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PubMed2005

Technology insight: Current status of endoscopic ultrasonography.

Endoscopic ultrasound (EUS) has become the most accurate imaging modality for locoregional cancer staging of the gastrointestinal tract. Fine-needle aspiration (FNA) has added a new level of accuracy for EUS in nodal staging, with reported numbers in the 90% range for luminal and pancreaticobiliary disease. In addition, new non-gastrointestinal applications are being evaluated, such as the role of EUS-FNA for the staging of non-small-cell lung cancer and exploration of the posterior mediastinum. Furthermore, the same techniques that make safe tissue sampling possible are being explored for their use as interventional applications, such as EUS-guided celiac plexus neurolysis, fine-needle injection, EUS-guided pseudocyst drainage, and EUS-guided cholangiography and pancreatography. This review describes the current clinical status of EUS in gastrointestinal oncology, as well as future and novel indications and therapeutic strategies for this technology.

Biopsy, Fine-Needle↗

PubMed2006

Magnetic resonance--guided musculoskeletal interventional radiology.

As an imaging modality, magnetic resonance (MR) guidance has great potential to direct diagnostic and therapeutic procedures performed in the musculoskeletal region and influence patient management. MR-guided interventional procedures involving bone, soft tissue, intervertebral discs, and joints are safe and sufficiently effective for use in clinical practice. This article discusses and illustrates the procedural characteristics and techniques when performing MR-guided musculoskeletal interventions. Biopsy procedures are similar to other modalities for bone and soft tissue lesions. MR guidance is advantageous if the lesion is not visible by other modalities and for regions adjacent to hardware and implants, subselective targeting, intra-articular locations, and periarticular cyst aspiration. MR guidance has also been used for a host of spine injections and pain management procedures such as sacroiliac joint injections, discography, transforaminal epidural injection, selective nerve block, sympathetic block, celiac plexus block, and facet joint cryotherapy neurotomies. Future directions of clinical applications include tumor ablation and multimodality procedure suites. MR-guided musculoskeletal procedures will continue to be a growth area particularly for the diagnosis and treatment of bone and soft tissue neoplasia.

Humans↗

PubMed1998

A swine model for teaching endoscopic ultrasound (EUS) imaging and intervention under EUS guidance.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasonography (EUS) has evolved into a clinically useful imaging modality. Widespread application of EUS has been hampered by the long learning curve and the paucity of training programs. We report here our efforts to develop an animal model for teaching endoscopic ultrasound. MATERIALS AND METHODS: The protocol for performing endoscopic ultrasound in live pigs included general anesthesia, endotracheal intubation, and mechanical ventilatory support. An echo-endoscope was then inserted into the pig gastrointestinal tract, and attempts were made to obtain ultrasound images that were comparable to human endoscopic ultrasound images. Intervention under EUS guidance was then attempted in the swine. RESULTS: It was possible to image the esophageal and gastric wall, pancreas, aorta, celiac artery, superior mesenteric artery, liver, and portal vein. The images obtained were analogous to human endoscopic ultrasound images. EUS-guided interventional techniques were also carried out, including EUS-guided fine-needle aspiration and celiac plexus neurolysis. CONCLUSIONS: A swine model appears to be useful for hands-on teaching in endoscopic ultrasound imaging and intervention under endoscopic ultrasound guidance.

Animals↗

PubMed2003

Pancreatic duct stent insertion for functional smoldering pancreatitis.

BACKGROUND: Some patients with smoldering pancreatitis in the absence of necrosis, pseudocyst, and ductal disruption experience unremitting abdominal pain caused by persistent pancreatic inflammation. Experience with the use of pancreatic duct stents in this patient population was reviewed. PATIENTS AND METHODS: Data for 11 patients with smoldering pancreatitis who underwent ERCP with pancreatic duct stent placement were reviewed retrospectively. All patients had severe, daily pain that worsened with ingestion of food, had required narcotic analgesics for control of pain, had lost weight, and had persistently elevated serum levels of pancreatic enzymes as well as pancreatic inflammatory changes on CT (without necrosis or pseudocyst). Six patients were being treated with parenteral nutrition. OBSERVATIONS: The mean duration of symptoms from the onset of pancreatitis until pancreatic duct stent insertion was 74 days (range 14-151 days). Stents were placed for a mean of 7 weeks (range 2-19 weeks). Pancreatic stent placement provided permanent pain relief in 10 (91%) patients within a mean of 9 days (range 3-20 days); one patient had persistent symptoms requiring celiac plexus blockade after 5 months. Parenteral nutrition and treatment with narcotic agents were discontinued for 10 patients within a mean of 15 days (range 7-39 days) after pancreatic duct insertion. CONCLUSIONS: Smoldering pancreatitis may result from functional obstruction, possibly caused by edema or spasm, of the papillary orifice. Insertion of a stent into the pancreatic duct alleviates pain, enables early resumption of oral intake of food, and facilitates pancreatic duct drainage. It also may help to prevent complications arising from persistent pancreatic inflammation.

