A Comparison of Ultrasound and Fluoroscopy-Guided Celiac Plexus Neu- Rolysis in Patients with Pancreatic Cancer

246 Send Orders for Reprints to [email protected] Current Cancer Therapy Reviews, 2020, 16, 246-252

RESEARCH ARTICLE

ISSN:1573-3947 eISSN:1875-6301 A Comparison of Ultrasound and Fluoroscopy-guided Celiac Plexus Neu- rolysis in Patients with Pancreatic Cancer

BENTHAM SCIENCE

Khadeja M. Elhossieny¹,*, Waseem M. Seleem², Sherief Abd-Elsalam3, Tamer Haydara4, Nashwa Mohamed El Gharbawy5

1Anaethesiology Department, Faculty of Medicine, Zagazig University, Ash Sharqia Governorate 44519, Egypt; 2Internal Medicine Department, Hepatology and Endoscopy Division, Zagazig University, Ash Sharqia Governorate 44519, Egypt; 3Tropical Medicine Department, Tanta University, Tanta, Egypt; 4Faculty of Medicine, Kafrelsheikh Uni- versity, Kafr El Sheikh, Egypt; 5Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt

Abstract: Background & Aims: Celiac plexus neurolysis is an elegant way of reducing pain in patients with pancreatic cancer. The aim of this work was to compare the effectiveness of ultrasound versus fluoroscopy-guided celiac plexus neurolysis in pancreatic cancer management. Methods: This study included 60 patients presenting with pancreatic cancer pain; who were subjected to one session of celiac plexus neurolysis and were divided equally into two groups: - Group (1): included 30 patients (12 females&18 males); who were exposed to ultrasound (US)- guided celiac plexus neurolysis and group (2): included 30 patients (10 females & 20 males) who A R T I C L E H I S T O R Y were exposed to fluoroscopy-guided celiac plexus neurolysis. Abdominal pain was assisted by visual analogue score (VAS). Received: March 06, 2019 Revised: August 05, 2019 Results: Regarding VAS, our results revealed that all patients showed improvement after celiac Accepted: August 08, 2019 plexus neurolysis either through ultrasound technique or via percutaneous fluoroscopy technique. DOI: 10.2174/1573394715666190904091145 Furthermore, the ultrasound group recorded more significant pain relief with improved VAS than the fluoroscopy group immediately and on long-term follow-up with mean ± SD as follows: - Immediately (9.2 ± 0.8) to (2.5 ± 0.7) vs. (9.1 ± 0.7) to (3.5 ± 0.82, respectively); After 1 week (1.1 ± 0.8 vs. 3.6 ± 1.7, respectively), after 1 month ( 1 ± 0.9 vs. 3.7 ± 1.9), after three months (1.7 ± 1.01 vs. 5.9 ± 1.7, respectively) and after 6 months (2.3 ± 0.6 vs. 7.5 ± 1.6, respectively). Conclusion: The study revealed that ultrasound-guided celiac plexus neurolysis is more durable, tolerable, effective and safe compared to fluoroscopy-guided neurolysis of patient suffering from pancreatic cancer pain.

Keywords: Celiac plexus neurolysis, pain, management, visual analogue score, analgesia, pancreatic cancer, ultrasound- guided, fluoroscopy-guided.

