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Acute Iatrogenic Pancreatitis Complicating CT-Guided Celiac Ganglion Neurolysis in Chronic Pancreatitis
LETTERS TO THE EDITOR Acute Iatrogenic Pancreatitis Complicating CT-Guided Celiac Ganglion Neurolysis in Chronic Pancreatitis From: Jason S. Chu, BS Eric vanSonnenberg, MD Ishaan Kalha, MD Departments of Radiology (J.S.C., E.v.) and Medicine (I.K.) Kern Medical Center 1700 Mt. Vernon Ave Bakersfield, CA 93306; Department of Medicine (E.v.) UCLA David Geffen School of Medicine Los Angeles, California; Department of Radiology (E.v.) University of Arizona College of Medicine Phoenix, Arizona
Editor: Celiac ganglion neurolysis (CGN) with alcohol instillation has been used for pain management in patients experiencing intense abdominal pain refractory to conventional pain management. Pain relief has been reported in as many as 90% of patients, with only minor complications, such as transient hypotension and diarrhea (1). The bilateral posterior approach is the preferred method of CGN by some authors (2), but the anterior approach with computed tomography (CT) guidance often has been selected by radiologists in view of its relative simplicity in the supine position, as well as patient comfort (2). Although it has been theorized that pancreatitis could result from needle traversal of the pancreas en route to the celiac ganglia via the anterior approach (2), the actual complication itself has not been reported to our knowledge. Herein we report an apparently technically successful CGN in a patient who eventually developed severe pancreatitis after treatment from an anterior approach. A 51-year-old man was referred to the interventional radiology service from the gastroenterology service for CT-guided CGN to relieve his chronic abdominal pain. His pain was secondary to chronic pancreatitis that had been diagnosed 4 months earlier, likely precipitated by previous episodes of gallstone pancreatitis. He had undergone a cholecystectomy previously. He was a chronic alcohol and tobacco user, and had other diseases of the gastrointestinal system, including possible irritable bowel syndrome, inflammatory bowel disease, severe gastritis, hiatal hernia, and scattered diverticulosis on imaging. None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.12.565
For the CGN procedure, the patient underwent conscious sedation. Xylocaine was used as a local anesthetic agent. A 22-gauge needle was used for the block via an anterior approach. A midline approach was selected. The needle was placed into the region of the celiac ganglion, between the celiac and the superior mesenteric arteries, and anterior to the aorta (Fig 1a). Ten milliliters of 1% lidocaine were injected initially, and 15 mL of a 4% contrast medium solution was then infused into the region near the celiac plexus via the 22-gauge needle (Fig 1b). The dispersion appeared appropriate based on contrast appearance: anterior to the right crus of the diaphragm, passing over the aorta to the left, and in the space between the celiac and superior mesenteric arteries. Twelve milliliters of 91% alcohol were then injected. The patient tolerated the procedure well, and no intraprocedural complications occurred. The patient was observed for 3 hours in the hospital, and was asymptomatic at the time of discharge. That same evening, the patient returned to the emergency department with new onset of severe epigastric pain radiating to the back. His admission blood tests revealed an amylase level of 895 U/L and a lipase level of 6,600 U/L, as well as leukocytosis of 17,800/μL with 17 bands. CT of the abdomen demonstrated fluid surrounding the head and body of the pancreas, extending into the right anterior pararenal space, as well as intraperitoneally around the liver into the subhepatic space (Fig 2a). The patient was admitted to the hospital with a diagnosis of acute-on-chronic pancreatitis. He underwent conservative management, and received several antimicrobial agents, including 500 mg Primaxin (Merck, Whitehouse Station, New Jersey) daily for a complete course of 14 days because of possible peritonitis, 1 mg of vancomycin (ViroPharma, Downingtown, Pennsylvania), and 100 mg of caspofungin (Merck) daily because of fevers as high as 101.91F during the initial 5 days in the hospital. Repeat CT of the abdomen on day 14 showed a large amount of fluid still surrounding the pancreas (Fig 2b), corresponding to a persistently elevated lipase level of 1,575 U/L on day 16 despite initial improvement. The patient’s symptoms improved gradually, and he was discharged home in stable condition after a total of 21 days of hospitalization. Despite eventual resolution of the increase in lipase levels 21 days following discharge, the patient’s chronic abdominal pain prompted him to visit the emergency department four times in 14 months because of similar episodes of abdominal pain. Fifteen months after discharge from our hospital, he underwent a repeat CGN at an outside institution. After that procedure, he returned to the emergency department again for severe abdominal pain. No evidence of acute pancreatitis was found during that visit, and the patient was discharged.
