It's good to be here. Thank you for spending your weekend with us. I know I was in the backwoods of Minnesota 24 hours ago, actually flew in to Indianapolis last night about midnight and got up again this morning to be here. So a lot of the work for my talk is from actually my former colleague who is here today, actually Julia LeBlanc. She left us about maybe 10 years ago, but a lot of her early career was involved with celiac plexus blocks. So I'll be citing some of our studies from IU Health as well. These are my disclosures. None of these are relevant to the talk today. So as Dr. Lee talked about definitions, I think it's important to talk about definitions for this technique because if you read the studies and look at the literature, particularly as it's evolved over time, the terms are different for different papers. So I want to make sure we're all on the same page. The term block or celiac plexus block generally refers to not use of an ablative agent, such as alcohol, radiofrequency ablation, or something that's designed to kill something. It's more designed to sort of mask the pain. So we would typically be calling this with like a cane, marcaine, bupivacaine, something like that. I use, you know, when people don't know what this is, I often, for women or for people who've had a child, you know, maybe those who've had an epidural, same medication. So a lot of times are there for their teeth and they might get numbing for their teeth. So that's really all a block is. A neuralysis implies that you're injecting something, typically alcohol, to kill something. So again, block versus neuralysis is important for the consent forms you'll see to understand what this is. Now, for the technique of actually applying that or injecting that stuff, there can be different ways. There can be a central, which is typically done with the needle right over where that notch of the aorta and celiac artery are, and then the fluid is just injected. That's typically a central injection. So it just diffuses everywhere, retroperitoneally. Bilateral would be where the endoscope is actually torqued on each side of the celiac artery, generally where the artery, you know, you see the artery, you turn it just a little bit, the artery goes away, you inject there, then you do the same thing on the other side. Broad plexus injection is, there's one study from Japan, which has looked at injecting actually all the way down to the SMA, and then coming back and doing this over the celiac artery. That's what they term as a broad plexus injection. The most recent literature, and where people probably do it today, is the ganglia injection. And there's either the ganglia alone or combined ganglia. Combined ganglia would be injecting into the ganglia, and then also after that, whatever's left over would just go diffusely, usually in a single central injection. Okay? So this is a cartoon. So the ganglia injection, this is a picture of what the ganglia actually look like. The ganglia alone would be into here, and then combined would be injecting your three to five CCs or eight CCs, and then the rest would be just diffusely over the celiac artery. So we have a lot of choices to make, and I'm going to try to answer some of these. So should you use an FNA needle, or should you use perhaps a 20-gauge celiac plexus needle, which I think is still available. I don't use it, but I think it's still available. I sort of alluded to, should you use the one side, or should you use a two-sided injection? Should we use steroids, or should we, particularly for patients who get celiac block, should we use steroids at all, or should we actually use alcohol? Should we inject into the ganglia, or should we not? For the celiac block, should we do this at all? Or if we do it, should we do it more than once? How many times can we do it? What are our endpoints for response? Is it quality of life? Is it morphine equivalents? Is it pain relief? How do we measure quality of life? Should we use antibiotics or not? When should we do the injection, particularly for cancer patients? Should we do it early, or should we wait until the problem happens? And then should we use the EUS, or should we go percutaneous? So you can see there are a lot of questions to answer. I'm not going to answer all of these. I'm going to try to allude to a lot of these, but again, when this, you know, typically when we see celiac block, we just go in there, inject the stuff, we're done, takes five to ten minutes. You get to build six and a half RVUs. By the way, make sure you build that's four, three, two, five, three. I didn't put that on here, but it's one of the easiest RVUs you'll ever make. But you know, the question is how should we do this? And I think there are some studies that help answer these questions and some that we don't have access to. So I'm going to start out with just celiac block. Again, this is referring to steroids and or bupivacaine for benign disease, okay? So again, this is not neuralysis, this is not cancer. Before EUS was first used for this in the early to mid-1990s, and again, this was done first at IU Health, well, actually it was IU back then, the primary way to do this was percutaneous. And you can see this is a really, I've never seen it done, I've only seen pictures, but you can imagine getting one or two needles through your back. They have to do this at a certain angle, usually 60 degrees or else they're going to hit a major structure. But this is the way they used to do this before EUS has since taken over. Some of the earliest studies, which I'm going to show you, were actually comparing EUS to the percutaneous approach. And this is one of those two trials. This is one of two published randomized controlled trials on looking at EUS versus percutaneous. And this enrolled from India, importantly, mostly idiopathic chronic pancreatitis, so take that for a grain of salt. But they randomized 56 subjects to either EUS