Celiac block for the treatment of pancreatic pain

Contribution to the variability in the coeliac plexus structure and formation

BACKGROUND

The coeliac plexus is often approached due to the diagnosis and treatment of the intractable pain associated with cancerous or non-cancerous pathology of the pancreas or neighbouring organs. Various methods of coeliac plexus blocks are used and the variations in its structure are causes of the failures of such procedures.

METHODS

Twenty human cadavers (17 male, 3 females, age range 30-86 years, without any abdominal pathology) were dissected in the supine position. The abdominal autonomics was studied bilaterally after the incision of the abdominal wall the peritoneal sac was cut and the abdominal organs were removed. The coeliac plexus becomes visible after removing the hepatogastric and hepatoduodenal ligaments and pulling the stomach to the left and the pancreas downward.

RESULTS

The largest coeliac ganglion was 45 mm on the right and 25 mm on the left. The average distance of the ganglia from the coeliac trunks was 6-9 mm from the right and left. The size of coeliac ganglia varies from 5 to 45 mm and their number from 2 to 12. Ganglia can be diffusely or concentrically organized. The coeliac plexus almost always receives the branches from the greater splanchnic and vagus nerves. Sometimes the contributions from the lesser splanchnic nerve, phrenic nerve, and accessory phrenic nerve (60%) were observed. Very rarely are missing both phrenic nerves.

CONCLUSION

Sympathectomy (splanchnicectomy), as well as the coeliac blocks (under US, CT control, or laparotomic) aimed at pain relief usually by pancreatic cancer, should consider these possible variabilities.

Celiac plexus neurolysis for the treatment of upper abdominal cancer pain

Optimal treatment of oncologic pain is a challenge to all professionals who deal with cancer and its complications. The management of upper abdominal pain is usually difficult and it is often refractory to conservative therapies. In this context, celiac plexus neurolysis (CPN) appears to be an important and indispensable tool because it alleviates pain, gives comfort to patients and is a safe procedure. In this study, the importance of CPN is reviewed by a retrospective study of 74 patients with pain due to upper abdominal cancer. Almost all cases evaluated (94.6%) had an excellent result after CPN and the majority of side effects were transitory.

Ejaculatory failure after unilateral neurolytic celiac plexus block

Abdominal pain associated with chronic pancreatitis is often difficult to control with analgesics and can be severely debilitating with significant impairment of quality of life. In these patients, neurolytic celiac plexus block (NCPB) is an effective treatment option with a low complication rate. However, there is a risk of ejaculatory failure after NCPB, which may be a problem in patients with a long life expectancy. We report a case of ejaculatory failure after unilateral NCPB in a patient with chronic pancreatitis.

Interventional pain treatments for cancer pain

Cancer pain is prevalent and often multifactorial. For a segment of the cancer pain population, pain control remains inadequate despite full compliance with the WHO analgesic guidelines including use of co-analgesics. The failure to obtain acceptable pain or symptom relief prompted the inclusion of a fourth step to the WHO analgesic ladder, which includes advanced interventional approaches. Interventional pain-relieving therapies can be indispensable allies in the quest for pain reduction among cancer patients suffering from refractory pain. There are a variety of techniques used by interventional pain physicians, which may be grossly divided into modalities affecting the spinal canal (e.g., intrathecal or epidural space), called neuraxial techniques and those that target individual nerves or nerve bundles, termed neurolytic techniques. An array of intrathecal medications are infused into the cerebrospinal fluid in an attempt to relieve refractory cancer pain, reduce disabling adverse effects of systemic analgesics, and promote a higher quality of life. These intrathecal medications include opioids, local anesthetics, clonidine, and ziconotide. Intrathecal and epidural infusions can serve as useful methods of delivering analgesics quickly and safely. Spinal delivery of drugs for the treatment of chronic pain by means of an implantable drug delivery system (IDDS) began in the 1980s. Both intrathecal and epidural neurolysis can be effective in managing intractable cancer-related pain. There are several sites for neurolytic blockade of the sympathetic nervous system for the treatment of cancer pain. The more common sites include the celiac plexus, superior hypogastric plexus, and ganglion impar. Today, interventional pain-relieving approaches should be considered a critical component of a multifaceted therapeutic program of cancer pain relief.

CT-guided percutaneous neurolytic celiac plexus block technique

Up to now, the studies in the world have demonstrated that CT-guided percutaneous neurolytic celiac plexus block (PNCPB) is an invaluable therapeutic modality in the treatment of refractory abdominal pain caused by cancer. Its efficacy of pain relief varied in reported studies. The main technical considerations which would affect the analgesic effects on abdominal pain included the patients' cooperation, needle entry approaches, combined use of blocking approaches, localization of the target area, dosage of the blocker, and so on. A success of PNCPB depends greatly on close cooperation with patients. The patient should be educated about the purpose and steps of the procedure, and trained of breathing in and breathing hold. The needle entry can be divided into the posterior approach and the anterior approach. The former one is the most commonly used in clinical practice, but the latter one is rarely used except in the cases that the posterior approach becomes technically difficult. Bilateral multiple blocking of celiac plexus and splanchnic nerves is often required to achieve optimal analgesia. The needle entry site, insertion course, and depth should be preselected and simulated on CT monitor prior to the procedure in order to ensure an accurate and safe celiac plexus block. The magnitude of analgesic effect is closely related to the degree of degeneration and necrosis of the celiac plexus. Maximally filling with blocker in the retropancreatic space is an indication of sufficient blocking. We also provided an overview of indications and contraindications, preoperative preparations, complications and its treatment of PNCPB.

