The benefit of celiac ganglion injection remains unclear

The recently published paper by Doi et al. [1] concluded that endoscopic ultrasound (EUS)-guided celiac ganglion neurolysis (CGN) with ganglion injection is more effective than EUS-guided celiac plexus neurolysis (CPN). It is crucial to consider that CPN can be performed with a “central” technique (as used in the Doi study) or a “bilateral” technique. I respectfully submit that readers should not conclude that CGN with ganglion injection is more effective than either bilateral or central CPN without ganglion injection, or that attempts to inject the ganglion will always improve outcomes. I believe that bilateral CPN may be just as effective as EUS-guided CGN.

Previous studies have shown that injecting a neurolytic drug using the bilateral approach is more effective than the central approach – presumably because more ganglia are located next to the celiac axis than at the base of the celiac axis [2] [3] [4]. With EUS-guided CGN, although the drug is injected into the ganglia, it is conceivable that drug also diffuses beyond the targeted ganglia and destroys adjacent, invisible ganglia that were not targeted directly, or that the needle traverses invisible ganglia and therefore targets them “accidentally.”

The positive response rates in the study by Doi et al. (73.5 % vs. 45.5 %; P = 0.026) were remarkably similar to those observed in our previous comparison of bilateral vs. central CPN (77.5 % vs. 50.7 %; P = 0.0005).

To truly determine whether direct ganglia injection is more effective than bilateral CPN with no direct ganglia injection, a study needs to be performed in which the control group undergoes bilateral drug injection but without targeting visible ganglia. Therefore, to avoid any confusion, I believe a more precise and appropriate conclusion of the Doi study would be that EUS-guided CGN is more effective than central CPN – which is not surprising – but that further work is required to determine whether EUS-guided CGN is more effective than bilateral CPN without direct ganglion injection.

• References

• 1 Doi S, Yasuda I, Kawakami H et al. Endoscopic ultrasound-guided celiac ganglia neurolysis vs. celiac plexus neurolysis: a randomized multicenter trial. Endoscopy 2013; 45: 362-369
• 2 Sahai AV, Lemelin V, Lam E et al. Central vs. bilateral endoscopic ultrasound-guided celiac plexus block or neurolysis: a comparative study of short-term effectiveness. Am J Gastroenterol 2009; 104: 326-329
• 3 Sakamoto H, Kitano M, Kamata K et al. EUS-guided broad plexus neurolysis over the superior mesenteric artery using a 25-gauge needle. Am J Gastroenterol 2010; 105: 2599-2606
• 4 Iwata K, Yasuda I, Enya M et al. Predictive factors for pain relief after endoscopic ultrasound-guided celiac plexus neurolysis. Dig Endosc 2011; 23: 140-145