804
’
Letters to the Editor
Chu et al
’
JVIR
Figure 1. (a) Optimal CGN needle placement: The needle is shown to traverse the pancreas (arrow) en route to the celiac ganglion. (b) Contrast medium dispersion anterior to the right crus of the diaphragm (arrow), passing over the aorta to the left, and in the space between the celiac and superior mesenteric arteries. This is considered ideal needle placement from an anterior approach and early contrast medium dispersion.
Figure 2. (a) Admission CT scan. The patient presented with severe abdominal pain, and was admitted for acute-on-chronic pancreatitis. There is fluid in the lesser sac (white arrow) and anterior pararenal space (black arrow) extending into the subhepatic space (arrowhead). (b) Follow-up CT on day 14 shows persistent inflammatory changes in the mesentery surrounding the vasculature at a more caudal location (arrow).
In interventional radiology procedures that involve a needle passing through the pancreas, acute pancreatitis has been hypothesized as a potential complication even with the use of fine needles (2). In one report (3), an anterior approach through the pancreas for percutaneous fine needle adrenal biopsy caused acute pancreatitis (3). However, in several metaanalysis studies and a procedural review in which the anterior approach to CTguided CGN was used, there is no documented report of acute pancreatitis (1,2). Thus, in the literature, traversal of the pancreas has been safe. Retrograde leakage of alcohol into the pancreatic tissue during the injection might be an alternative etiology of our patient’s pancreatitis. The alcohol may have chemically irritated the pancreas. However, to our knowledge, this scenario has not been described previously as a cause in any other report, and, in our patient, the CGN needle was located optimally on CT. An interesting occurrence was that the patient again experienced severe abdominal pain after a second attempt at CGN at an outside institution. With the patient’s extensive history of various gastrointestinal diseases, it raises the possibility that he may have been
more susceptible than other patients to insults that produce inflammation of the pancreas and other visceral organs. However, this is conjecture, and innumerable patients with alcohol-induced pancreatitis have undergone CGN without developing acute pancreatitis. A stone in the common bile duct may also be considered as another possible etiology for the patient’s pancreatitis, especially given the rarity of this complication following a CGN and the patient’s history. However, this scenario is unlikely, as the patient had negative findings on endoscopic ultrasonography after cholecystectomy for stones 1 month before the original neurolysis procedure. Additionally, the temporal relationship of this case favors CGN as the etiology. Based on the considerations enumerated here, we postulate that needle passage through the pancreas was the most likely cause of this patient’s acute pancreatitis, as needle transgression and perturbation of pancreatic tissue may have incited the inflammatory changes. Although this is only a single case, we conclude that, even though CGN is typically safe, acute pancreatitis is likely a potential complication of CGN, as has been postulated by other authors (2).
Volume 25
’
Number 5
’
May
’
2014
REFERENCES 1. Eisenberg E, Carr B, Chalmers TC. Neurolytic celiac plexus block for treatment of cancer pain: a meta-analysis. Anesth Analg 1995; 80: 290–295.
Testicular Artery Hemorrhage after Inguinal Hernia Repair From: Ahmed Sheikh, BA David Klyde, MD Sohail Contractor, MD Rutgers Biomedical and Health Sciences University Rutgers, The State University of New Jersey University Hospital H 108 150 Bergen Street Newark, NJ 07101
805
2. Kambadakone A, Thabet A, Gervais DA, et al. CT-guided celiac plexus neurolysis: a review of anatomy, indications, technique, and tips for successful treatment. Radiographics 2011; 31:1599–1621. 3. Kane NM, Korobkin M, Francis IR, et al. Percutaneous biopsy of left adrenal masses: prevalence of pancreatitis after anterior approach. AJR Am J Roentgenol 1991; 157:777–780.
