title: EUS-guided celiac ganglia neurolysis: a clinical and human cadaver study (with video).
abstract: OBJECTIVE
  There is little evidence that structures targeted during EUS-guided celiac ganglia neurolysis (EUS-CGN) are celiac ganglia and that selective ethanol injection into ganglia is feasible. We aimed to visualize celiac ganglia, confirm that these structures are ganglia, and visualize ethanol spread after EUS-CGN and EUS-guided celiac plexus neurolysis (EUS-CPN).
  
  
  METHODS
  First, celiac ganglia were sought during 97 consecutive EUS procedures. Second, ganglia were identified in a prosected human cadaver by placing a linear echoendoscope next to the celiac trunk and removing the underlying tissue for histology. Finally, various EUS-CGN and EUS-CPN techniques were performed in human cadavers; EUS-CGN was performed with 1 mL ethanol in 1 ganglion, 1 mL per ganglion (both low volume), and 4 mL per ganglion (high volume). EUS-CPN was performed with a central (20 mL) and a bilateral (2*10 mL) approach. Transverse sections (75 μm) were obtained and photographed to allow visualization of the spread of ethanol.
  
  
  RESULTS
  A total of 204 ganglia were detected in 83 patients. Mean (± standard deviation) size of the long axis was 8.1 mm (± 7.4 mm). Histology of the removed region in the cadaver showed only nerve cell bodies. After low-volume EUS-CGN in cadavers, ethanol spread well beyond the targeted ganglion. After high-volume EUS-CGN in cadavers, a larger ethanol spread was seen, which also reached unidentified ganglia; the spread was comparable to the spread after EUS-CPN.
  
  
  CONCLUSIONS
  Specific EUS-CGN is not feasible because ethanol spreads well beyond the targeted ganglion. Unidentified celiac ganglia are better reached with high-volume EUS-CGN, and this would likely result in a more thorough neurolysis. High-volume EUS-CGN should be preferred to low-volume EUS-CGN.
authors.affiliation: Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Wouter F W
authors.initials: WFW
authors.lastname: Kappelle
authors.affiliation: Department of Anatomy, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Ronald L A W
authors.initials: RLAW
authors.lastname: Bleys
authors.affiliation: Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Albert J M
authors.initials: AJM
authors.lastname: van Wijck
authors.affiliation: Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.
authors.forename: Peter D
authors.initials: PD
authors.lastname: Siersema
authors.affiliation: Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Frank P
authors.initials: FP
authors.lastname: Vleggaar
mesh_terms: D015746:Abdominal Pain / Q000628:therapy*; D000328:Adult; D000368:Aged; D002102:Cadaver; D019160:Endosonography; D000431:Ethanol / Q000627:therapeutic use*; D005260:Female; D005728:Ganglia, Sympathetic / Q000000981:diagnostic imaging*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009407:Nerve Block / Q000379:methods*; D012997:Solvents / Q000627:therapeutic use*
chemical_list: D012997:Solvents; D000431:Ethanol