guided in 27 or percutaneous in 29. And then a six-month follow-up, what they injected with was, they used 20-gauge, and they injected with bupivacaine and triamcinolone. And they measured pain scores three hours post-procedure, then up to six months using a visual analog score, and a positive response was considered a decrease of that visual analog score less than or equal to three, excuse me, greater than or equal to three. And there were no complications. And what you can see is that this is a Kaplan-Meier plot of the pain scores over time. And you can see it basically three hours after the procedure, almost everybody was better. If you look at one month out, you can see that the EUS is a little bit better than this percutaneous group. And over time, you can see that their end point, which was a return to pretreatment baseline pain, was much better with the EUS group. So this suggested that EUS was preferred with steroids and bupivacaine for treatment. Now, this was also confirmed in another randomized controlled trial. So I think this and the other trial really show that for celiac block, for benign disease, chronic pancreatitis, we should be using the EUS approach. We looked at comparing one versus two sides for EUS-guided celiac block. And we used 20 cc's of bupivacaine and then 80 milligrams of triamcinolone. This was before ganglia were really recognized as a way to possibly do this. And we have 51 patients, 23 with one injection, 28 with two. We found no difference in pain relief in one versus two. About 60% relief with both groups. About a quarter were able to reduce their pain medications. Interestingly, the time to relief was up to a week in some patients. And it lasted for up to a month in some patients. Two important things from this trial, no difference of one versus two. Most patients get an immediate relief. But it usually only lasts for up to a few weeks. Now, this is a lot of meta-analyses in this field, because we don't have a lot of data. So people who don't do this will then do randomized meta-analyses. But this is one of up to data through 2007. I'm showing this because it broke down chronic pancreatitis and cancer. But I'm just going to show you the data with chronic pancreatitis, because it's really the best one I've seen on this. This is the studies looking at over 10 patients and looking at celiac plexus block. And I'm just going to, this is a small slide. You probably can't read the font. But there were some prospective randomized trials done at our center when Frank Gress was there back in the early to mid-90s. Dr. LeBlanc did a prospective randomized studies. But you can see that the endpoints for a lot of these were visual analog scores where it's saying I have two out of 10, I have six out of 10. Other endpoints were persistence of pain. But what you can see from this, a couple of interesting things. This is actually the summarizing of the data. The relief you can see down here is only about 50%. So I tell patients who have, right here you can see 50%. This mouse isn't working very well, sorry. But to me, when I tell a patient with chronic pancreatitis that they are gonna get a celiac block, I tell them it's only about a 50-50 chance. So it really is not, I don't try to make them feel like this is going to be a panacea. If they get relief, the median duration of relief is going to be about a month. And that's what I tell patients. So the average patient is gonna get response in 50%. It probably will last about a month. So what that means is that some patients won't respond. And those that do respond, it probably won't last very long. Now, a very important question was asked by Tyler Stevens, and I don't see a lot of people adopting this for some reason, but I'm just gonna show, it's a very important study. The question is, are steroids necessary? I've never understood why people use steroids for this, because it's not an inflammatory condition. We don't know what goes on with the ganglia, and you're not injecting into the pancreas. So anyways, this was a single center blinded randomized trial of patients with painful chronic pancreatitis. And he randomized them to bupivacaine with steroids or bupivacaine alone. And then looking at questionnaires, baseline it at one month, primary endpoint was a decrease in the pain disability score of at least 10 points, and then a bunch of other secondary endpoints. But basically, what he found was that there was no benefit from the addition of steroids, whether he was using the intention to treat or per protocol analysis. No difference in pain scores, narcotic requirements, and this study was actually stopped early. So based on this, when this came out over 10 years ago, I have not given steroids to a patient with chronic pancreatitis in 10 years. So I think, again, it's something, the only data we have comparing the two, it's not difficult to add steroids, but to me, it's really added no benefit to patients. So I've stopped giving steroids to these patients. So the question is, can we give it more than once? And this is data from our institution that Julia LeBlanc published about 10 years ago. Looking at up to that point, 250 patients over 17 years that have been given CELAC blocks, really asking two important questions. Can we do it more than once? And if so, do they maintain response? And what you can see is that we started out with, out of those 248 patients who had CELAC blocks, we were able to evaluate 233 patients after that first block and about three quarters had relief. Of those who came back for number two, we had outcomes for 107. And if you look consistently down between 80 and 100% of patients were able to obtain relief. Now, this is retrospective data and this data is a little higher than most prospective studies cite. But what you can see is that there seems to be a group of patients who come back and are able to maintain relief. And what we looked at when we looked at patients