Computed tomography-guided celiac plexus neurolysis for intractable pain of unresectable pancreatic cancer

Feasibility of celiac axis delineation and treatment on combined magnetic resonance imaging and linear accelerator systems

Trials have been performed on irradiating celiac plexus for pancreatic cancer pain management. Images from a combined magnetic resonance imaging and linear accelerator system (MR-linac) for ten patients were assessed for delineation of celiac ganglia, aiming for smaller target volumes and reducing treatment risks versus standard linac-based treatments. MRI-linacs showed superior soft tissue contrast, enabling increased dose to ganglia while irradiating smaller target volumes versus regular linacs (median: 0.8 cm3 vs. 32.2 cm3, p < 0.05 for ten pairs of plans). While further studies are needed, MR-linac treatments could improve targeting precision, minimize dose to organs-at-risk and enhance effectiveness in palliative care.

Utility of Intranasal Tapentadol in Redefining Postoperative Pain Management in Total Knee Arthroplasty: A Prospective Observational Study

Introduction Effective strategies to minimize postoperative pain following total knee arthroplasty (TKA) are essential to improve functional outcomes. This study aimed to evaluate the effectiveness and safety of tapentadol nasal spray as a form of patient-controlled analgesia (PCA) for postoperative pain management after TKA. The intranasal route was chosen for the study as intranasal tapentadol has been shown to have superior pain reduction as compared to intravenous tapentadol. Intranasal instillation of tapentadol is rapid and more effective than the parenteral or oral route. Additional advantages of the intranasal route include enhanced comfort, convenience, and safety. Methods The present study was a single-center prospective observational study including 120 patients undergoing unilateral TKA who were administered tapentadol nasal spray post-surgery (22.5 mg of tapentadol per spray). Pain was objectively assessed using the visual analog scale (VAS) on postoperative days (POD) 1, 2, and 3, before and after spray administration. The pain severity was graded into mild (VAS 1-3), moderate (VAS 4-6), and severe (VAS 7-10) based on the VAS score. The time duration required for the pain severity to become mild from the pre-spray level post-administration of the nasal spray was recorded on all three PODs. The time required in hours for the pain severity to worsen from mild (VAS 1-3) to moderate (VAS 4-6) or severe (VAS 7-10) was also recorded on all three PODs. The statistical analysis plan for this study involved the analysis of VAS scores collected on PODs 1, 2, and 3. Categorical variables were expressed as percentages, while numerical variables were presented as means and standard deviations. The significance of differences between pre and post-treatment VAS scores was analyzed using Student's t-test. Differences between proportions were analyzed using the Chi-square or Fisher's exact test. The Kolmogorov-Smirnov test was used to test the normality of the quantitative data. The Analysis of Variance (ANOVA) test was applied to compare the means across the three PODs. A two-tailed significance level of 0.05 was set for all tests to determine statistical significance. Results The mean pre-spray VAS scores recorded on POD 1, 2, and 3 were 8.07, 7.64, and 7.40 respectively. The mean post-spray VAS scores recorded on POD 1, 2, and 3 were 4.63, 4.71, and 3.95 respectively. There was a statistically significant reduction in the VAS scores on each of the three days when measured before and after spray administration (p<0.001). The average time needed for the pain severity to become mild from the pre-spray level in minutes on POD 1, 2, and 3 was 14.07, 13.36, and 12.34 respectively. Thus, this metric significantly declined (p<0.001) from POD 1 to POD 3. The time taken in hours for the pain severity to worsen from mild to moderate or severe on POD 1, 2, and 3 was 6.57, 6.70, and 6.98 respectively indicating that there was a significant increase in the time till the pain severity worsened from POD 1 to POD 3 (p<0.001). There were no major drug-induced adverse reactions following the administration of intranasal tapentadol. Conclusion Intranasal tapentadol spray (22.5 mg per spray) is an acceptable modality of postoperative pain management in patients undergoing TKA. It has a long-lasting effect, rapid onset, minimal side effects, and can be self-administered by the patient.

Efficacy and Safety of Celiac Plexus Neurolysis in the Treatment of Chronic Pain Secondary to Oncological Pathology of the Upper Hemiabdomen: A Systematic Review and Meta-Analysis

Objectives

The management of chronic pain among patients with abdominal cancer is complex; against that, the neurolysis of the celiac plexus (CPN) is the best technique at the moment to determine the efficacy and safety in the treatment of chronic pain secondary to oncological pathology of the upper abdomen.

Material and Methods

This was a systematic review of controlled clinical trials between 2000 and 2021, in the sources MEDLINE/PubMed, Cochrane, Scopus, Web of Science, and Google Scholar. Three independent evaluators analysed the results of the bibliographical research. The quality of the studies was assessed with the Jadad scale and the mean difference (95% confidence interval) and heterogeneity of the studies (I2) were calculated with Review Manager 5.3.

