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Matsumoto T, Yoshimatsu R, Osaki M, Miyatake K, Kitaoka N, Baba Y, Yamagami T. Percutaneous splanchnic nerve neurolysis analgesic efficacy and safety for cancer-related pain: a systematic review and meta-analysis. Support Care Cancer 2023; 31:324. [PMID: 37148332 DOI: 10.1007/s00520-023-07746-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 04/11/2023] [Indexed: 05/08/2023]
Abstract
PURPOSE To perform a systematic review and meta-analysis of publications to evaluate the analgesic efficacy and safety of percutaneous splanchnic nerve neurolysis (SNN) for cancer-related pain. METHODS We searched PubMed, Cochrane Library, and Ichushi-Web for English or Japanese articles published up to July 2022 and reporting patients who underwent percutaneous SNN for cancer-related pain. The outcome measures assessed in the systematic review and meta-analysis were the pain measurement scales and morphine equivalents daily dose (MEDD) before and after the intervention and the rate of complications. RESULTS Pooled pain measurement scores at pre-intervention, 1-2 weeks, and at 1, 2, 3, and 6 months post-intervention were 6.65 (95% confidence interval [CI], 5.77-7.67, I2 = 97%), 2.79 (95% CI, 2.00-3.88, I2 = 88%), 2.82 (95% CI, 2.49-3.20, I2 = 55%), 2.86 (95% CI, 2.64-3.10, I2 = 0%), 2.99 (95% CI, 2.56-3.46, I2 = 82%), and 3.09 (95% CI, 1.44-6.65, I2 = 70%), respectively. Mean MEDD was described in 8 of the 11 included articles. In all 8 articles, MEDD decreased up to 3 months post-intervention. The pooled minor complication rates for diarrhea and hypotension were 28% (95% CI, 13-49%, I2 = 85%) and 31% (95% CI, 16-51%, I2 = 80%), respectively. The pooled major complication rate was 2% (95% CI, 1-2%, I2 = 0%). CONCLUSIONS Analysis indicates that percutaneous SNN for cancer-related pain can be performed safely with sustained reduction of pain measurement scales while reducing the administration of opioids.
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Affiliation(s)
- Tomohiro Matsumoto
- Department of Diagnostic and Interventional Radiology, Kochi Medical School, Kochi University, Oko-Cho, Kohasu, Nankoku, Kochi, 783-8505, Japan.
| | - Rika Yoshimatsu
- Department of Diagnostic and Interventional Radiology, Kochi Medical School, Kochi University, Oko-Cho, Kohasu, Nankoku, Kochi, 783-8505, Japan
| | - Marina Osaki
- Department of Diagnostic and Interventional Radiology, Kochi Medical School, Kochi University, Oko-Cho, Kohasu, Nankoku, Kochi, 783-8505, Japan
- Department of Radiology, Kochi Health Sciences Center, 2125-1 Ike, Kochi, 781-0111, Japan
| | - Kana Miyatake
- Department of Diagnostic and Interventional Radiology, Kochi Medical School, Kochi University, Oko-Cho, Kohasu, Nankoku, Kochi, 783-8505, Japan
| | - Noriko Kitaoka
- Department of Palliative Medicine, Kochi Medical School, Kochi University, Kohasu, Nankoku, Kochi, Oko-Cho, 783-8505, Japan
| | - Yasutaka Baba
- Department of Diagnostic Radiology, International Medical Centre, Saitama Medical University, 1397-1 Yamane, Hidaka, 350-1298, Japan
| | - Takuji Yamagami
- Department of Diagnostic and Interventional Radiology, Kochi Medical School, Kochi University, Oko-Cho, Kohasu, Nankoku, Kochi, 783-8505, Japan
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Roberts DA, Watson E, Macdonald C, Khan Y, Prideaux S, Puthiyakunnel Saji A, Postaleniec E, Selvakumar J, Haghighat Ghahfarokhi M, Davidson B, Gurusamy K. Management of pain and cachexia in pancreatic cancer: Protocol for two systematic reviews, network meta-analysis, surveys and focus groups (Preprint). JMIR Res Protoc 2023; 12:e46335. [PMID: 37014692 PMCID: PMC10139686 DOI: 10.2196/46335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 02/26/2023] [Accepted: 02/26/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Approximately 75% of people with pancreatic cancer experience pain, and >50% of them have cachexia (weakness and wasting of the body). However, there is considerable uncertainty regarding the management of these distressing symptoms. OBJECTIVE Our primary objectives are to compare the relative benefits and harms of different interventions for pain in people with unresectable pancreatic cancer and for prevention and treatment of cachexia due to pancreatic cancer, through systematic reviews and network meta-analysis. Our secondary objectives are to develop an evidence-based clinical care pathway to manage pain and prevent and treat cachexia in people with pancreatic cancer through surveys and focus groups involving patients, carers, and health care professionals. METHODS We will perform 2 systematic reviews of the literature related to pain and cachexia in people with pancreatic cancer using searches from Cochrane Library, MEDLINE, Embase, Science Citation Index, and trial registries. Two researchers will independently screen for eligibility and identify randomized controlled trials (no language or publication status restriction), comparing interventions for pain or cachexia based on full-texts for articles shortlisted during screening. We