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Endoscopy 2012; 44(S 02): E267
DOI: 10.1055/s-0032-1309709
Unusual cases and technical notes
© Georg Thieme Verlag KG Stuttgart · New York

Fatal complication after endoscopic ultrasound-guided celiac plexus neurolysis

A. Z. Gimeno-García
1   Gastroenterology Department, University Hospital of Canary Islands, La Laguna, Tenerife, Spain
,
A. Elwassief
2   Internal Medicine Department, Gastroenterology Unit, Alhossien Hospital, Alazhar University, Cairo, Egypt
,
S. C. Paquin
3   Gastroenterology Department, Saint Luc Hospital, Centre Hospitalier de l’université de Montréal, Montreal, Canada
,
A. V. Sahai
3   Gastroenterology Department, Saint Luc Hospital, Centre Hospitalier de l’université de Montréal, Montreal, Canada
› Author Affiliations
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Publication History

Publication Date:
13 July 2012 (online)

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A 57-year-old woman with a diagnosis of idiopathic recurrent pancreatitis and progressive epigastric pain radiating to her back was admitted to the hospital. Abdominal computed tomography (CT) showed a suspicious 3-cm pancreatic head mass involving the superior mesenteric artery (SMA) and vein. Endoscopic ultrasound (EUS) showed the suspicious pancreatic head mass with bile duct and main pancreatic duct dilatation and changes compatible with chronic pancreatitis. However, EUS-guided fine needle aspiration cytology was negative on three occasions.

EUS-guided celiac plexus neurolysis (EUS-CPN) was carried out using a 19-gauge needle. Absolute alcohol (10 cc) and bupivacaine 0.5 % (5 cc) were injected on each side of the celiac takeoff. Color Doppler imaging after the procedure revealed the permeability of the SMA and celiac takeoff.

After the procedure, the patient experienced stabbing pain radiating to the back, with nausea, hypotension, and fever. CT demonstrated complete thrombosis of the celiac takeoff, as well as wall thickening and bubble-like pneumatosis of the stomach, duodenum, jejunum, ileum loops, and ascending colon. Signs of hepatic infarction of segments I and III, and near-total right-kidney and splenic infarction were discovered. Conservative management was carried out and the patient died 8 days later.

Major complications have rarely been reported using EUS-CPN or EUS-guided celiac plexus block ( [Tab.1]) [1] [2] [3] [4] [5] [6] [7]. The present case is the first to document a fatal outcome. The sclerosing effect of absolute ethanol, arterial embolisms after injection, and vasospasm could explain the necrosis of organs distant to the celiac takeoff [8]. All cases of major complications due to CPN, except one, were reported in the setting of chronic pancreatitis ([Tab. 1]). The issue of using CPN in patients with chronic pancreatitis is still a matter of debate [9].

Table 1

Reported complications secondary to the endoscopic ultrasound (EUS)-guided celiac plexus neurolysis (CPN) or celiac plexus block technique.

Author

Procedures

Complication

Indication

Technique

Substance

Gress et al. [6]

 80

1 Retroperitoneal bleeding
1 Retroperitoneal abscess

CP

Bilateral

Alcohol + bupivacaine
Triamcinolone + bupivacaine

Mahajan et al. [4]

167

3 Empyema

CP

Unstated

Triamcinolone + bupivacaine

Muscatiello et al. [3]

  1

1 Retroperitoneal abscess

PC

Unstated

Alcohol + bupivacaine

Sahai et al. [2]

160

1 Retroperitoneal bleed

CP

Bilateral

Triamcinolone + bupivacaine

O’Toole et al. [1]

220

1 Retroperitoneal abscess

CP

Unstated

Triamcinolone + bupivacaine

Ahmed et al. [7]

  1

1 Ischemia

CP

Unstated

Alcohol + bupivacaine

Lalueza et al. [5]

  1

1 Brain abscess

CP

Unstated

Alcohol + bupivacaine

Current study

  1

Ischemia/dead

PC?, CP

Bilateral

Alcohol + bupivacaine

CP, chronic pancreatitis; PC, pancreatic cancer.

In conclusion, major complications of CPN can include death. It may be preferable to limit EUS-guided CPN to patients with histologically proven cancers.

Endoscopy_UCTN_Code_CPL_1AL_2AG

 

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