who had relief with that first injection versus those who don't, those who obtained relief with that first block were more likely to obtain relief with that second block. So if patients are not getting relief with that first block, I'm kind of hesitant to bring them back again because they're probably not gonna get relief. But if they do get relief, I offer them, there's a pretty good chance we're gonna help you again. But oftentimes there's a decremental response in patients over time. When we looked at patients with or without EUS criteria for chronic pancreatitis, there was no difference between those two. A lot of these patients without evidence of chronic pancreatitis were SOD, three patients who were still having persistent pain after endoscopic therapy. Any questions with just the celiac block stuff before I move to neuralysis? If not, you can just hold the questions. Okay, so I'm gonna transition from block to neuralysis here. And again, I wanna emphasize just the points. This is usually with alcohol, so it's ablation. There's one injection versus bilateral. There's broad plexus, which is extending that injection diffusely down to the SMA. And then there's single ganglia versus single ganglia plus a diffuse injection. There's really not time to go over the entire literature, so I'll just kind of summarize just some of the important studies. Dr. Sahai from Montreal showed that bilateral was superior to unilateral, but we and others have found no difference between the two. This study published in Endoscopic Ultrasound 10 years ago showed no difference in central versus bilateral. We randomized patients to 10 versus 20, really didn't find any difference. This study, which is the only one using broad plexus injection, which was again, was they injected, they tried to get fluoroscopically up to six quadrants injected with the agent. They found that if they were able to get down to the SMA and then confirm that there was, in fact, injectate down there, they were more likely to get response. I'll only mention that there's this randomized control trial from the Florida group looking at RFA versus CPN. They found that the RFA was better when they were able to target that. It's the only study that I'm aware of where they did RFA, but again, something that I think we need more data looking at. Now, Dr. Levy and others really pioneered this maybe 10 to 15 years ago in that we can actually detect ganglia by EUS. Before I joined to IU Health back about 20 years ago, the guy that I actually replaced had detected these ganglia actually back in the 1990s. He FNA'd what he thought were lymphocytes, sorry, excuse me, lymph nodes. And our rapid onsite review were telling us we were getting ganglia. So that was when he first realized that we were actually seeing the ganglia, but he never published that. But the studies that have been looked at this showed that up to 80% and Dr. Levy actually had it in about 500 patients, up to 98% of patients were able to accurately differentiate ganglia from lymphocytes. So the question is, what do these ganglia actually look like? And this is a short video of ganglia. They tend to look like these little sausage shaped structures. This is a video, this is the left adrenal and the left kidney. Here's the left adrenal. You can see that as I come back towards the aorta, there's this structure right here, which can often appear and change. They're often irregular, they're dark. And sometimes you can actually trace these down to the SMA, but you can see right here that I'm outlining and just marking. This is what a celiac ganglia looks like. This is right next to the left crystal diaphragm. And when you inject these, I usually try to go very, very slowly because I don't want to spill this if I can avoid it. But if you inject these very slowly, half CC every 10 seconds or so, you can often see these expand. They become these large, big, giant hot dogs instead of just these little small, skinny hot dogs. But when you see ganglia and inject them, this is, again, what I'm trying to go for. Lymph nodes in this area tend to be more circular. You can sometimes see that stripe running through them. But the location of these, I found, is a lot easier to find on the left side versus the right side. So if you rotate your scope clockwise towards the left adrenal and the kidney, it's often much easier to see these. Just make sure when you're injecting these or trying to visualize this, you're not getting the wing of the adrenal. It can look a lot like that where that wing of the adrenal has that sort of, I guess, longitudinal appearance. Just rotate a little bit more away from that and you'll find it. Let's see. All right, so when the detection of the ganglia came out, there was a lot of interest initially into the question of are we better injecting the ganglia or are we not? Some early studies from the University of Miami and others, which I don't have here, showed that the detection and injection of the ganglia was an independent risk factor to improve pain scores. So this was one of two randomized control trials looking at detection of, is ganglia neuralysis better than just injection alone? And what this study found was that there was a barely statistically relevant decrease in pain scores with the ganglia neuralysis. Again, about 30 patients in both studies, but the duration of response was really not different between the two groups. So this study suggested that perhaps pain relief could be better with ganglia neuralysis. Now this study didn't get as much press as I think it should have, but this was a study where Mike Levy really did a wonderful job randomizing patients with pancreatic cancer to ganglia neuralysis versus what would be considered a combined approach. So he had one group got basically just a single injection broadly on both sides. The other group got ganglia injection until it was finished and then a diffuse injection. And what he