Complications of inguinal hernia surgery include injury to bladder, bowel, vas deferens, and vasculature of the inguinal canal (1). Vascular injury during inguinal hernia repair can occur by damage to any of the following vessels: rectus muscle vessel, inferior epigastric vessels, venous plexus at the pubic symphysis, aberrant obturator vein, testicular vessels, and iliac vessels (1). Figure 4 illustrates some of the vascular structures supplying the inguinal canal. Injury to the inferior epigastric and other pelvic vessels during surgical dissection or stapling of the mesh can result in bleeding (2). Avoidance of traction and preperitoneal
Editor: This report met criteria for institutional review board exemption at our institution. A 56-year-old man with no significant past medical or surgical history underwent elective left hernia surgery with a standard Lichtenstein open mesh repair. He became unstable 4 hours postoperatively with a systolic pressure of 70 mm Hg and a pulse of 130 and suprapubic and left lower quadrant discomfort. Abdominal examination revealed fullness in the left lower quadrant. A decrease in hemoglobin level from 15 g/dL to 8.1 g/dL was observed. Blood transfusions were initiated, and exploratory surgery was performed, which failed to reveal active bleeding. A preperitoneal hematoma with expressible blood clots from the internal ring was noted. Surgical packing was attempted with a transient response, and the patient was subsequently transferred to interventional radiology. A left pelvic and femoral angiogram failed to reveal hemorrhage. A subsequent aortogram showed extravasation from the distal left testicular artery 10–12 cm cephalad to the operative site (Fig 1). The left testicular artery was selectively catheterized with a 5-F SOS Omni catheter (AngioDynamics, Queensbury, New York), and brisk hemorrhage from the distal vessel was seen (Fig 2a, b). Subselective catheterization using a 3-F microcatheter (Renegade Hi-Flo; Boston Scientific, Natick, Massachusetts) and embolization using flow-directed absorbable gelatin sponge (Gelfoam; Ethicon, Somerville, New Jersey) slurry infusion until stasis were performed (Fig 3a, b). No further evidence of clinical bleeding was seen. However, the patient developed an ischemic left testicle and underwent left orchiectomy. He was discharged 8 days later and was healthy at follow-up evaluation at 2 months.
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.12.003
Figure 1. Aortogram demonstrates extravasation from the testicular artery above the inguinal canal (arrow).
Editor: Celiac ganglion neurolysis (CGN) with alcohol instillation has been used for pain management in patients experiencing intense abdominal pain refractory to conventional pain management. Pain relief has been reported in as many as 90% of patients, with only minor complications, such as transient hypotension and diarrhea (1). The bilateral posterior approach is the preferred method of CGN by some authors (2), but the anterior approach with computed tomography (CT) guidance often has been selected by radiologists in view of its relative simplicity in the supine position, as well as patient comfort (2). Although it has been theorized that pancreatitis could result from needle traversal of the pancreas en route to the celiac ganglia via the anterior approach (2), the actual complication itself has not been reported to our knowledge. Herein we report an apparently technically successful CGN in a patient who eventually developed severe pancreatitis after treatment from an anterior approach. A 51-year-old man was referred to the interventional radiology service from the gastroenterology service for CT-guided CGN to relieve his chronic abdominal pain. His pain was secondary to chronic pancreatitis that had been diagnosed 4 months earlier, likely precipitated by previous episodes of gallstone pancreatitis. He had undergone a cholecystectomy previously. He was a chronic alcohol and tobacco user, and had other diseases of the gastrointestinal system, including possible irritable bowel syndrome, inflammatory bowel disease, severe gastritis, hiatal hernia, and scattered diverticulosis on imaging. None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.12.565
For the CGN procedure, the patient underwent conscious sedation. Xylocaine was used as a local anesthetic agent. A 22-gauge needle was used for the block via an anterior approach. A midline approach was selected. The needle was placed into the region of the celiac ganglion, between the celiac and the superior mesenteric arteries, and anterior to the aorta (Fig 1a). Ten milliliters of 1% lidocaine were injected initially, and 15 mL of a 4% contrast medium solution was then infused into the region near the celiac plexus via the 22-gauge needle (Fig 1b). The dispersion appeared appropriate based on contrast appearance: anterior to the right crus of the diaphragm, passing over the aorta to the left, and in the space between the celiac and superior mesenteric arteries. Twelve milliliters of 91% alcohol were then injected. The patient tolerated the procedure well, and no intraprocedural complications occurred. The patient was observed for 3 hours in the hospital, and