
Brown* 74 96% 88%-99%
* 5-yr follow up; CA developed in 2 patients with EUS features of chronic pancreatitis
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T1 Pancreatic Head Carcinoma
16.3 mm x 13.1 mm
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EUS for Detection of Pancreatic Cancer
• Panc CA: 4th leading cause of Ca death in men and women
• Overall 5-yr survival = 4%• Survival is inversely proportionate to tumor
size• Small tumors, LN (-), Vascular Invasion (-) =
25% 5-yr survival• EUS superior to CT/MR for lesions < 2-cm• Accurate detection of small lesions impacts
timing and type of therapyAhmad et al. Amer J Gastroenterol 2001;96:2532-4.
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T3 Pancreatic Cancer
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EUS T-Staging Accuracy
Author # Staged by EUS
# Surgical Patients
Staging Accuracy
Accuracy
Buscail1999
73 26 19/26 73%
Gress1999
151 75 64/75 85%
Ahmad2000
na 89 55/79 69%
Total 190 138/180 77%*
* 95% CI = 70%-83%
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EUS N-Staging Accuracy
Author # Staged by EUS
# Surgical Patients
Staging Accuracy
Accuracy
Buscail 73 26 18/26 69%
Gress 151 71 51/71 72%
Ahmad na 89 35/67 54%
Total 186 104/164 63%*
* 95% CI = 56%-71%
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EUS vs Helical CT for Pancreatic Cancer
Series EUS CT EUS CT EUS CTLegman1998 27/27 25/27 20/22 19/22 6/7 7/7Midwinter1999 33/34 26/34 25/30 23/30 13/16 9/16Tierney2001 30/31 25/31 16/16 10/16Mertz2000 29/31 16/31 16/16 13/16 6/6 3/6
Total 97%* 73% 91% 83% 91%* 64%
* P < 0.001
DetectionAccuracy
of resectabilit
y
Sensitivity for
vascular invasion
When both EUS and MRI agree on resectability, 89% of cases were resectable
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EUS Guided FNA for Pancreatic Tumors
• Sensitivity = 90%• Specificity = 100%• Accuracy = 94%• For lesions as small as sub-cm• Yield is enhanced with on-site
cytopathologist• May require up to 3-5 passes• Biopsy primary, LNs, & liver lesions
Faigel et al. J Clin Onc 1997;15:1439-43Faigle et al. Diagn Cytopath 1998;18:98-109
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EUS for Pancreatic Neuroendocrine Tumors
All Tumors Gastrinomas Insulinomas
N 75 36 36Sensitivity 93% 100% 88%Specificity 95% 94% 100%PPV 98% 95% 100%NPV 83% 100% 43%Accuracy 93% 97% 89%
Anderson, et al. AJG 2000;95:2271-7
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Pancreatic Lymphoma
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EUS for Non-Pancreatic Primary Tumors
• Lymphoma– FNA diagnosis with flow cytometry– Good prognosis– Directed therapy
• Metastases– Breast– Renal Cell
Lewis et al. AJG 1998;93:834-6
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Overview
• EUS– Anti-tumor therapy– Palliation of jaundice– Palliation of pain
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EUS Guided radio-frequency or ETOH tumor ablation
Goldberg. GIE 1999;50:392Barclay. GIE 2002;55:266
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Immune Therapy
Background• Tumors are immunosuppressive and block the host
immune response
• Injection of lymphocyte culture (“Cytoimplant”) directly into tumors may block tumor immunosuppression and enhance host immune response
• Phase I study using Cytoimplant performed on pancreatic cancer showed extended survival and no toxicity
Chang et al. Cancer 2000; 88:1325-1335
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Phase II-III Studies of Cytoimplant
Results• Multi center study
• Compared Cytoimplant to Gemcitibine
• Study stopped because interim analysis showed chemotherapy was better than Cytoimplant
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Viral Therapy-backgroundONYX-015 viral therapy
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EUS- guided injection of Onyx 015 for pancreatic cancer
• 18 pts • Concomitant gemcitibine• 3 minor responses (< 50% tumor
reduction)• 2 sepsis, 1 abscess, 2 duodenal
perforations
Bedford et al. Gastointest Endosc 2000;51(4):AB 97
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Gene Therapy TNF-α
• TNF-α strong anti-tumor activity• TNF-α high toxicity with systemic administration• TNFarade-adenovirus vector carries the TNF-α gene• Gene promoter is radiation inducible• 37 Pts with locally advanced pancreatic Ca injected
with TNFarade followed by Chemo/XRT• Tumor stable or decrease in size in 74% at 3 mo
Chang KC. Gastrointest Endosc. 2004Farrell JJ. Gastrointest Endosc. 2006;63 AB93
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Local ChemotherapyPaclitaxel (OncoGel)
• OncoGel– Water soluble hydrogel– Releases paclitaxel continuously up to 6 weeks
• Porcine model• EUS guided injection of OncoGel• High and sustained concentration in pancreas• No toxicity
Matthes K. GIE 2007;65:448
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Palliation of Jaundice
If ERCP fails, is there an alternative to PTC or surgical drainage?