found was that, again, numbers of pain response are lower in the 50% range that typically the prospective studies found. No difference between the two groups, but what he found was that survival was shorter in the group that got the ganglia neuralysis, okay? Suggesting that maybe we're actually doing something detrimental to these patients. This decrease in quality, I'm sorry, decrease in survival was greatest for the patients who had non-metastatic cancer. So in other words, your patient with maybe just portal vein invasion. Now this, there was no difference in quality of life and no difference in adverse events, but the study suggests, it doesn't convince, but it strongly suggests that in patients who have pancreatic cancer, who have perhaps potentially resectable disease, we shouldn't be doing a ganglia neuralysis, okay? There's no followup with this, but this study was obviously very well done in prospective randomized trial, but I think should call into question us doing ganglia neuralysis, particularly for pancreatic cancer patients who have potentially early disease. This study is a meta-analysis of studies looking at the difference in techniques. This was published last year in Pancreatology and they looked at three primary techniques. You can see there's the central injection, where it's just the one injection and poof and you're done. Bilateral injection, putting it on both sides, and then the final one was the ganglia neuralysis. And if you look at the data, there's really no difference in week one, week two, I'm sorry, week one, week four, or week eight. But what you can see consistently across the studies is there's about a 50 to 60% relief early, but that there's just a gradual decrease over time of about 10 to 15% over about a four to eight week period of time. So by week eight, you can see you're getting relief of between maybe 40% or 30%. And this looked at the difference, is there any difference in response by the bilateral, the central, or the single ganglia injection? The answer is no. They all seem to get about a 50 to 60% response at two weeks and then again at four weeks. Now, I can't talk about CPN without talking about adverse events. The most common adverse events that are reported, as you can see across the list, are diarrhea, hypotension, and then increased pain. There are patients who you do the neuralysis and they actually wake up in recovery and they're worse off than they were when they walked in. And those are obviously very scary. You're wondering, did I have an adverse event? How long is this gonna last? Your patient's asking you, I thought I came here to feel better. There are patients who have diarrhea for three to four days afterwards. And then some patients actually, you can see their blood pressure drop in recovery. So what I do is I tell patients up front they may have diarrhea. They may wanna increase their fiber or take perhaps those who have diarrhea up front, maybe take something to bulk up their stools. I give patients usually a half liter or a liter of saline, a little bit pre-procedurally, and then continue with that in recovery until they're done. So I tell the nurses to open it wide open unless their blood pressure is like 170 systolic or something, I usually tell them to finish that liter. The most worrisome adverse events are these two down here. They call it spinal ischemia or paralysis or paraplegia. There are reports of this. And I think it's important to tell patients that there are this one in 10,000 to one in 100,000 risk that they could have a severe adverse event. There's been deaths reported. There's been spinal paraplegia. There's been gastric necrosis. And these are just some other, lethal necrosis and perforation of the stomach, fatal complication after a neuralysis, hepatic and splenic infarction, anterior spinal cord infarction. Again, obviously these are very scary adverse events. I think I do tell patients that this is a risk for this. One way to minimize the chance of this happening is to use just the central injection. The other study, which I showed you back here. Let's see if I can go back. You can see the two spinal cord infarctions here. They call the spinal strokes with a ganglia injection. This has not been reported with just a central injection. So just again, more evidence and maybe you just wanna do the central injection as opposed to ganglia. But one of the things which is important is just to make sure your needle is actually out of the stomach wall. Then you're not injecting alcohol directly into the stomach. Make sure that needle has actually penetrated the gastric wall so you're not injecting alcohol there. Just to finish it up about, this is looking at adverse events between celiac block and CPN. You can see that for the celiac plexus block, the first 481, major complications, 0.6%, minor complications, again, diarrhea, hypotension and pain. Celiac plexus neuralysis, major complications, 0.2%. So just an important number to remember, 0.2% for severe adverse events. Now, when I started doing a lot of neuralysis, particularly as patients who had more pain afterwards, I would get this call from the ER outside. And this is actually a patient of mine from over 10 years ago. The patient was four hours, six hours, post celiac neuralysis. They went to the hospital ER with pain and they got a CT scan and this is what they had. And the ER called me all freaking out that there's this fluid around the celiac artery and there's air. And it took me a while to say, okay, wait a minute. This is what I did. Dr. LeBlanc, one of my colleagues, did a study on fluoroscopy. You see this stuff going all the way up and down the aorta. And this is why they get this. And it's not a reason to freak out. It's kind of like when we see pneumoperitoneum after POEM. It's again, ER doctors and radiologists need to be aware that this is something that we see. But if your patient has pain, you see a little bit of