will assess risk of bias in the trials using the Cochrane risk of bias tool (version 2.0) and obtain data related to baseline prognostic characteristics, potential effect modifiers and outcome data related to overall survival, health-related quality of life, treatment-related complications, and resource utilisation. We aim to conduct network meta-analysis on outcomes with multiple treatment comparisons where possible, otherwise, meta-analysis with direct comparisons, or narrative synthesis. We will perform various subgroup and sensitivity analyses. Using information obtained from both systematic reviews, we will conduct 2 surveys: one directed to patients or carers to assess acceptability of interventions, and the other to health care professionals to assess feasibility of delivery in the National Health Service. Four mixed focus groups will be conducted to evaluate findings and foster consensus in the development of the care pathway. RESULTS Funding was awarded from April 2022 (NIHR202727). Both systematic review protocols were prospectively registered on PROSPERO in May 2022. Formal searches began thereafter. Approval by the University College London Research Ethics Committee (23563/001) was received in December 2022. Data collection began in January 2023; data analysis will begin in May 2023 (completion expected by October 2023). CONCLUSIONS This study will comprehensively encompass major interventions for management of pain in people with unresectable pancreatic cancer, and prevention and treatment of cachexia in people with pancreatic cancer. Key stakeholders will facilitate the development of an evidence-based care pathway, ensuring both acceptability and feasibility. The project ends in April 2024 and published results are expected within 12 months of completion. We aim to present the findings through patient group websites, conferences, and publications, irrespective of the findings, in a peer-reviewed journal. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/46335.
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Affiliation(s)
- Danielle Amanda Roberts
- Division of Surgery and Interventional Science, Hampstead Campus, University College London, London, United Kingdom
| | - Eila Watson
- Supportive Cancer Care Research Group, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, United Kingdom
| | | | | | - Sarah Prideaux
- Patient and Public Involvement Representative, England, United Kingdom
| | | | - Emilia Postaleniec
- Leicester Medical School, The University of Leicester, Leicester, United Kingdom
| | - Jashan Selvakumar
- St George's, University of London Medical School, London, United Kingdom
| | | | - Brian Davidson
- Division of Surgery and Interventional Science, Hampstead Campus, University College London, London, United Kingdom
| | - Kurinchi Gurusamy
- Division of Surgery and Interventional Science, Hampstead Campus, University College London, London, United Kingdom
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Langversion 2.0 – Dezember 2021 – AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:e812-e909. [PMID: 36368658 DOI: 10.1055/a-1856-7346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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4
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Kurzversion 2.0 – Dezember 2021, AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:991-1037. [PMID: 35671996 DOI: 10.1055/a-1771-6811] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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5
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Coveler AL, Mizrahi J, Eastman B, Apisarnthanarax SJ, Dalal S, McNearney T, Pant S. Pancreas Cancer-Associated Pain Management. Oncologist 2021; 26:e971-e982. [PMID: 33885205 PMCID: PMC8176967 DOI: 10.1002/onco.13796] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 04/02/2021] [Indexed: 12/12/2022] Open
Abstract
Pain is highly prevalent in patients with pancreas cancer and contributes to the morbidity of the disease. Pain may be due to pancreatic enzyme insufficiency, obstruction, and/or a direct mass effect on nerves in the celiac plexus. Proper supportive care to decrease pain is an important aspect of the overall management of these patients. There are limited data specific to the management of pain caused by pancreatic cancer. Here we review the literature and offer recommendations regarding multiple modalities available to treat pain in these patients. The dissemination and adoption of these best supportive care practices can improve quantity and quality of life for patients with pancreatic cancer. IMPLICATIONS FOR PRACTICE: Pain management is important to improve the quality of life and survival of a patient with cancer. The pathophysiology of pain in pancreas cancer is complex and multifactorial. Despite tumor response to chemotherapy, a sizeable percentage of patients are at risk for ongoing cancer-related pain and its comorbid consequences. Accordingly, the management of pain in patients with pancreas cancer can be challenging and often requires a multifaceted approach.