Abdominal Pain↗

PubMed2004

Evidence report on the treatment of pain in cancer patients.

Pain associated with cancer is of widespread concern. We conducted a systematic review to evaluate the best available evidence on the efficacy of treatments of cancer-related pain. The sources used were MEDLINE, CancerLit, and the Cochrane Library from 1966 through April 2001, as well as bibliographies of meta-analyses and review articles. We selected randomized controlled trials (RCTs) reporting on cancer pain treatment. We recorded the study characteristics, patient and disease characteristics, treatment comparisons, outcome measures, and results. The methodological quality, applicability, and magnitude of treatment effect for each study were graded. We screened 24 822 titles and selected 213 RCTs to address specific questions. RCTs of cancer pain control often enroll few subjects, have low methodological quality, offer little detail about pain characteristics and mechanisms, and involve heterogeneous interventions and outcomes. Nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, selected adjuvant medications, bisphosphonates, radionuclides, external radiation, palliative chemotherapy, and neurolytic celiac plexus block are each efficacious in relieving cancer pain. However, the retrieved RCTs indicate no difference in the analgesic efficacies of NSAIDs versus other NSAIDs, NSAIDs plus opioids versus NSAIDs alone, or NSAIDs versus opioids. Studies of adjuvant medications and behavioral therapies are too few and varied to synthesize. RCTs of the analgesic effects of corticosteroids were not retrieved in our review, although we did conduct supplemental evidence reviews concerning pain control in oral mucositis, acute herpes zoster, or postherpetic neuralgia. RCTs confirm the efficacy of diverse interventions in relieving cancer pain. The optimal initial and subsequent sequence of choices among analgesic drug types cannot be inferred from the retrieved RCTs. Patient preferences, the relative efficacy of different routes of drug administration, the side effects of analgesics, and the relation of pain control to quality of life have not been studied comprehensively. The quantity and quality of scientific evidence on cancer pain relief compare unfavorably with evidence related to treatment of other high-impact conditions, including cancer itself. One contributor to this gap is the heterogeneity of outcomes instruments employed: of 218 retrieved trials, there were 125 distinct pain outcomes assessed. In the current era of patient-centered care, improving the quality and combinability of trials on cancer pain relief should be a high research priority.

Analgesics, Opioid↗

PubMed2005

Endoscopic palliation of pancreatic adenocarcinoma.

PURPOSE OF REVIEW: Endoscopic therapies have become an indispensable modality in the treatment and palliation of complications from pancreatic adenocarcinoma. This review focuses on treatment of biliary obstruction, malignant gastric outlet obstruction, and intractable abdominal pain resulting from unresectable pancreatic adenocarcinoma. Novel and emerging endoscopic approaches are also briefly discussed. RECENT FINDINGS: Endoscopic placement of a biliary stent is the modality of choice for palliation of biliary obstruction. Biliary self-expanding metal stents should be placed if expected survival is more than 6 months and plastic stents if expected survival is less than 6 months. For endoscopic palliation of gastric outlet obstruction, enteral self-expanding metal stents should be placed. Biliary self-expanding metal stents should be considered prior to the placement of a duodenal stent. Palliation of intractable abdominal pain can safely be performed with endoscopic ultrasound-guided celiac plexus neurolysis using bupivacaine and absolute alcohol. Exciting novel endoscopic approaches are being evaluated especially in the area of drug-eluted biliary stents, endoscopic creations of enteral anastomoses, and endoscopic ultrasound-guided injection of gene vectors. SUMMARY: The frontier of endoscopic palliative therapies for pancreatic adenocarcinoma is expanding. Clinical trials are needed to evaluate novel endoscopic approaches.