air right around the celiac artery, don't freak out. If you see obviously massive pneumoperitoneum, then that's a different story. The problem is when patients have a lot of pain after a neuralysis, it could be one of these major complications and you sometimes just don't know. It's probably a good idea to get a CT scan to make sure you're not dealing with one of those. All right, so what do I do? For celiac plexus block, for chronic pancreatitis, I offer it to patients who have continued pain that maybe endoscopic therapy has not worked. They may have chronic pancreatitis. It doesn't require endotherapy at that point. I'll offer it at least one time. I use Bupivacaine alone. I don't do neuralysis in these patients. I do sometimes do a ganglion block if I see it because I think there's just not the concern about the decreased life expectancy with these patients compared to cancer. I usually use a 22-gauge needle. I reserve alcohol for cancer patients. We do use this for patients who don't have pancreatic cancer. So there are patients who have perhaps diffuse lymphoma if they have it all over their abdomen or other metastatic cancers. This does work as well for that. I didn't really allude to that. If ganglia are visible for SELAC blocks, I do target the ganglia first and I inject just a little bit of Bupivacaine into those ganglia. And then I just move proximally. And then after that, ganglia are all, either I can't see them anymore or whatever, then I'll just do a single diffuse injection with my Bupivacaine that's left over. For patients with pancreatic cancer, I, again, prefer not to inject ganglia based on this data. Again, it's just one study, but it's significant enough to me that I, particularly for patients who have resectable disease, I'll just do a single injection of Bupivacaine. I'll finish my Bupivacaine. You can mix them together. The problem is with alcohol, once you get that, I don't really have, I should have shown a video, but you just get this really graying out effect of your ultrasound. It can be almost like looking at a snowstorm and you really can't see your anatomical landmarks anymore. If that alcohol is injected and spills a little bit, you can't see your ganglia anymore. So I just try to inject Bupivacaine into the ganglia. And then once I'm finished with that, then I'll just do a single injection over the celiac artery. I'll do bilateral injection if I don't see any ganglia. And as was mentioned too before, I don't have data. I have it in my other slides, but there's been studies looking at, is there any increased risk of infectious complications when antibiotics are not given? And the answer is no. So I do not give antibiotics to these patients at all, whether it's benign disease or cancer. All right, so I'll conclude with prospective data on celiac blocks is about 50-50, okay? It's gonna be a median survival, survival, median relief of about a month. You probably can do it again, but in patients who don't get a lot of relief the first time, I don't usually think it's something that we should be offering them a second time. I don't use steroids, but again, most people do, but again, reconsider that. There's conflicting data on one side versus two, but there is definitely two good randomized trials showing that EUS is superior to percutaneous, so that's probably what should be done. For pancreatic cancer, response rates are about 2 3rds, but they decrease over about two months. Broad plexus or bilateral injections probably increase response. I consider avoiding injection into the ganglia, particularly for early cancer patients. If a patient has stage four cancer, they've got liver mets or maybe a little bit of ascites, survival's not gonna be as big a deal. They're not gonna live five months, as the difference in that study showed, so I think maybe injecting the ganglia there would be an option. Injecting more alcohol doesn't seem to be better, so maybe sticking to 10 cc's would be enough. I think that's my last slide. Thank you. Any other questions? Let me just say it. Sorry. So any data on EUS RFA of the ganglia for chronic pancreatitis patients that require frequent celiac blocks? Not that I know of. Not that I know of. So the study that, the only one I know of that was published was a randomized trial for cancer patients. I don't know. Probably something that is an option. We had in our center an early study actually trying to inject very small amounts of alcohol into the ganglia. I think the study was terminated by the investigator, not because of adverse events, just because it was hard to get patients to do that. But right now, I don't know of any studies looking at that. John. Regarding the triamcinolone, I mean, classically it's bupivacain and triamcinolone, but you're saying that you don't think there's much use of the triamcinolone? Yeah. It's not a widely cited study or known study. It was obviously 10 years ago now, and I was at the oral presentation when Tyler gave it, was blown away by it, because we were, again, all these dogmas that we have in medicine that once they're tested, they don't work. I haven't used it since, because I never thought it made sense to me from a physiological standpoint, and the only study looking at it showed no difference, so I've stopped using it, even though I think I'm the only one in my institution who doesn't use it. So just something that I think, consider. I'm not saying do it, but I don't do it. So I know that there are a lot of people who are saying, why do celiac plexus block at all in chronic pancreatitis? It sounds like you still do do it. And so I'm just interested to hear your thoughts on that, and also, because I guess I look at it as, what's the downside to offering it to a patient if they've tried all these other things and they're just in horrible pain? So I'm just interested to hear your thoughts on that, and I also wanted to hear your thoughts a little bit more on, in the