Celiac Plexus Block: A New Technique Using the Left Lateral Approach

We describe a new celiac plexus block approach in a patient with cholangiocarcinoma who was referred to the Pain Clinic due to uncontrollable abdominal pain. The patient was initially programmed for a neurolytic celiac plexus block using the anterior approach with helical computerized tomography (CT) guidance. The CT scan revealed interposition of the transverse colon in the anterior approach territory, which made the anterior approach technique difficult, and also difficulty to practice the posterior approach without injuring the kidneys. We decided to attempt a left lateral atypical approach because the CT revealed the possibility of using a left lateral window to arrive to the celiac area. The left lateral access allowed us to carry out the neurolytic block using 50% alcohol without injuring any viscera. The patient tolerated the technique and was discharged without pain. No complications regarding either the punction or the block were observed.

Retroperitoneal abscess after neurolytic celiac plexus block from the anterior approach

BACKGROUND AND OBJECTIVES

The anterior approach for celiac plexus block has the potential risks of infection, hemorrhage, and fistula formation. We report a case of a patient who developed a retroperitoneal abscess with the formation of a vascular-enteric fistula after a neurolytic celiac plexus block from the anterior approach.

CASE REPORT

A 60-year-old female with a history of pain secondary to chronic idiopathic calcifying pancreatitis (VAS 7-8) underwent a subtotal resection of the head of the pancreas with an end-to-side pancreatojejunostomy using a Roux-en-Y loop. Pain continued secondary to chronic pancreatitis. Because of intolerance (vomiting and constipation) of morphine and transdermal fentanyl over a 2-month period, it was decided to perform a neurolytic celiac plexus block using the anterior approach with ultrasound guidance. The patient's pain was completely relieved, enabling withdrawal of oral analgesics. Pain reappeared after 2 years, and the same technique was repeated. Ten days later, she was admitted with diabetic ketoacidosis and lower gastrointestinal bleeding. Computed tomography showed a left paravertebral retroperitoneal abscess; arteriography suggested a fistula between the mesenteric vein and the jejunum. Urgent surgery was undertaken, revealing a leak of the pancreatojejunostomy and a large abscess around the celiac plexus. A distal pancreatectomy and partial resection of the Roux-en-Y loop was performed. The patient was discharged 1 month later in good clinical condition. Because of recurrent pain, she has required repeated neurolytic celiac plexus blocks via a posterior approach without complications.

CONCLUSION

The posterior approach for neurolytic celiac plexus block should be considered in particular in patients with previous pancreatic surgery.

Neurolytic celiac plexus block for visceral abdominal malignancy: is prior diagnostic block warranted?

Neurolytic celiac plexus block is a recognised treatment for visceral abdominal pain due to malignancy. The need for a diagnostic celiac plexus block prior to neurolytic blockade is of questionable value, as it may not predict a positive response and may incorrectly predict a lack of response. Our objective is to evaluate the efficacy of diagnostic celiac plexus block. The records of 59 patients treated with celiac plexus block during 1994-2000 were retrospectively reviewed. Diagnostic block was performed on 32 patients prior to the decision for subsequent neurolytic block (Group 1). Another 27 patients were directly treated with a neurolytic celiac plexus block (Group 2). Response of Group 1 to diagnostic and neurolytic blocks was compared. Data from Group 2 was used to project the response of Group 1 should those patients with negative response to diagnostic block proceeded to neurolytic block. A two-by-two table was then constructed. The diagnostic celiac plexus block predicted a positive response with a sensitivity of 93% and a specificity of 37%. The positive predictive value was 85% and the negative predictive value was 58%. The estimated "number needed to test" before a "true" nonrespondent to lytic block to be detected was 16.7. Therefore, a positive response to diagnostic block correlates positively with neurolytic celiac plexus block for abdominal visceral pain due to malignancy. However, diagnostic block is a poor predictor when the response is negative. Hence, its clinical role is questionable and may not be warranted for patients with terminal malignancy.

Neurohistopathologic findings after a neurolytic celiac plexus block with alcohol in patients with pancreatic cancer pain

Pancreatic cancer has a very poor prognosis resulting in the death of 98% of patients. Pain may be severe and difficult to treat. Management of pain includes chemotherapy, radiotherapy, pharmacologic treatment, and neurolytic celiac plexus block. Recent reviews of the efficacy of neurolytic celiac plexus block however, have reached conflicting conclusions. In this paper, we present two patients with severe pancreatic cancer pain resistant to pharmacologic treatment. Analgesic effect following repeated neurolytic celiac plexus blocks with alcohol was limited in time. Post-mortem neurohistopathologic examination of the celiac plexus revealed an abnormal celiac architecture with a combination of abnormal neurons with vacuolization and normal looking neuronal structures (ganglionic structures and nerve fibers) embedded in fibrotic hyalinized tissue. Our results show that a neurolytic celiac plexus block with alcohol is capable of partially destroying the celiac plexus. These findings may explain the significant but short-lasting analgesic effect following neurolytic celiac plexus block with alcohol.

Supportive care for patients with pancreatic adenocarcinoma: symptom control and nutrition

Pancreatic cancer is most frequently a fatal disease with many associated morbidities. Clinicians skilled in its treatment are adept at management of symptoms caused by local and systemic effects of the malignancy. Patients should be assured that there are many treatments that can be used aggressively to maintain their comfort and independence for as long as possible. Patients should be encouraged to inform their health care providers of any discomfort or medical or psychological problems they are experiencing. At times, referrals to specialists can be beneficial for consideration of specific symptom-improving interventions. Timely referral to a palliative medicine service and hospice can have significant beneficial impact on the total care of the patient and on home caregiver.