1. INTRODUCTION muscles. The medical analgesia of pancreatic cancer begins with opioid drugs, such as paracetamol, to opiates, such as Pancreatic cancer incidence has dramatically increased tramadol and, ultimately, stronger opioids, such as morphine over the past decade. It is worth noting that for pancreatic or fentanyl. However, the dosage of opioids sometimes cancer patients, the standard survival rate in 5 years is about reaches a level of inducing side effects, such as nausea, con- 6-10%; thus, palliative treatment is critical in management stipation, drowsiness, addiction, confusion or respiratory [1-4]. depression, and failure to achieve adequate attenuation [5]. In this context, pain is one of the most important symp- In these cases, nerve-destructive methods, involving the toms to be treated. In the initial stage, the pain is visceral, major pancreatic pain pathways such as celiac block or but with the development of the disease, somatic and not just thoracoscopic splanchnicectomy, appear to be effective [6]. visceral pain may occur, especially because of the invasion across the pancreas of the peri-pancreatic neural structures or Pain control by celiac plexus neurolysis can be achieved by injecting a neurolytic agent such as phenol or alcohol around or into the celiac plexus to disrupt the neural im- pulses to the brain [7]. *Address to correspondence to this author at the Tropical Medicine Depart- ment, Tropical Medicine Department, Tanta University, Tanta, 35127, Percutaneous celiac plexus neurolysis significantly de- Egypt; Tel: 201147773440; E-mail: [email protected] creased opioid dose requirement in patients with pancreatic Current Cancer Therapy Reviews 1875-6301/20 $65.00+.00 © 2020 Bentham Science Publishers A Comparison of Ultrasound and Fluoroscopy- guided Celiac Plexus Current Cancer Therapy Reviews, 2020, Vol. 16, No. 3 247 cancer pain when compared with patients treated with medi- baseline mean arterial blood pressure, heart rate, and oxygen cal therapy [8]. saturation were taken. Opioid use was not a prerequisite to enter in this study. Since the description of percutaneous celiac plexus neurolysis; improvements in this technique have been proposed 2.1. (WHO Modified Analgesic Step Ladder) Scale: to improve the success rate, reduce morbidity and enhance technical accuracy of the block. The routes used for celiac Step 1 (mild pain): non-opioid analgesics plus adjuvant. plexus neurolysis are anterior Trans-abdominal and posterior Step 2 (moderate pain): weak opioids plus non-opioid Trans-crural under guidance of fluoroscopy, computerized analgesics plus adjuvant. tomography, endoscopic ultrasound (EUS) and ultrasound get a real-time visualization of needle injection and avoid Step 3 (severe pain): strong opioids plus non-opioid an- intravascular injection in celiac artery [9]. algesics plus adjuvant. The aim of this work was to compare the effectiveness of Step 4: interventional techniques [10]. ultrasound versus fluoroscopy-guided celiac plexus neuroly- 2.1.1. Ultrasound-guided Celiac Plexus Neurolysis sis in pancreatic cancer management. Patients lied in supine position; IV sedation was per- 2. MATERIALS AND METHODS formed using midazolam (0.01-0.02 mg/kg). Sterilization of the abdomen was done and covered by sterile drapes, curvi- This study was performed in Zagazig University Hospi- linear transducer was applied at subxiphoid region or epigas- tal; Tanta University hospital and Kafr-Elsheikh University tric area to define the common celiac trunk at its origin from Hospital, Anesthesiology Departments, pain clinic units in the aorta. After sterilization, skin anesthesia by Lidocaine collaboration with gastroenterology units in internal medi- 2% was done and a 20-gauge 15 cm-20 cm Chiba needle was cine department in these major university hospitals in the introduced into the epigastrium via paramedian approach to period from November 2016 to June 2018. Institutional ethi- the transversely placed ultrasound transducer. Under ultra- cal committee approval was obtained, and informed consent sonographic guidance, the