chronic pancreatitis folks that you're doing block on with only the bupivacaine, are you always trying to inject the ganglia then? So, good question. So for the first question, we offer it primarily because there's very little downside. It's a five-minute, 10-minute procedure with propofol sedation. I use bupivacaine just alone, and I try to inject the ganglia first. And once I run out of that, I do a single injection over the aorta. I offer it because, as you guys know, there's very little else we have to offer. Some of the patients who have, PERT doesn't work to help pain. Patients who have, perhaps, moderate disease, but no endoscopic, no duct therapy, no stricture, no stones, no obstruction, just a two to three millimeter duct that's maybe tortuous, but nothing to treat there. And they're maybe on opioids. They're not sick enough that they're having either complication from the opioids or don't wanna get a pain stimulator. They're in that group where they're just, their quality of life is poor, and I think it's a reasonable thing to try on those patients, but I tell them this information. There's a 50-50 chance you're gonna get better. It may not work after a month or two, and it may not respond as well the second time. If they're willing to try that, then I'm willing to offer it to them. I think we all, for us to do this, there are patients, and some you believe and some you don't believe. I'm not trying to say that we shouldn't believe our patients, but this is a difficult population, but there are some that come back once or twice a year for that block, and they swear that that nine months that they have that they haven't seen you, they're better, and when they miss it, their quality of life is poor. So there are patients who do come back to see us once or twice a year to get the blocks, but those are few, but we do offer it to patients because we do believe that they're telling us the truth, that their quality of life is good. Yeah. You know, there was an intriguing study, I think it was from Spain, regarding single-dose radiation therapy for painful chronic pancreatitis. Do you have any opinion about that, Modelli? I am not aware of that study, David. If you have any more information, let me know. So I think, you know, I have the concern about the ganglia for cancer based on that data. I think for benign disease, it may be ripe for trying more things like RFA or some other ablative agent, or as we were trying earlier, just a little, one or two cc's of alcohol, you know, into that ganglia to try to destroy it. I think it's a safe procedure, but I don't know that for sure, so. In pancreatic cancer, yeah, hi, in pancreatic cancer, do you offer it at the time of diagnosis if pain is not a major part of their presentation, if they're non-resectable, or do you wait until they have more pain? There's some question about whether earlier is better. I don't think the data is extremely strong to advocate that we should be doing it sort of prophylactically, or if they're just having a twinge of pain requiring some Tylenol. If patients come for a new diagnosis, or a new suspected diagnosis, if it's particularly in the body and tail, four centimeters pressing on the celiac artery and the retroperitoneum causing a lot of pain, even if they're not on narcotics at that time, or their quality of life is not horrible, I mean, they're having maybe some difficulty sleeping, or they're on, you know, five milligrams of oxycodone twice a day, I'll offer them a neuralysis at the same time as I do their biopsy. Because I think that's a group that's probably gonna, you know, they're not in that category where they're potentially early, as that study showed that their time difference was different, and I think you can get them that quality of life, which is gonna be important, because their mean survival is gonna be about a year, right, for that locally advanced cancer. It's about a year. So if you can make their quality of life better, I'll offer them that at the time. If it's not terrible, they're not on narcotics, they might have a little bit of problems, I'll tell them your pain or your suspected pain is probably from your cancer. You can, you know, I'll get your diagnosis today. Go start your chemotherapy. If your pain worsens or you don't wanna take the narcotics, I'll offer you a celiac neuralysis. A lot of patients don't know it's an option, so I educate them about, you know, your pain doesn't have to be just opioids. It can be a neuralysis, and, you know, have your oncologist, if you're having constipation or some problems from your opioids, you know, come back for a neuralysis, and a lot of them come back and do that. I'm also curious to hear, because some people have said for, again, chronic pancreatitis patients who may be candidates for islet cell, you know, auto-transplantation and whatnot, total pancreatectomy, you know, do you feel like if there's a response to celiac plexus block that maybe that portends a better outcome with that kind of surgery because the pain hasn't completely centralized yet? So I'm just curious to hear your thoughts on that. I don't know any data on that. Yeah, I haven't seen any data. Yeah, I don't know the answer to that. If somebody else has information on that, the only data that I know is what we showed that in those patients who respond at least to the block, they're more likely to have a response if you bring them back compared to those who don't from that initial response, but it certainly makes sense to translate to that. The other thing I have heard, again, just anecdotal reports are if alcohol is used particularly repeatedly, it can make, you know, that's why we frown upon using alcohol for benign disease. It can make the surgery a little more problematic once a surgeon tries to get in the retroperitoneum, particularly dissecting around the pancreatic body. So again, I would not use alcohol for benign disease for that reason, if