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Interventional EUS
EUS-guided injection for diagnosis
Cholangiography Wiersema et. al., 1995 GIE Pancreatography
Gress et. al., 1996 GIE
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EUS GUIDED Hepatico-Gastrostomy
Sahai GIE 1998;47:AB37Gastrointest Endosc. 2006 Jul;64:52
Panc. cancer
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EUS GUIDED CHOLEDOCHO-DUODENOSTOMY
Kahaleh GIE 2004;60:138-42
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What is the best way to palliate pain in pancreatic cancer?
Narcotics? or Celiac Plexus Block?
How about chronic pancreatitis?
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Chronic Abdominal Pain
Can be a clinically challenging problem. Management of chronic pain can be difficult There are many approaches to treating the
patient with chronic pain: - narcotic analgesia - celiac plexus block - surgery (ie; ganglionectomy)
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Why CPB or CPN?
• Pain relief• Palliative• Improve quality of life
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EUS-Guided Celiac Plexus Block and
EUS-Guided Celiac Plexus Neurolysis
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Celiac Plexus BlockCeliac Plexus Block
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Fine Needle AspirationFine Needle Aspiration
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Celiac Plexus BlockCeliac Plexus Block
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EUS Guided Celiac Plexus Block
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• Pain score reduction in 78% of patients• Mean pain score decreased by 50%
EUS-guided Celiac Plexus Neurolysis for Cancer
Gunaratnam NT, GIE 2001;54:316
58 patientspancreatic cancer
Follow-up 6 mo
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Relationship between pain and survival in pancreatic cancer
Pain correlates with resectability p=0.04
• No pain before op 15 mo
• Pain before op 5.7 mo
Median Survival
Kelsen et al Surgery 1997;122(1):53-9
P=0.003
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Effect of neurolysis on survival
• Neurolysis decreased pain scores and delayed or prevented onset of pain compared to placebo p<0.05
• In patients with pre-operative pain, neurolysis improved survival compared to placebo p<0.0001
137 pts randomized to intra-opneurolysis or placebo
Lillemoe et al Ann Surg 1993;217(5):447-55
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Effect of Neurolysis on Pain, Survival and Quality of Life
• Pain reduction at 1 week• % of patients with pain > 5/10• Survival at one year• Quality of life
100 Patients randomized to percutaneous celiac block or analgesic p.o. + sham block
Neurolysis Analgesic
53% 27% P=.005
14% 40% P=.005
16% 6% P=0.26
No difference
Wong GY et al. JAMA 2004:292:1092-99
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Meta Analysis of 5 RCT-302 patients
Yan BM. Am J Gastroenterol. 2007;102:430
Narcotic use at 2 and 8
wks
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Meta Analysis of 5 RCT-302 patients
Yan BM. Am J Gastroenterol. 2007;102:430
Survival at8 wks
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CT vs. EUS CELIAC PLEXUS BLOCK FOR TREATMENT OF PAIN ASSOCIATED WITH
CHRONIC PANCREATITIS
Pain benefit @ 8 wks 40% 25%
Pain benefit @ 24 wks 30% 12%
CTN=8
EUSN=10
Gress. Am J Gastroenterol 1999;94:872-4
Bupivacaine + Triamcinolone
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EUS-guided celiac plexus block for chronic pancreatitis