whole needle was well-defined was signed by every patient before the start of the study. All and the needle tip was advanced into the area of the celiac authors had access to the study data, and reviewed and ap- trunk. Once the tip of the needle was in position, aspiration proved the final manuscript. The study included 60 patients was done to confirm that the needle tip is not inside blood suffering from abdominal pain due to pancreatic cancer; they vessel then diagnostic block was performed by injecting a were equally divided as follows; Group (1) that included 30 local anesthetic (10 ml of 0.25% bupivacaine 0.5%) for the patients (12 females & 18 males) subjected to ultrasound- enforcement of a diagnostic celiac plexus block, 10 min after guided celiac plexus neurolysis using10 ml of 0.25% successful prognostic block, 20 ml of 100% ethanol was in- bupivacaine +20ml of 100% alcohol; group (2) that included jected under US guidance. Ethanol appears echogenic on 30 patients (10 females & 20 males) subjected to fluoros- ultrasound. Before the needle was removed, 2 ml of lido- copy-guided celiac plexus neurolysis using 10 ml of 0.25% caine1% was injected to avoid irritation by alcohol then pa- bupivacaine +20 ml of 100% alcohol. tients were observed for 2 hours in the recovery room and reevaluated using VAS for assessment of the degree of pain The study included patients complaining of upper ab- relief. The assessment ranges from 0 (no pain) to 10 (severe dominal cancer pain due to pancreatic cancer, which was not pain). VAS was scored immediately after injection, 1 week, controlled by step (3) WHO analgesic step ladder and/or 1 month, 3 months and 6 months later post-neurolysis. Anal- those suffering from a complication of analgesic drugs. gesic requirements and complications were documented. Patients who refused to participate in the study, patients Recurrent abdominal pain was treated according to WHO with coagulopathy (INR >1.5), thrombocytopenia (platelets analgesic step ladder. < 50 000/cu mm), severe colonic gas distension, altered anat- 2.1.2. Percutaneous fluoroscopy-guided Celiac Plexus Neu- omy (e.g. gastric bypass surgery, huge lymphadenopathy or rolysis active abdominal infection were excluded from the study. Patient lied in prone position using pillow under abdo- Complete history of all the patients was taken, complete men to flat the lumbar vertebrae in the lumbar region, after physical examination was conducted to obtain a baseline taken deep sedation using (0.01-0.02 mg/kg) midazolam and pain score using visual analogue score(VAS) (range: 0-10) 0.5 mg/kg ketamine, complete sterilization and towels drapes with ‘0’means no pain and ‘10’ means severe pain, and rou- were done, posterior approach using a 20-gauge 15-20 cm tine investigations including platelets count, INR, abdominal Chiba needle advanced using walking off the vertebra and ultrasound and chest X-ray and pain medications were positioned two centimeters anterior to the upper border of stopped overnight. the first lumbar vertebra. Aspiration was done to rule out the Patients were treated according to WHO analgesic step presence of needle in blood vessels. Contrast was injected to ladder, post-procedure VAS score was recorded immediately confirm the correct position of the needle tip guided by fluo- and one week, 1 month, 3 months and 6 months later after roscopy, diagnostic block using 10ml of 0.25% bupivacaine the procedure. The scoring chart was explained to the patient 0.5%, then 20 ml of 100% ethanol was injected followed by before they were randomized to celiac plexus neurolysis. 2 ml 1% xylocaine, and then patients were observed for 2 h Patients came to the operating room fasting for 8 h and had in the recovery room and reevaluated using VAS for assess- IV cannula size 20 G, all patients received 500 ml ringer ment of the degree of pain relief. The assessment ranges solution,1g ceftriaxone IV, standard monitors were used, and from 0 (no pain) to 10 (severe pain). VAS was scored imme- 248 Current Cancer Therapy Reviews, 2020, Vol. 16, No. 3 Elhossieny et al.