Results

Seven hundred and forty-four publications were identified, including 13 studies in the qualitative synthesis and three studies in the quantitative synthesis. No difference was found in the decrease in pain intensity between 1 and 12 weeks after the intervention, comparing the experimental group with the control (P > 0.05). The adverse effects related to neurolysis were not serious and transitory, mentioning the most frequent adverse effects and reporting a percentage between 21% and 67% (with 17% for echoendoscopic neurolysis and 49% for percutaneous neurolysis).

Conclusion

Celiac plexus neurolysis for the treatment of severe chronic pain secondary to oncological pathology in the upper hemiabdomen produces similar pain relief as conventional pharmacological analgesic treatment. It is a safe analgesic technique since the complications are mild and transitory.

Effect of cilostazol on preventing paclitaxel-induced neuropathy in patients with breast cancer: A randomized controlled trial

STUDY OBJECTIVE

Paclitaxel-induced peripheral neuropathy is a significant clinical problem can markedly deteriorate patient's quality of life (QoL). Preclinical evidence exists about the preventive capacity of cilostazol against peripheral neuropathy. However, this hypothesis has not yet been clinically investigated. This proof-of-concept study evaluated the effect of cilostazol on the incidence of paclitaxel-induced peripheral neuropathy in patients with non-metastatic breast cancer.

DESIGN

This is a parallel randomized placebo-controlled trial.

SETTING

The Oncology Center at Mansoura University, Egypt.

PATIENTS

Patients with breast cancer scheduled to receive paclitaxel 175 mg/m2 biweekly.

INTERVENTIONS

Patients were randomized to either cilostazol group who received cilostazol tablets 100 mg BID, or to control group who received placebo instead.

MEASUREMENTS

The primary endpoint was the incidence of paclitaxel-induced neuropathy evaluated through common terminology criteria for adverse event (NCI-CTCAE) version 4. Secondary endpoints included assessment of the patient's QoL by the Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity (FACT-GOG-NTx) subscale. Exploratory outcome measures included changes in serum levels of biomarkers namely nerve growth factor (NGF), and neurofilament light chain (NfL).

MAIN RESULTS

The incidence of grade 2 and 3 peripheral neuropathies were significantly lower in the cilostazol group (40%) compared to the control group (86.7%) (p < 0.001). The incidence of clinically significant worsening in neuropathy-related QoL was higher in control group compared to the cilostazol group (p = 0.001). A higher percent increase from baseline in serum NGF was observed in the cilostazol group (p = 0.043). The circulating levels of NfL deemed comparable between the two arms at the end of the study (p = 0.593).

CONCLUSION

Adjunctive use of cilostazol is as a novel option that might reduce the incidence of paclitaxel-induced peripheral neuropathy and improve the patients' QoL. Future larger clinical trials are warranted to confirm these findings.

Robotic computed tomography-guided celiac plexus neurolysis: our experience of technique and outcomes

Aim: We report the use of robot assistance for computed tomography-guided celiac plexus neurolysis for the first time. Materials & methods: Four patients of upper abdominal cancer with intractable pain despite opioids were positioned prone on the PET-computed tomography scanner, which measured the accurate coordinates for the entry, depth and angle of the target point. The robot positioned its arm over the patient in accordance with the set needle path. The physician manually inserted needle through it and injected 20 ml of 0.75% alcohol after dye confirmation. Results: Significant reduction in pain scores and oral morphine consumption were observed in patients during 3 months follow-up. Conclusion: The robot precisely orients and helps in accurate placement of the needle through the robotic arm.

Direct intraoperative versus percutaneous computed tomographyguided celiac plexus neurolysis in non-resectable pancreatic cancer: A randomized, controlled, non-inferiority study

BACKGROUND

Celiac plexus neurolysis (CPN) has been used to control pancreatic cancer (PC) pain, up to our knowledge, there is no study compared intraoperative CPN and computed tomography (CT)-guided techniques.

OBJECTIVES

To compare the effects of intraoperative and CT-guided CPN in unresectable PC on pain intensity and analgesic requirements.

METHODS

A total of 90 patients were enrolled in this prospective, randomized, open label, controlled, non-inferiority study, 20 patients were excluded or lost to follow up. The patients were randomly allocated to either intraoperative or CT-guided CPN group. A mixture of 20 mL ethanol 90%, 100 mg lignocaine and 5 mg dexamethasone was infused on each side of the aorta in both groups. Visual analogue score (VAS) and oral daily tramadol consumption were recorded at day 7, 14, 30, 60, 120 and 180 days after intervention. Occurrence of any intervention related complications were reported.

RESULTS

Median VAS was similar in both intraoperative and CT-guided CPN groups from day 7 up to 180 days after intervention. The median daily analgesic consumption of oral tramadol (mg) was comparable in both intraoperative and CT-guided CPN groups after intervention at day 7 (50 versus 50), day14 (50 versus 50), day 30 (50 versus 50), day 60 (50 versus 50), day 120 (100 versus 75) and day 180 (100 versus 100). The incidence of diarrhea, vomiting, hypotension and back pain was similar in both groups.

