This ASG video tip is sponsored by Braintree, maker of the newly approved Suflav and SuTab. Hi, this is Pradeep Perera with the ASGE tip for EOS-guided celiac plexus neurolysis. These are my relevant disclosures. So today we'll talk about indications and contraindications for celiac plexus neurolysis. We're going to also talk about the technique, both the bilateral and unilateral technique for celiac plexus neurolysis and factors to consider both with patient selection and post-procedural considerations. The goal for neurolysis, as opposed to the non-neurolytic nerve blocks, is for permanent destruction of the visceral afferent nerves to the spinal cord. As opposed to the nerve blocks, we are going to be using a neurolytic agent along with the local anesthetic agent. This is typically done in patients with severe abdominal pain that are usually secondary to a malignant process. These are patients who are either maximized on their opioids or suffering a lot of adverse effects from opioid medication and need pain relief. Again, this is aiming for permanent destruction of the nerve. Contraindications, obviously if the patient is hemodynamically unstable or there is a coagulopathy, i.e. a platelet count of less than 50,000, INR is greater than 1.5, or if there's any anticoagulation use outside of aspirin 81 milligrams that cannot be held for whatever reason. As opposed to the nerve blocks, for the neurolysis, you actually don't need antibiotic prophylaxis, and that's because you'll be using dehydrated or absolute alcohol. You are going to get more issues with post-procedural hypotension, and that is due to the unopposed parasympathetic tone you're going to get, because we'll be disrupting the sympathetic tone. So, IV hydration is important before the procedure and actually during the procedure. Typically, we give about one to two liters. This is usually done with anesthesia, either with MAC or General, and you're going to need a facility where you can perform hemodynamic monterey post-procedure. Then we check in all the statics just to make sure that the hypotension is corrected before discharge. You will also need a 20-gauge plexus injection needle or a 22-gauge FNA needle. For the unilateral technique, you're going to be using that 20-gauge plexus injection needle. You're going to be using 8 milliliters of bupivacaine and 20 milliliters of the dehydrated or absolute alcohol and a 5 milliliter flush. For the bilateral technique, you're going to be using the 22-gauge FNA needle, and you're going to split the dose of the bupivacaine and dehydrated absolute alcohol. So, they'll both get the same volume. It's a split over two different injections. You're going to enter with a linear echoendoscope and advance to the lesser curvature of the gastric fundus. You're going to identify the aorta and then come down and look for both the celiac trunk and the SMA. With the unilateral injection technique, you want to make sure you flush the needle to clear it of air. Once you identify your landmark, and again, you're going just above the celiac artery takeoff, you're going to puncture with the needle, aspirate to ensure no blood. You inject 8 milliliters of bupivacaine followed by injection of 20 milliliters of dehydrated or absolute alcohol. After injection is complete, it's very important to then flush the needle with 3 to 5 milliliters of normal saline. This leads to clearing the needle of any of the absolute alcohol because you want to reduce any leakage when the needle goes back, as this can lead to spinal nerve injury if there's any leaking of the absolute alcohol. With a bilateral injection, you're going to visualize celiac artery takeoff. You want to then rotate your scope clockwise until you not see the celiac artery SMA takeoff and insert the needle. Again, you're going to either side of that celiac artery takeoff to hit that plexus. Again, very important, you aspirate to ensure no blood return. Inject the bupivacaine and the dehydrated absolute alcohol. You're going to flush the needle before you bring it back in to your scope. You're then going to rotate the scope counterclockwise and then do the same. Again, very important that after the alcohol injection, you flush with 3 to 5 cc's of normal saline just to clear that injection path. As you're injecting, you're going to see a nice haziness of cloud in, so it's very important just to keep visualization because your visualization will get a little bit disrupted. With this, you may get some Western abdominal pain up to 48 hours afterwards. You are going to get transient hypertension more likely than with nerve blocks. Again, that unopposed parasympathetic tone. So typically after the procedure is done, we check orthostatics to see whether the patient is safe enough to go home. They can have issues with diarrhea afterwards. A few complications that have been reported in literature are paralysis or spinal nerve injury, very rare. And again, it highlights the importance of clearing that needle off the alcohol injection. So when you bring the needle back into your scope, there is no leaking of the agent. So in conclusion, sciatica nerve neurolysis is something to consider in patients you have with severe abdominal pain secondary to a malignancy that either are intolerant of opioids or maximizing opioids. You're using your neurolytic agent with corticosteroids. And again, the goal is for permanent injury to the afferent nerves. And the most important thing to consider is flushing the needle after you inject the alcohol to prevent any leaking amongst the spinal nerves with your neurolytic agent.

ASG sponsored video

celiac plexus neurolysis

abdominal pain

malignancy

pain relief