Adenocarcinoma↗

PubMed2006

Interventional applications of endoscopic ultrasound.

Endoscopic ultrasound, which was developed more than 20 years ago, is currently a valuable investigative tool for endoscopists. It began as a diagnostic instrument and in the short span of a decade made a clinical impact as a therapeutic tool with a promising potential for various interventional applications. The introduction of the curved linear array echoendoscope in the 1990s enabled a whole range of interventional applications of endoscopic ultrasound ranging from fine needle aspiration of lesions surrounding the gastrointestinal tract to celiac plexus block and drainage of pancreatic pseudocyst. This review article outlines the current interventional applications of endoscopic ultrasound and discusses potential future procedures. These procedures include endoscopic ultrasound guided creation of communication between the gastrointestinal tract and adjacent organs, such as hepaticogastrostomy and choledochoduodenostomy.

Digestive System Diseases↗

PubMed1964

HUMORAL FACTOR FROM THE BRAIN WHICH ACTIVATES GASTRIC MOTILITY.

When the vagus nerves in the neck of the dog are cut and the ends toward the brain are stimulated, gastric contractions follow. These contractions are not abolished by section of the cervical spinal cord, section of anterior and posterior thoracic and lumbar spinal nerves, section of the splanchnic nerves, or paralysis or excision of the celiac plexus. Evidence for the existence of a humoral blood-borne substance originating in the brain was obtained by experiments with an isolated perfused head, by perfusion of isolated stomachs by donor dogs, by cross-perfusion between two dogs, and by plasmapheresis. stimulates the stomach.

Animals↗

PubMed1991

Insulinomas: localization with selective intraarterial injection of calcium.

To facilitate the noninvasive preoperative localization of islet cell tumors less than 15 mm in diameter, the authors examined the use of calcium as an insulin secretagogue in an arterial stimulation venous sampling (ASVS) technique. In four patients with episodic hypoglycemia, calcium gluconate (0.01-0.025 mEq Ca2+/kg) was injected directly into branches of the celiac plexus (gastroduodenal, splenic, and hepatic arteries) and the superior mesenteric artery. In all patients, serum levels of insulin rose abruptly in blood samples taken from the right hepatic vein 30 and 60 seconds after the infusion of calcium into the artery supplying the tumor; injection into an artery not supplying the tumor did not result in a similar rise. Accurate localization of the insulinomas was verified at surgery in three patients. In the fourth patient, who did not undergo surgery, arteriographic results were positive for insulinoma at the predicted site. On the basis of these results, the authors believe noninvasive ASVS may replace invasive portal venous sampling as the most effective method for the localization of occult insulinomas.

Angiography↗

PubMed1999

Pseudoaffective cardioautonomic responses to gastric distension in rats.

We examined the heart rate response to gastric distension, the involvement of vagal and sympathetic sensory afferents, adrenergic and cholinergic neural pathways, and the effects of capsaicin on this response in anesthetized rats. Gastric distension volume dependently decreased heart rate by 24.5% (resting rate = 219.87 +/- 14.06 beats/min, mean rate during gastric distension with 15 ml = 165.97 +/- 17.36 beats/min, P < 0.05). The bradycardic response was significantly decreased after removal of the celiac plexus (9.71 +/- 1.77 vs. 38.03 +/- 7.06% in controls, P < 0.05) or after bilateral subdiaphragmatic vagotomy (6.38 +/- 2.65%, P = 0.05). The response to gastric distension was largely prevented by systemic capsaicin (29.92 +/- 4.93% in controls, 2.58 +/- 4.19% after systemic capsaicin, P < 0.05) and decreased by perivagal capsaicin (18.72 +/- 4.75%, P < 0.05). Atropine almost completely prevented the cardiac response to distension, while propranolol and bretylium partially blocked it, implying the response is primarily mediated by cholinergic efferents but also involves adrenergic pathways. We conclude that unmyelinated, capsaicin-sensitive vagal afferents are essential to the pseudoaffective cardioautonomic response to a noxious gastric stimulus.

Animals↗

PubMed1998

Endoscopic ultrasonography.