Table 1. VAS assessment before and after neurolysis.

M6 M3 M1 W1 Immediate Pre -

2.3 ± 0.6 1.7 ± 1.01 1 ± 0.9 1.1 ± 0.8 2.5 ± 0.7 9.2 ± 0.8 Group 1

7.5 ± 1.6 5.9 ± 1.7 3.7 ± 1.9 3.6 ± 1.7 3.5 ± 0.82 9.1 ± 0.7 Group 2

0.001 0.001 0.001 0.001 0.001 0.85 *P P>0.05 insignificant*. P<0.001 highly significant*.

Yellow arrow=Pancreatic cancer; red arrow=Aorta; black arrow=Celiac trunk.

Fig. (1). A case with pancreatic cancer. diately after injection, 1 week, 1 month, 3 months and 6 One month later after the procedure; the decrease in pain months post-neurolysis. Analgesic requirements and compli- severity was maintained in the first group (1 ± 0.9) vs. 3.7 ± cations were documented. Recurrent abdominal pain was 1.9 in the second group. Later, at the third month; pain sever- treated according to WHO analgesic step ladder. ity started to increase after three months (1.7 ± 1.01 vs. 5.9 ± Statistical presentation and analysis of the present study 1.7, respectively) and after 6 months (2.3 ± 0.6 vs. 7.5 ± 1.6, respectively (Table 2). was conducted, using the mean, standard deviation and chi- square test by SPSS V.20. Real-life images of the cases were recorded; with Fig. (1) shows a case of pancreatic cancer; and Fig. (2) shows ultra- 3. RESULTS sound-guided celiac plexus neurolysis and Fig. (3) shows Regarding VAS assessment before and after neurolysis; fluoroscopy-guided celiac plexus neurolysis. marked decrease in pain severity in both groups of patients Regarding complications; there were no major complica- was noted as there was a sharp fall of the VAS score in the tions, only two patients in the second group (6.66%) and six first day after neurolysis with the stationary course for 6 patients in the first group had diarrhea that spontaneously months (Table 1). resolved within two days while in the ultrasound group; Pre-neurolysis VAS score was 9.2 ± 0.8 for ultrasound there was only one patient (3.33%) vs. three patients in the group versus 9.1 ± 0.7 for fluoroscopy group with no signifi- fluoroscopy group who had postural hypotension; they were cant difference. Immediate pain relieve was accomplished managed with intravenous ringer solution; this might be at- after neurolysis in both groups, with pain severity decreasing tributed to celiac plexus neurolysis. Back pain was recorded markedly to 2.5 ± 0.7 for the ultrasound group in comparison in ten (33.3%) patients in the fluoroscopy group and this was to the fluoroscopy group (3.5 ± 0.82), one week after the managed by hot fomentations, topical analgesia and muscle procedure; the decrease in pain severity was maintained at relaxant. Neuritis was a rare complication that was 1.1 ± 0.8 regarding the first group & 3.6 ±1.7 in the second reported in only one patient in the study in the fluoroscopy group. A Comparison of Ultrasound and Fluoroscopy- guided Celiac Plexus Current Cancer Therapy Reviews, 2020, Vol. 16, No. 3 249

Black arrow showing ultrasound-guided celiac plexus neurolysis (after injection). Fig. (2). Ultrasound-guided celiac neurolysis.

Black arrow=Fluoroscopy-guided celiac plexus neurolysis (walk-off technique). Fig. (3). Fluroscopy-guided celiac plexus block. 250 Current Cancer Therapy Reviews, 2020, Vol. 16, No. 3 Elhossieny et al.

Table 2. Complications in both groups.

Hypotension Diarrhea Group Back Pain Neuritis No (%) No (%)

Group 1 1 (3.33%) 6 (20%) 0 (0%) 0 (%)

Group 2 3 (10%) 2 (6.66%) 10 (33.3%)) 1 (3.33%)