your patient is, especially if they're gonna go to surgery. Yeah. So for the patient with chronic abdominal pain, just say you're bringing them in to do an EOS to rule out chronic pancreatitis. Do you typically offer the block when you're consenting that patient if the EOS is positive for chronic pancreatitis, and if you do, do you have any issues with insurance coverage? Because I think that's been one of the things in the community that I've noticed, that you have to bring them back for a second procedure sometimes. Yeah, great question. So I typically do not offer them the block if it is whatever. Some physicians do actually request that. They'll, that'll be the request. EOS to exclude chronic pancreatitis, and if positive, please offer a block. I will honor that request from the referring physician, but I do require to be specific at least five criteria on my EOS. So if they have two or three, I'm not gonna offer it. Obviously, if they have stones or a clearly defined stricture, or perhaps lobularity that's honeycombing, I'll consider the block at that point. Again, primarily because it is a benign, pretty benign procedure, doesn't add that much time to the procedure, and may actually improve the patient. I don't do that myself. I'll usually kind of do the EOS first to look to see what I think, and then discuss with them about options for treatment for their pain short of a block. But it is, sometimes, I'm not sure if you guys get referrals for that, but that's the way some of our referring doctors, if the patient has smoke or a drink or reasons to have had chronic pancreatitis, that actually will be the referral, is look for it, and then treat it if it's there. All right. Any questions for Dr. Lee? Apparently, they know everything about draining pseudosis and walled-off necrotic cavities. I just wanna add, the way I do things, it's interesting to hear the way people do things differently. The way I do this is that I do not do a necrosectomy at that first session. I'll actually dilate the lambs and stick my nose in the cavity to get sort of a lay of the land to sort of help me figure out, like, okay, what am I up against? Because it's often vastly different than what the CT scan shows, as you know. It also helps me to see, like, did I stick it in the right place? To know, am I gonna be able to get at this stuff? And if so, like, okay, if I see where the necrosis is, how's it gonna be at that next time that they actually come back? And I'm very aggressive about bringing them back. I try to bring them back twice, three times a week until that necrosis is gone, and then try to get that lambs out as soon as possible. So we don't actually wait for that to develop into a problem. We often bring them back fairly aggressively, particularly while they're an inpatient. If they're doing well after that second or third necrosectomy and they're still an inpatient, then there's no more signs of SIRS. They feel well. They're able to consume a full liquid diet. We'll let them go home and then maybe come back for that fourth and fifth or whatever necrosectomy. So that's sort of the pattern that we use. But as you can see, there's no clearly right, best way to do this for that patient. So, yeah. Hi, I have a question for Dr. Lee. Before I came, I received a patient, 51 years old, with acute necrotizing pancreatitis for six weeks. He was in different hospital. After that, he started to improve and he was discharged. And he came to me as a second opinion. I found that the collection drained spontaneously through the D1 in the posterior wall. But now, there is no collation, but there is a necrotic area in the orifice in the D1 posterior wall. What to do with that patient? So, he's feeling fine now. Yeah. And you're saying he developed a spontaneous fistula. Right. Yeah, we had a patient just like this too, actually, recently, that we presented at our multidisciplinary pancreas conference, where he too had acute necrotizing pancreatitis, had a significant walled off necrotic cavity, and then it just spontaneously drained somewhere. We're not sure where, because we didn't see an actual fistula's communication to the stomach or duodenum, but we're assuming it drained somewhere there, because now his collection's almost gone and he's feeling fine. So, we said, okay, do nothing, because if he's feeling fine and the collection's gone, there's honestly nothing to do. And you can just watch him, follow him, maybe see him back in clinic in a month or so to make sure he's doing okay. I guess you could do repeat imaging. I don't know if you wanted to. I feel like if he's feeling well, why image him if the most recent imaging looked good? And then you can just check for fecal elastase, et cetera, at some point down the road, hemoglobin A1C, all of that. Okay. Yeah, very interesting. Yeah, we had the exact same case. Yeah. It's an important teaching point that if you have a patient who doesn't look very sick, but has gas in their collection, they probably fistulized rather than being infected. And sometimes in these cases, I'll actually dilate that tract and put double pigtails in there. So, if the collection is still there, you can do that, right? I mean, if the collection is still there, then there's no harm in, what David is saying is that. I have done that before, but through the stomach. But this one, this case, No, right through the fistula. This is the D1 posterior wall. So, it could be more difficult, maybe I haven't done in that area, but it could be more difficult to go in the cavity. Actually, no. Just use a guide wire under fluoro, find the cavity, and then dilate. It will be my next step, if I. I mean, if there's no cavity, I mean, then I wouldn't do anything. Yeah, if there's no cavity, then there's no point, yes. Yeah, yeah, yeah. 100%. Yeah. These necrotic cavities love to erode into stuff. If they get from the colon, that's a big deal. Those patients need to almost always