was asymptomatic at the time of discharge. That same evening, the patient returned to the emergency department with new onset of severe epigastric pain radiating to the back. His admission blood tests revealed an amylase level of 895 U/L and a lipase level of 6,600 U/L, as well as leukocytosis of 17,800/μL with 17 bands. CT of the abdomen demonstrated fluid surrounding the head and body of the pancreas, extending into the right anterior pararenal space, as well as intraperitoneally around the liver into the subhepatic space (Fig 2a). The patient was admitted to the hospital with a diagnosis of acute-on-chronic pancreatitis. He underwent conservative management, and received several antimicrobial agents, including 500 mg Primaxin (Merck, Whitehouse Station, New Jersey) daily for a complete course of 14 days because of possible peritonitis, 1 mg of vancomycin (ViroPharma, Downingtown, Pennsylvania), and 100 mg of caspofungin (Merck) daily because of fevers as high as 101.91F during the initial 5 days in the hospital. Repeat CT of the abdomen on day 14 showed a large amount of fluid still surrounding the pancreas (Fig 2b), corresponding to a persistently elevated lipase level of 1,575 U/L on day 16 despite initial improvement. The patient’s symptoms improved gradually, and he was discharged home in stable condition after a total of 21 days of hospitalization. Despite eventual resolution of the increase in lipase levels 21 days following discharge, the patient’s chronic abdominal pain prompted him to visit the emergency department four times in 14 months because of similar episodes of abdominal pain. Fifteen months after discharge from our hospital, he underwent a repeat CGN at an outside institution. After that procedure, he returned to the emergency department again for severe abdominal pain. No evidence of acute pancreatitis was found during that visit, and the patient was discharged.
804
’
Letters to the Editor
Chu et al
’
JVIR
Figure 1. (a) Optimal CGN needle placement: The needle is shown to traverse the pancreas (arrow) en route to the celiac ganglion. (b) Contrast medium dispersion anterior to the right crus of the diaphragm (arrow), passing over the aorta to the left, and in the space between the celiac and superior mesenteric arteries. This is considered ideal needle placement from an anterior approach and early contrast medium dispersion.
Figure 2. (a) Admission CT scan. The patient presented with severe abdominal pain, and was admitted for acute-on-chronic pancreatitis. There is fluid in the lesser sac (white arrow) and anterior pararenal space (black arrow) extending into the subhepatic space (arrowhead). (b) Follow-up CT on day 14 shows persistent inflammatory changes in the mesentery surrounding the vasculature at a more caudal location (arrow).
In interventional radiology procedures that involve a needle passing through the pancreas, acute pancreatitis has been hypothesized as a potential complication even with the use of fine needles (2). In one report (3), an anterior approach through the pancreas for percutaneous fine needle adrenal biopsy caused acute pancreatitis (3). However, in several metaanalysis studies and a procedural review in which the anterior approach to CTguided CGN was used, there is no documented report of acute pancreatitis (1,2). Thus, in the literature, traversal of the pancreas has been safe. Retrograde leakage of alcohol into the pancreatic tissue during the injection might be an alternative etiology of our patient’s pancreatitis. The alcohol may have chemically irritated the pancreas. However, to our knowledge, this scenario has not been described previously as a cause in any other report, and, in our patient, the CGN needle was located optimally on CT. An interesting occurrence was that the patient again experienced severe abdominal pain after a second attempt at CGN at an outside institution. With the patient’s extensive history of various gastrointestinal diseases, it raises the possibility that he may have been
more susceptible than other patients to insults that produce inflammation of the pancreas and other visceral organs. However, this is conjecture, and innumerable patients with alcohol-induced pancreatitis have undergone CGN without developing acute pancreatitis. A stone in the common bile duct may also be considered as another possible etiology for the patient’s pancreatitis, especially given the rarity of this complication following a CGN and the patient’s history. However, this scenario is unlikely, as the patient had negative findings on endoscopic ultrasonography after cholecystectomy for stones 1 month before the original neurolysis procedure. Additionally, the temporal relationship of this case favors CGN as the etiology. Based on the considerations enumerated here, we postulate that needle passage through the pancreas was the most likely cause of this patient’s acute pancreatitis, as needle transgression and perturbation of pancreatic tissue may have incited the inflammatory changes. Although this is only a single case, we conclude that, even though CGN is typically safe, acute pancreatitis is likely a potential complication of CGN, as has been postulated by other authors (2).