X2 1.07 2.3 10.4 0.4 P value 0.3 0.13 0.001 0.55

X2 = chi-square. group and that was managed by pregabalin 75 mg twice structures as the tip of the needle is anterior to the spinal daily. arteries and spinal canal [15]. Regarding post-procedure complications; the patients did 4. DISCUSSION not develop major complications, only one patient in PCFG Pancreatic cancer pain impairs quality of patients' life; group (3.33%) had neuritis in the form of burning sensation pain management is difficult in these patients as they may in nerve distribution which was resolved using oral pre- not respond to analgesics even opioid. Celiac plexus neuro- gabalin 75 mg twice daily for 5 days. This was matched with lysis provides a signiﬁcant pain relief in most of them [11]. Gunaratnam et al. who found that PCFG had neurological complications resulting from posterior spread of neurolytic In our study; Ultrasound-guided (USG) celiac plexus towards the lumbar plexus in 1% of patients [16], while in neurolysis technique provided more effective pain relief for USG group; no patient had developed neuritis as this tech- longer duration (up to six months) than fluoroscopy- guided nique provided better localization of the celiac plexus and neurolysis (PCFG) technique that provided pain relief only better-targeted injection so patients had less complications for three months, this may be related to the accuracy of the and less risk of intravascular injection. This was in agree- real-time image of USG technique that provided better visu- ment with Narouze and Gruber as they found most important alization of the needle trajectory and hence accurate and ef- advantage of the anterior approach is the lower risk of para- fective spread of the neurolytic drug to the target. This is in plegia [17]. agreement with Santosh et al. who found that PCFG technique provided pain relief for three months [12]. In our study, orthostatic hypotension developed in one patient (3.33%) in the USG group and three patients (10%) Gimenez et al. performed celiac plexus neurolysis (CPN) in the PCFG group and they had good response to intrave- under ultrasonographic guidance. There was complete pain nous ringer lactate 10-15 ml/kg infusion, this was in agree- relief in 61% of patients at first week, at six months and in ment with Santosh et al. who recorded orthostatic hypoten- 39% of patients for one year. They have attributed it to the sion in one patient in PCFG group. Regarding diarrhea; our hindrance of the spread of neurolytic solution around the study revealed 6 patients (20%) in USG group and 2 patients celiac plexus. Also, they recorded longer duration than that (6.66%) in PCFG group that spontaneously resolved within of our study; as our study included larger number of patients few days. Side effects in our study were fewer in incidence presenting with pancreatic cancer abdominal pain [13]. than that reported by Bhatnagar et al. who found that hy- In this study, as regards patient’s position; the USG tech- potension occurred in 15% of patients, diarrhea occurred in nique was more comfortable than PCFG technique because 55% of patients, and pain at site of injection occurred in 85% patients lied in supine position with mild sedation (IV mida- of the studied group [18]. zolam 0.01 mg/kg) and this provided easy accessibility and In this study; we found that US-guided procedure was management of their airway while in PCFG technique; pa- safer; as it avoided the unnecessary exposure of the patient tients lied in prone position with difficult accessibility and and physician to the radiation of fluoroscopy. Also, ultra- management of their airway and so; they required deep seda- sound guidance was quicker and economical as it provides a tion (IV midazolam 0.01-0.02 mg/kg). real-time imaging in contrast to fluoroscopy which carries In our study; USG technique is a real-time monitor tech- the risk of exposure to hazards of radiation; moreover; it is nique which provided better visualization of blood vessels time-consuming and expensive. and other soft tissues than PCFG technique that had relation Pain is one of the most common and painful symptoms in to bone only with poor anatomic resolution. Also, PCFG cancer patients. Abdominal pain is common in pancreatic technique does not distinguish the celiac plexus from the cancer as well as intra-abdominal malignancies like liver adjacent structures such as pancreas, blood vessels, tumors cancer and gastric carcinoma [19-22]. This is primarily due and lymph nodes [14]. to visceral interference arising from a primary or transitional Akhan et al. also found that ultrasound guidance is safe lesion involving the abdominal or pelvic viscera. and effective for celiac plexus block as it eliminates the risk The advantage of USG technique over fluoroscopy is that of inadvertent injection of ethanol into vascular or intradural it is less invasive, requires no deep sedation which is more A Comparison of Ultrasound and Fluoroscopy- guided Celiac Plexus Current Cancer Therapy Reviews, 2020, Vol. 16, No. 3 251 safe and tolerable. Ultrasound-guided technique is safe, ef- [2] Nienhuijs SW, van den Akker SA, de Vries E, de Hingh IH, Visser fective and should be attempted for celiac plexus block O, Lemmens VE. Nationwide improvement of only short-term sur- whenever possible as it almost completely eliminates the risk vival after resection for pancreatic cancer in the Netherlands. Pan- creas 2012; 41(7): 1063-6. of inadvertent injection