Reply to Dr. Sahai

We appreciate the comments made by Dr. Sahai regarding our study in which we concluded that endoscopic ultrasound (EUS)-guided celiac ganglia neurolysis (EUS – CGN) is more effective than the “central” technique of EUS-guided celiac plexus neurolysis (EUS – CPN) [1]. Since EUS – CPN (the central technique) was first introduced by Wiersema et al. [2], some modified techniques have been developed, which have aimed to increase the spread of the drug to a wider area than that achieved by the original central technique; moreover, the outcomes of the new techniques have been shown to be superior to those of the central technique [3] [4].

As mentioned by Dr. Sahai, some previous studies have shown that the “bilateral” technique is more effective than the central technique. However, we believe that the central technique is still the standard technique because it is simpler and safer compared with the bilateral technique. Moreover, the central technique seems to yield a uniform effect irrespective of the operators, and therefore, we believe that the central technique is suitable for the control group in multicenter randomized controlled studies, such as our recent study.

As Dr. Sahai suggests, the positive response rate of EUS – CGN and the bilateral technique may be similar. However, a further randomized controlled trial comparing the bilateral technique of EUS – CPN with EUS – CGN is necessary to confirm this finding, because various definitions of positive response have been used in previous studies.

In addition, we feel that CGN may be easier and more advantageous than the bilateral technique. Based on the results of our study, EUS – CGN yielded a similar effect, even if different operators with varying degrees of experience with this procedure performed the technique. Once the celiac ganglia have been visualized by EUS, the procedure of needle puncture and drug injection into the ganglia is very simple and may not be associated with any technical difficulties [1]. However, the imperfect rate of detection of celiac ganglia remains a disadvantage of this technique, although we believe that the celiac ganglia can be detected in most patients by experienced operators.

• 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 Wiersema MJ, Wiersema LM. Endosonography-guided celiac plexus neurolysis. Gastrointest Endosc 1996; 44: 656-662
• 3 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
• 4 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