Volume 25
’
Number 5
’
May
’
2014
REFERENCES 1. Eisenberg E, Carr B, Chalmers TC. Neurolytic celiac plexus block for treatment of cancer pain: a meta-analysis. Anesth Analg 1995; 80: 290–295.
Testicular Artery Hemorrhage after Inguinal Hernia Repair From: Ahmed Sheikh, BA David Klyde, MD Sohail Contractor, MD Rutgers Biomedical and Health Sciences University Rutgers, The State University of New Jersey University Hospital H 108 150 Bergen Street Newark, NJ 07101
805
2. Kambadakone A, Thabet A, Gervais DA, et al. CT-guided celiac plexus neurolysis: a review of anatomy, indications, technique, and tips for successful treatment. Radiographics 2011; 31:1599–1621. 3. Kane NM, Korobkin M, Francis IR, et al. Percutaneous biopsy of left adrenal masses: prevalence of pancreatitis after anterior approach. AJR Am J Roentgenol 1991; 157:777–780.
Complications of inguinal hernia surgery include injury to bladder, bowel, vas deferens, and vasculature of the inguinal canal (1). Vascular injury during inguinal hernia repair can occur by damage to any of the following vessels: rectus muscle vessel, inferior epigastric vessels, venous plexus at the pubic symphysis, aberrant obturator vein, testicular vessels, and iliac vessels (1). Figure 4 illustrates some of the vascular structures supplying the inguinal canal. Injury to the inferior epigastric and other pelvic vessels during surgical dissection or stapling of the mesh can result in bleeding (2). Avoidance of traction and preperitoneal
Editor: This report met criteria for institutional review board exemption at our institution. A 56-year-old man with no significant past medical or surgical history underwent elective left hernia surgery with a standard Lichtenstein open mesh repair. He became unstable 4 hours postoperatively with a systolic pressure of 70 mm Hg and a pulse of 130 and suprapubic and left lower quadrant discomfort. Abdominal examination revealed fullness in the left lower quadrant. A decrease in hemoglobin level from 15 g/dL to 8.1 g/dL was observed. Blood transfusions were initiated, and exploratory surgery was performed, which failed to reveal active bleeding. A preperitoneal hematoma with expressible blood clots from the internal ring was noted. Surgical packing was attempted with a transient response, and the patient was subsequently transferred to interventional radiology. A left pelvic and femoral angiogram failed to reveal hemorrhage. A subsequent aortogram showed extravasation from the distal left testicular artery 10–12 cm cephalad to the operative site (Fig 1). The left testicular artery was selectively catheterized with a 5-F SOS Omni catheter (AngioDynamics, Queensbury, New York), and brisk hemorrhage from the distal vessel was seen (Fig 2a, b). Subselective catheterization using a 3-F microcatheter (Renegade Hi-Flo; Boston Scientific, Natick, Massachusetts) and embolization using flow-directed absorbable gelatin sponge (Gelfoam; Ethicon, Somerville, New Jersey) slurry infusion until stasis were performed (Fig 3a, b). No further evidence of clinical bleeding was seen. However, the patient developed an ischemic left testicle and underwent left orchiectomy. He was discharged 8 days later and was healthy at follow-up evaluation at 2 months.
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.12.003
Figure 1. Aortogram demonstrates extravasation from the testicular artery above the inguinal canal (arrow).