of ethanol into vascular or intradural [http://dx.doi.org/10.1097/MPA.0b013e31824c3dbf] [PMID: structures. Mary and Remon recommended USG technique 22617713] as a safe and effective procedure in decreasing pain severity [3] Bosetti C, Bertuccio P, Malvezzi M, et al. Cancer mortality in in patients suffering from upper abdominal cancer with high Europe, 2005-2009, and an overview of trends since 1980. Ann success rates [23]. Oncol 2013; 24(10): 2657-71. [http://dx.doi.org/10.1093/annonc/mdt301] [PMID: 23921790] [4] Ziada DH, El Sadany S, Soliman H, et al. Prevalence of hepatocel- CONCLUSION lular carcinoma in chronic hepatitis C patients in Mid Delta, Egypt: In conclusion, USG celiac plexus neurolysis is more effi- A single center study. J Egypt Natl Canc Inst 2016; 28(4): 257-62. [http://dx.doi.org/10.1016/j.jnci.2016.06.001] [PMID: 27378258] cient, durable, safe, and easy technique than PCFG tech- [5] Abdelfattah AAM, Rizk F, Hawash N, Hanafy A, El-Kalla F, Abd- nique. Elsalam S. Randomized trial of preoperative administration of oral pregabalin for postoperative analgesia in patients scheduled for ra- AUTHORS’ CONTRIBUTION diofrequency ablation of focal lesions in the liver. Int J Hyperther- mia 2018; 34(8): 1367-71. All authors have substantially contributed to the concep- [http://dx.doi.org/10.1080/02656736.2018.1424946] [PMID: tion and design, acquisition of data, data analysis and inter- 29308685] pretation. All authors have agreed on the content of the [6] Seicean A. Celiac plexus neurolysis in pancreatic cancer: the endoscopic ultrasound approach. World J Gastroenterol 2014; 20(1): manuscript. 110-7. [http://dx.doi.org/10.3748/wjg.v20.i1.110] [PMID: 24415863] ETHICS APPROVAL AND CONSENT TO PARTICI- [7] Kambadakone A, Thabet A, Gervais DA, Mueller PR, Arellano RS. PATE CT-guided celiac plexus neurolysis: A review of anatomy, indica- tions, technique, and tips for successful treatment. Radiographics The research was approved from Faculty of Medicine, 2011; 31(6): 1599-621. Tanta University, Egypt (Approval no. 31358\02\17). [http://dx.doi.org/10.1148/rg.316115526] [PMID: 21997984] [8] Wong GY, Schroeder DR, Carns PE, et al. Effect of neurolytic celiac plexus block on pain relief, quality of life, and survival in pa- HUMAN AND ANIMAL RIGHTS tients with unresectable pancreatic cancer: a randomized controlled trial. JAMA 2004; 291(9): 1092-9. No animals were used for the studies that are basis of this [http://dx.doi.org/10.1001/jama.291.9.1092] [PMID: 14996778] research. All the humans used were in accordance with the [9] Ghai A, Kumar H, Karwasra RK. Ultrasound guided celiac plexus ethical standards of the committee responsible for human neurolysis by anterior approach for pain management in upper abdominal malignancy: Our experience. Anaesth Pain Intensive Care experimentation (institutional and national), and with the 2015; 19(3): 274-81. Helsinki Declaration of 1975, as revised in 2013 (http:// eth- [10] Miguel R. Interventional treatment of cancer pain: the fourth step ics.iit.edu/ecodes/node/3931). in the World Health Organization analgesic ladder? Cancer Contr 2000; 7(2): 149-56. [http://dx.doi.org/10.1177/107327480000700205] [PMID: CONSENT FOR PUBLICATION 10783819] Informed consent was signed by every patient before the [11] Staats PS, Hekmat H, Sauter P, Lillemoe K. The effects of alcohol celiac plexus block, pain, and mood on longevity in patients with start of the study. unresectable pancreatic cancer: A double-blind, randomized, pla- cebo-controlled study. Pain Med 2001; 2(1): 28-34. AVAILABILITY OF DATA AND MATERIALS [http://dx.doi.org/10.1046/j.1526-4637.2001.002001028.x] [PMID: 15102315] The authors’ institution does not allow public data [12] Santosh D, Lakhtakia S, Gupta R, et al. Clinical trial: a randomized access. trial comparing fluoroscopy guided percutaneous technique vs. endoscopic ultrasound guided technique of coeliac plexus block for treatment of pain in chronic pancreatitis. Aliment Pharmacol Ther FUNDING 2009; 29(9): 979-84. [http://dx.doi.org/10.1111/j.1365-2036.2009.03963.x] [PMID: None. 19222416] [13] Giménez A, Martínez-Noguera A, Donoso L, Catalá E, Serra R. CONFLICT OF INTEREST Percutaneous neurolysis of the celiac plexus via the anterior approach with sonographic guidance. AJR Am J Roentgenol 1993; The authors declare no conflict of interest, financial or 161(5): 1061-3. otherwise. [http://dx.doi.org/10.2214/ajr.161.5.8273610] [PMID: 8273610] [14] Wang PJ, Shang MY, Qian Z, Shao CW, Wang JH, Zhao XH. CT- guided percutaneous neurolytic celiac plexus block technique. Ab- ACKNOWLEDGEMENTS dom Imaging 2006; 31(6): 710-8. [http://dx.doi.org/10.1007/s00261-006-9153-5] [PMID: 17151902] Declared none. [15] Akhan O, Ozmen MN, Basgun N, et al. Long-term results of celiac Ganglia block: correlation of grade of tumoral invasion and pain re- REFERENCES lief. AJR Am J Roentgenol 2004; 182(4): 891-6. [http://dx.doi.org/10.2214/ajr.182.4.1820891] [PMID: 15039160] [1] Paulson AS, Tran Cao HS, Tempero MA, Lowy AM. Therapeutic [16] Gunaratnam NT, Sarma AV, Norton ID, Wiersema MJ. A prospec- advances in pancreatic cancer. Gastroenterology 2013; 144(6): tive study of EUS-guided celiac plexus neurolysis for pancreatic 1316-26. cancer pain. Gastrointest Endosc 2001; 54(3): 316-24. [http://dx.doi.org/10.1053/j.gastro.2013.01.078] [PMID: 23622141] [http://dx.doi.org/10.1067/mge.2001.117515] [PMID: 11522971] 252 Current Cancer Therapy Reviews, 2020, Vol. 16, No. 3 Elhossieny et al.