Endoscopic ultrasonography (EUS) is nowadays a clinically relevant technology and its findings can have a major impact on patient management. This technique is currently indicated for staging digestive cancers, assessment of submucosal tumors, diagnosis of intestinal wall infiltrative diseases, common bile-duct stones and gut neuroendocrine tumors. As far as neoplasms are concerned, EUS appears to be a reliable and safe technique, thus making the physician able to plan either an aggressive surgical treatment, or a conservative palliative therapy. This is of the utmost importance in order to optimize medical-related costs, and to make the best therapeutic decision for each individual patient. EUS is also helpful in monitoring the course of a disease, as it is simple and virtually without complications. When EUS findings are not sufficient for a complete diagnosis, it is now possible to perform an EUS-guided fine-needle biopsy, which can allow a cytological diagnosis. Finally, some therapeutic endosonography-guided procedures are being increasingly adopted, such as cystoenterostomy, celiac plexus neurolysis, cholangio-pancreatography and selective injection of botulinum toxin in the muscle layer of the lower esophageal sphincter.

Biliary Tract Diseases↗

PubMed2005

Clinical applications of endoscopic ultrasound to oncology.

Endoscopic ultrasound (EUS) is a useful imaging modality in patients with certain gastrointestinal malignancies as well as lung cancer. In many cases, EUS has been shown to have superior staging accuracy compared with other imaging techniques such as computed tomography, magnetic resonance imaging and positron emission tomography. This article will review the role of EUS in diagnosing and staging esophageal, rectal, pancreatic and lung cancers as well as subepithelial lesions. Newer therapeutic applications of EUS, namely endoscopic mucosal resection for removal of localized lesions as well as celiac plexus neurolysis for pain control, will also be discussed.

Digestive System Neoplasms↗

PubMed2006

Interventional endoscopic ultrasound in pancreatic diseases.

During the last 15 years, endoscopic ultrasound (EUS) has become an important imaging procedure for diagnosis and management of pancreatic diseases. The clinical interest of EUS is now enhanced by interventional procedures. Noteworthy, fine-needle aspiration biopsy is one of the most important contributions of EUS, in particular for the investigation of patients with pancreatic cancer and cystic tumors. EUS-guided fine-needle aspiration appears to be a safe and reliable technique to obtain tissue from pancreatic masses with a low risk of complications. EUS became also a therapeutic procedure, especially applied for celiac plexus neurolysis, pseudocyst drainage, and pancreaticogastrostomy. Further developments are expected by improvement of needle devices such as pancreatic pseudocyst drainage kits. In the future, EUS might be also a support for local application of new treatments of pancreatic tumors, such as gene or cellular therapy products. In this review, we discuss the current clinical applications of interventional EUS and the future development for diagnosis and management of pancreatic diseases.

Animals↗

PubMed1994

Chronic pancreatitis: management of pain.

Pain is the main symptom in chronic pancreatitis (CP). Since frequency, duration, severity and cause of pain in CP differ in patients, pain management becomes a challenge for physicians, which often requires a multidisciplinary approach. The first step is the exclusion of any anatomic abnormality (e.g. pseudocysts, compression of adjacent visceral structures) that could be the origin of pain. Medical measures such as abstinence from alcohol, use of analgesics, and suppression of exocrine pancreatic secretion may be useful, mainly in patients with early- to moderate-stage CP. Endoscopic interventions may alleviate pain in some selected cases. When nonoperative measures fail to alleviate pain and pain interferes significantly with the quality of life, surgery should be considered. Celiac plexus block and epidural anesthesia are procedures to be used only in selected cases.

Chronic Disease↗

PubMedDate not supplied

Endoscopic palliation for inoperable pancreatic cancer.

BACKGROUND: The majority of patients with pancreatic cancer are not candidates for surgical resection. Palliative therapy remains the cornerstone of management of this population. METHODS: We reviewed recent clinical and experimental studies on endoscopic palliative therapy of inoperable pancreatic cancer. RESULTS: Endoscopic placement of a biliary stent is the preferred mode of palliation of obstructive jaundice in patients with pancreatic cancer. The techniques of endoscopic stent insertion are briefly described. Episodic recurrence of jaundice and cholangitis due to stent occlusion is a major drawback of biliary polyethylene stents. Self-expandable metal stents with large diameters have lower rates of stent occlusion and are cost effective in patients who are expected to survive beyond 3 months. Palliation of duodenal obstruction with self-expandable enteral stents and endosonography-guided celiac plexus neurolysis are emerging options for the treatment of patients with advanced pancreatic cancer. CONCLUSIONS: Endoscopic therapy offers safe and effective management options for palliation of major symptoms associated with inoperable pancreatic cancer.