• 55% experienced significant improvement in pain score
• Mean pain score @ 4 and 8 wks: 8 2 p< 0.05• 26% experienced benefit > 12 wks• 10% experienced benefit > 24 wks
90 patients
Age < 45 and prior pancreatic surgery predictedno benefit to EUS-Guided Celiac Block
Gress. Am J Gastroenterol 2001;96:409-16
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Efficacy of EUS Guided Celiac Plexus Block (CPB) for Managing Abdominal Pain
Associated with Chronic Pancreatitis (CP): A Meta-analysis
• Aim: To evaluate the efficacy of EUS-guided CPB in alleviating chronic abdominal pain in CP
• Method: A Medline database search was performed of the English literature for trials evaluating the efficacy of EUS-CPB for the management of chronic abdominal pain in CP
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Efficacy of EUS Guided Celiac Plexus Block (CPB) for Managing Abdominal Pain
Associated with Chronic Pancreatitis (CP): A Meta-analysis
• The diagnosis of CP was based on clinical presentation and a minimum of 4 EUS features of CP
• Studies involving less than 10-patients were excluded. • Data on pain relief was extracted, pooled, and analyzed.• A Bayesian hierarchical model for the meta analysis was
developed. A Markov Chain Monte Carlo algorithm was implemented in the analysis.
• Results: 6-relevant studies were identified comprising a total of 221 patients. EUS-guided CPB was effective in alleviating abdominal pain in 52.44% of patients (95% CI 31.64, 74.9).
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Study
Pain relief reported out of total patients
Observed proportion Analysis for proportion Quartiles
Estimates SE 95% CI 25% 50% 75%
Gress et al 1999 5/10 0.5 0.5037 0.1308 (0.2538 , 0.7556) 0.4117 0.5032 0.5958
Gress et al 2001 50/90 0.55 0.5539 0.0511 (0.4500 , 0.6517) 0.52 0.5565 0.5898
Levy et al 2007 5/13 0.39 0.4099 0.1185 (0.1962 , 0.6508) 0.324 0.4075 0.4916
O’toole et al 2007 20/31 0.65 0.6314 0.0826 (0.4616 , 0.7831) 0.5762 0.6361 0.6873
LeBlanc et al 2007 27/51 0.53 0.5289 0.0681 (0.3959 , 0.6647) 0.4816 0.5279 0.5753
Stevens et al 2007 16/26 0.62 0.6025 0.0887 (0.4255 , 0.7661) 0.5423 0.6056 0.6641
Over All Studies 123/221 0.5244 0.1106 (0.3164, 0.7479) 0.449 0.5244 0.5994
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Efficacy of EUS Guided Celiac Plexus Block (CPB) for Managing Abdominal Pain
Associated with Chronic Pancreatitis (CP): A Meta-analysis
StudyGress 01Gress 99Levy 07O’toole 07LeBlanc 07Stevens 07
Summary
Observed0.55
0.50.390.65
530.62
Estimated0.55390.50370.40990.63140.52890.6025
0.52440.2 0.3 0.4 0.5 0.6 0.7
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Efficacy of EUS Guided Celiac Plexus Block (CPB) for Managing Abdominal Pain
Associated with Chronic Pancreatitis (CP): A Meta-analysis
Conclusion Meta-analysis demonstrates that EUS-guided
CPB results in the reduction of abdominal pain due to CP in at least 50% of patients.
Appropriate patient selection and refinement in technique will likely lead to better results. Further prospective randomized trials are needed.
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Conclusions• EUS
– Can deliver targeted anti-tumor therapies – Can provide biliary and pancreatic drainage – Celiac plexus neurolysis should be considered first line therapy
for in pancreatic Ca pain– Celiac plexus block has a limited role in selected patients with
chronic pancreatitis• ERCP with Direct Cholangioscopy
– Direct visualization– Targeted biopsy – Therapy
Unlimited opportunities for the future