[17] Narouze S, Gruber H. Ultrasound-guided celiac plexus block and boembolic complication after transarterial chemoembolization in neurolysis. In: Atlas of ultrasound-guided procedures in interven- hepatocellular carcinoma. Eur J Gastroenterol Hepatol 2017; 29(3): tional pain management. 2011; pp. 199-206. 317-21. [http://dx.doi.org/10.1007/978-1-4419-1681-5_15] [http://dx.doi.org/10.1097/MEG.0000000000000790] [PMID: [18] Bhatnagar S, Gupta D, Mishra S, Thulkar S, Chauhan H. Bedside 27893491] ultrasound-guided celiac plexus neurolysis with bilateral parame- [21] Elwan N, Salem ML, Kobtan A, et al. High numbers of myeloid dian needle entry technique can be an effective pain control tech- derived suppressor cells in peripheral blood and ascitic fluid of cir- nique in advanced upper abdominal cancer pain. J Palliat Med rhotic and HCC patients. Immunol Invest 2018; 47(2): 169-80. 2008; 11(9): 1195-9. [http://dx.doi.org/10.1080/08820139.2017.1407787] [PMID: [http://dx.doi.org/10.1089/jpm.2008.0082] [PMID: 19021480] 29182438] [19] Sheta E, El-Kalla F, El-Gharib M, et al. Comparison of single- [22] Mansour L, El-Kalla F, El-Bassat H, et al. Randomized controlled session transarterial chemoembolization combined with microwave trial of scleroligation versus band ligation alone for eradication of ablation or radiofrequency ablation in the treatment of hepatocellu- gastroesophageal varices. Gastrointest Endosc 2017; 86(2): 307-15. lar carcinoma: A randomized-controlled study. Eur J Gastroenterol [http://dx.doi.org/10.1016/j.gie.2016.12.026] [PMID: 28082116] Hepatol 2016; 28(10): 1198-203. [23] Tadros MY, Elia RZ. Percutaneous ultrasound-guided celiac plexus [http://dx.doi.org/10.1097/MEG.0000000000000688] [PMID: neurolysis in advanced upper abdominal cancer pain. Egyptian J 27362551] Radiol Nuclear Med 2015; 46: 993-8. [20] Negm O, Abou Saif S, El Gharib M, Yousef M, Abd-Elsalam S. Role of low-molecular-weight heparins in prevention of throm-