go to surgery. The small bowel's a little bit different. Some of these, eventually, as they enlarge, or whatever, will erode into the small bowel, and it's usually not as big of a deal. Another question. Question for Dr. Lee. Dr. Lee, what do you tell your patients who have large, asymptomatic collections? You know, I've had patients come in, no symptoms, 12, 14 centimeter cysts. They're very nervous that there might be cancer hidden in there. And you try to explain to them that this is likely a consequence of the inflammation, it's gonna settle down, don't have to worry about it, but they insist on something being done. What is your usual discourse in this situation? So this isn't somebody who had an attack of acute pancreatitis, and then developed this collection. Yeah, no, if they have no symptoms, and I reassure them that, I mean, honestly, the only thing I can do is make things worse and give them symptoms by something that I'm gonna do. And so, you know, if there was nothing there, and then suddenly it's just a result of the acute pancreatitis attack, again, I would just reassure them that as long as you're feeling fine, no fevers, no whatever pain, et cetera, et cetera, we don't need to intervene upon this. I think it makes sense to follow it with imaging every once in a while, to check and see and make sure it hasn't gone from like a 10 centimeter thing to suddenly a 20, you know, 30 centimeter thing, which may be a different scenario if something like that were happening. But that's honestly the most that I would do. I don't know if others would do anything different. Standard practice, right? That if it's asymptomatic, regardless of the size, then the disclaimer is I've been burned one time. There's a patient, 80 year old, he had a 12 centimeter pseudocyst, and I'm like, you know, you're not giving me any excuse to drain this. He's fine, and then lo and behold, he got admitted straight to, I mean, he came to the ER with bleeding. I mean, the cyst, but that can happen. At least, you know, I didn't cause the bleeding. So to your point is you can cause more problems, and then you have no defense. Right. That controversial, I mean, most people would consider rapid enlargement or enlargement alone, and I don't know what that size change is. Almost without any other symptoms, such as early satiety or jaundice as an indication for drainage. So if that cyst is eight, and then it goes to 12, and then 14, regardless of how they feel, most people would say that would be an indication for drainage, because you're probably not going to go the other direction. And so it might be easier to do before the patient has a gastrointestinal obstruction than it would be, you know. So that for me would be, if it's gone that direction, if they have no other symptoms, I'd still drain it. Yeah, so that's why you wanna follow them, right? You don't wanna just be like, hey, you feel fine. You have this 12 centimeter thing in your belly. Okay, you know, see you later. You don't wanna do that, right? So that's why you wanna monitor them to make sure it's not rapidly growing or something, yeah. In these patients with large amount of necrosis, do you think about pancreatic enzyme supplementation? Like you have, you know, probably thinking there's not draining properly the pancreatic duct. Would you? Yeah, so the, I'll be happy to let Dr. Lee say it, but there's a high incidence of eventually endocrine, and then eventually exocrine insufficiency developing after one attack of pancreatitis. Very high after necrosis, because you're just losing that part of the gland. I can't remember the numbers. It's like 40% for one and then 70% for the other. I think it's, so I would just monitor them. Often if they get tube feeds, it'll be, you know, put in the tube feeds as well. But if they're not on tube feeds, but they start developing symptoms, I don't give it prophylactically, but certainly let them know this is what you need to look for. But early on when they start developing dyspepsia or bergamot or a little bit of flatus, you know, that's probably where you're going with that. So I tell them it doesn't help your pain. It may help you with malabsorption. It may keep your weight on, but it's not gonna probably help your pain. That's with chronic pancreatitis too. Yeah, I don't give it prophylactically either, but that's also why it's important to see these, I mean, especially these necrotizing pancreatitis patients in follow-up, right? Even if they're doing okay because of their relatively high risk of developing exocrine insufficiency. And endocrine as well. So I think that's why it's important to see them, check a fecal elastase, check a hemoglobin A1c, you know, make sure those are looking okay. And then if not, then you can start the enzymes. Yeah, another question. Oh, can you press the button? This is in terms of celiac plexus block or neuralysis. If patients respond to it and we offer them twice or thrice, does it also suggest that these are patients who would respond from thoracic surgery where they just go and bilaterally resect this plastic nose? Would you then use that as a guide to refer them? That's a great question. We used to do that at our place probably well over 10 years ago. I don't recall a patient having that done at our place in the last 10 years. It was often, as you mentioned, a reason to do this for those who have responded because they don't want to come back. But we don't do that anymore. Maybe you do. But for me, that's not in my triage anymore. So I don't know. Do you guys still do that? No? Okay. Good question. All right, so I think for the sake of giving you guys a few minutes to have a break, let's break for maybe like five minutes now and then we can come back for the last couple of talks. Great questions. Thank you guys.

celiac plexus blocks

neuralysis

pain relief

bupivacaine

alcohol injection

chronic pancreatitis

pancreatic cancer

informed consent