CONCLUSION

Intraoperative CPN is non-inferior to CT-guided CPN as both techniques were similarly associated with reduced pain severity and analgesics requirements.

Direct intraoperative versus percutaneous computed tomographyguided celiac plexus neurolysis in non-resectable pancreatic cancer: A randomized, controlled, non-inferiority study

BACKGROUND

Celiac plexus neurolysis (CPN) has been used to control pancreatic cancer (PC) pain, up to our knowledge, there is no study compared intraoperative CPN and computed tomography (CT)-guided techniques.

OBJECTIVES

To compare the effects of intraoperative and CT-guided CPN in unresectable PC on pain intensity and analgesic requirements.

METHODS

A total of 90 patients were enrolled in this prospective, randomized, open label, controlled, non-inferiority study, 20 patients were excluded or lost to follow up. The patients were randomly allocated to either intraoperative or CT-guided CPN group. A mixture of 20ml ethanol 90%, 100mg lignocaine and 5mg dexamethasone was infused on each side of the aorta in both groups. Visual analogue score (VAS) and oral daily tramadol consumption were recorded at day 7, 14, 30, 60, 120 and 180 days after intervention. Occurrence of any intervention related complications were reported.

RESULTS

Median VAS was similar in both intraoperative and CT-guided CPN groups from day 7 up to 180 days after intervention. The median daily analgesic consumption of oral tramadol (mg) was comparable in both intraoperative and CT-guided CPN groups after intervention at day 7 (50 versus 50), day14 (50 versus 50), day 30 (50 versus 50), day 60 (50 versus 50), day 120 (100 versus 75) and day 180 (100 versus 100). The incidence of diarrhea, vomiting, hypotension and back pain was similar in both groups.

CONCLUSION

Intraoperative CPN is non-inferior to CT-guided CPN as both techniques were similarly associated with reduced pain severity and analgesics requirements.

Celiac Plexus Block Complications: A Case Report and Review of the Literature

Celiac plexus block (CPB) has been widely used as a treatment option for chronic intractable abdominal pain resulting from intra-abdominal malignancies as well as benign conditions. Complications resulting from CPB have been long reported and include diarrhea, back pain, paraplegia, postural hypotension, pneumothorax, and local anesthesia toxicity. Diarrhea and postural hypotension are two most common complications with studies reporting incidences occurring in 44% to 60% and 10% to 52% of patients, respectively. Diarrhea is most often transient, resolving within 48 hours; however, literature reports cases in which diarrhea was chronic, debilitating, and in some instances life threatening. Persistent diarrhea proves difficult to treat. We report a case of a 76-year-old male with unresectable pancreatic adenocarcinoma who underwent computed tomography-guided CBP complicated by persistent diarrhea and fecal incontinence. After conventional antidiarrheal failed to improve the symptoms, octreotide proved to be beneficial and the patient reported significant improvement in symptoms.

Contrast-enhanced ultrasound-guided celiac plexus neurolysis in patients with upper abdominal cancer pain: initial experience

OBJECTIVES

The purpose of this study was to determine the efficacy and safety of contrast-enhanced ultrasound (CEUS)-guided celiac plexus neurolysis (CPN) in patients with upper abdominal cancer pain.

METHODS

Thirty-five patients with upper abdominal cancers tortured by intractable upper abdominal pain underwent CEUS-guided CPN with ethanol. The pain alleviation and opioid intake were observed and evaluated during a 3-month follow-up after CPN. The dispersion of alcohol around the aorta was evaluated on 3D-CEUS. Complications were assessed during CPN and at follow-up.

RESULTS

All of the 35 patients' CPN was successfully achieved. Pain relief was observed in 28 (80%), 20 (57.1%), 27 (77.1%), 20 (57.1%), and 10 (29.4%) patients immediately, 1 day, 1 month, 2 months, and 3 months after CPN, respectively. The agent dispersion around the aorta on CEUS images of 28 patients who showed pain relief was at least 90° of the circumference around the aorta. The median duration of pain alleviation was 2.7 months (95% confidence interval [CI], 2.5-2.9). Less than half of the patients had minor complications including irritant pain at the puncture site (8 of 35; 22.9%), diarrhea (4 of 35; 11.4%), nausea and vomiting (3 of 35; 8.6%), and post-procedural hypotension (1 of 35; 2.9%).

CONCLUSIONS

CEUS-guided CPN is a safe and effective method to alleviate refractory upper abdominal pain in patients with upper abdominal cancers. CEUS image allows the visualization of puncture path and observation of drug dispersion. The pain relief is relevant to the dispersion of neurolytic agent around the aorta.

KEY POINTS

• CEUS-guided celiac plexus neurolysis (CPN) is feasible and easy. • It allows direct visualization of the diffusion of the neurolytic agent in the retroperitoneal anatomic space. • CEUS-guided CPN improves safety of CPN by clearly delineating the needle path.