Cholestasis↗

PubMedDate not supplied

Applications of endoscopic ultrasonography in pancreatic cancer.

BACKGROUND: Accurate staging of pancreatic cancer is essential for surgical planning and for identification of locally advanced and metastatic disease that is incurable by surgery. Advances in endoscopic sonography (EUS), computed tomography (CT), and positron emission tomography have improved the accuracy of staging and reduced the number of incomplete surgical resections. Tissue acquisition is necessary in nonsurgical cases when chemoradiotherapy is considered. The complex regional anatomy of the pancreas makes cytologic diagnosis of malignancy at this region difficult without exploratory surgery. Although CT-guided fine-needle aspiration (FNA) is used for this purpose, reports of an increased risk of peritoneal dissemination of cancer cells and a false-negative rate of nearly 20% make this a poor choice. The ability to position the EUS-transducer in direct proximity to the pancreas by means of the stomach and duodenum, combined with the use of FNA, increases the specificity of EUS in detecting pancreatic malignancies. METHODS: The current literature regarding the accuracy of EUS with FNA in the evaluation of pancreatic cancer is reviewed. RESULTS: EUS accuracy ranges from 78% to 94% for tumor staging and from 64% to 82% for nodal staging. EUS also enables FNA of lesions that are too small to be identified by CT or MRI or too well encased by surrounding vascular structures to safely allow percutaneous biopsy. The accuracy for detecting invasion into the superior mesenteric artery and vein is lower than that for detecting portal or splenic vein invasion, especially for large tumors. EUS permits delivery of localized therapy such as celiac plexus neurolysis for pain control and direct intra-lesional injection of antitumor therapy. CONCLUSIONS: EUS in combination with FNA is a highly accurate method of preoperative staging of pancreatic cancer, especially those too small to be characterized by CT or MRI, and it has the ability to obtain cytological confirmation of pancreatic cancer.

Adenocarcinoma↗

PubMed1996

Spinal cord infarction: etiology and outcome.

We reviewed 44 cases of ischemia and infarction of the spinal cord at two university hospitals. Three patients experienced transient ischemic attacks. Etiologies of completed strokes were diverse and included rupture and surgical repair of aortic aneurysms, aortic dissection, aortic rupture and thrombosis, global ischemia, anterior spinal artery embolism, repair and thrombosis of spinal arteriovenous malformations, hematomyelia, epidural hematoma, cervical osteophytosis, celiac plexus block, systemic lupus erythematosus, coagulopathy, and decompression sickness. Motor function improved in 12 patients, was substantial in only one, and occurred largely within the first 2 to 4 weeks. Favorable ambulatory outcome correlated with improving neurologic examinations and relatively preserved strength in hip abductors and knee extensors. More extensive deficits without initial improvement portended a more severe prognosis. Autonomic dysfunction, pain, paresthesia, and depression were common and impeded recovery in some patients. The mean level of deficit was at T-8 and in cases of global ischemia was at T-9, which leads us to dispute the classical view of a midthoracic watershed zone of ischemic vulnerability near T-4.

Adolescent↗

PubMed1989

Effects of bupivacaine on the membrane properties of nerve cell soma.

While the effects of local anaesthetics on axonal conduction and axonal membrane have been extensively studied, there is little information about the actions of these agents on nerve cell soma. Therefore, the effects of the amide local anaesthetic bupivacaine on the electrophysiologic properties of the nerve cell soma were studied on isolated superfused superior cervical ganglia of rats. Administration of 100-200 nM of bupivacaine to the preparation produced marked changes in membrane properties of the cell soma. The resting membrane potential did not change, but the membrane resistance decreased 20% (P less than 0.01). The firing threshold, the action potential duration at 50% of maximal amplitude, and the intracellular current threshold for firing the cells increased significantly (P less than 0.01), while the action potential amplitude decreased significantly (P less than 0.01), before its complete blockade. The results show that the cell soma is a major site of action of local anaesthetics. The implication of the results is that when local anaesthetics are applied to areas where cell bodies and processes (axons and dendrites) are present together, such as during celiac plexus block, lumbar sympathetic block, stellate ganglion block, etc., they will all be effectively depressed and/or blocked.

Action Potentials↗