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Affiliation(s)
- Andrew L Coveler
- Department of Medical Oncology, University of Washington, Seattle, Washington, USA
| | - Jonathan Mizrahi
- Department of Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bory Eastman
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | | | - Shalini Dalal
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Shubham Pant
- Department of Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Pain Relieving Effect of Intraoperative Chemical Splanchnicectomy of Celiac Ganglions in Patients with Resectable Pancreatic or Gastric Masses: A Randomized Clinical Trial. Pain Res Manag 2020; 2020:2675940. [PMID: 32300382 PMCID: PMC7132578 DOI: 10.1155/2020/2675940] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 02/27/2020] [Indexed: 11/17/2022]
Abstract
Background Trials of intraoperative chemical splanchnicectomy during resection of pancreatic and gastric masses resulted in significant difference in a patient's postoperative pain. This study aims to determine if splanchnicectomy by alcohol neurolysis can relieve postoperative pain after gastrectomy and Whipple surgery. The study explores differences in outcomes at first four months after surgery. Methods Fifty-eight patients with gastric and 60 patients with pancreatic resectable masses were included (28 were lost to follow-up). Each randomized in control and intervention subgroups. Intervention subgroups underwent chemical blockage of celiac ganglions by ethanol injection at both sides of suprapancreatic aorta. Participants were asked to report their pain intensity according to the Visual Analogue Scale (VAS) at specific times. Result The overall postoperative pain of injected Whipple and gastrectomy subgroups was lower than the noninjected Whipple and gastrectomy subgroups (p < 0.001). The pain-modifying effect of the injection was not different between Whipple and gastrectomy groups (p=0.125). Conclusion Splanchnicectomy is recommended for pain reduction after abdominal operations. Perspective. This article presents positive effect of intraoperative chemical splanchnicectomy during resection of pancreatic and gastric masses on postoperative pain. This is an easy, effective, safe, and inexpensive procedure recommended for all operable gastric or pancreatic masses to palliate the pain degree.
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Moffat GT, Epstein AS, O’Reilly EM. Pancreatic cancer-A disease in need: Optimizing and integrating supportive care. Cancer 2019; 125:3927-3935. [PMID: 31381149 PMCID: PMC6819216 DOI: 10.1002/cncr.32423] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/05/2019] [Accepted: 07/08/2019] [Indexed: 12/24/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy that continues to be challenging to treat. PDAC has the lowest 5-year relative survival rate compared with all other solid tumor malignancies and is expected to become the second-leading cause of cancer-related death in the United States by 2030. Given the high mortality, there is an increasing role for concurrent anticancer and supportive care in the management of patients with PDAC with the aims of maximizing length of life, quality of life, and symptom control. Emerging trends in supportive care that can be integrated into the clinical management of patients with PDAC include standardized supportive care screening, early integration of supportive care into routine cancer care, early implementation of outpatient-based advance care planning, and utilization of electronic patient-reported outcomes for improved symptom management and quality of life. The most common symptoms experienced are nausea, constipation, weight loss, diarrhea, anorexia, and abdominal and back pain. This review article includes current supportive management strategies for these and others. Common disease-related complications include biliary and duodenal obstruction requiring endoscopic procedures and venous thromboembolic events. Patients with PDAC continue to have a poor prognosis. Systemic therapy options are able to palliate the high symptom burden but have a modest impact on overall survival. Early integration of supportive care can lead to improved outcomes.
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Affiliation(s)
- Gordon T. Moffat
- Memorial Sloan Kettering Cancer Center (MSK), New York, New York, USA
| | - Andrew S. Epstein
- Memorial Sloan Kettering Cancer Center (MSK), New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Eileen M. O’Reilly
- Memorial Sloan Kettering Cancer Center (MSK), New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
- David M. Rubenstein Center for Pancreatic Cancer Research, MSK
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8
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Interventional Techniques to Management of Cancer-Related Pain: Clinical and Critical Aspects. Cancers (Basel) 2019; 11:cancers11040443. [PMID: 30934870 PMCID: PMC6520967 DOI: 10.3390/cancers11040443] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 03/14/2019] [Accepted: 03/26/2019] [Indexed: 01/20/2023] Open
Abstract
Interventional techniques to manage cancer-related pain may be efficient treatment modalities in patients unresponsive or unable to tolerate systemic opioids. However, indication and selection of the right technique demand knowledge, which is still incipient among clinicians. The present article summarizes the current evidence regarding the five most essential groups of interventional techniques to treat cancer-related pain: Neuraxial analgesia, minimally invasive procedures for vertebral pain, sympathetic blocks for abdominal cancer pain, peripheral nerve blocks, and percutaneous cordotomy. Furthermore, indication, mechanism, drug agents, contraindications, and complications of the main techniques of each group are discussed.
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Oguz G, Senel G, Kocak N. Transient paraplegia after neurolytic splanchnic block in a patient with metastatic colon carcinoma. Korean J Pain 2018; 31:50-53. [PMID: 29372026 PMCID: PMC5780216 DOI: 10.3344/kjp.2018.31.1.50] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 11/08/2017] [Accepted: 11/09/2017] [Indexed: 11/05/2022] Open
Abstract
We present a patient with metastatic colon carcinoma who developed paraplegia following a neurolytic splanchnic block. A 41-year old man with metastatic adenocarcinoma of the colon received a splanchnic neurolytic block using alcohol because of severe abdominal pain. Bilateral motor weakness and a sensorial deficit in both legs developed after the procedure. Diffusion magnetic resonance imaging revealed spinal cord ischemia between T8 and L1. The motor and sensorial deficits were almost completely resolved at the end of the third month. We think that anterior spinal artery syndrome due to reversible spasms of the lumbar radicular arteries using alcohol have resulted in transient paraplegia. The retrograde spread of alcohol to neural structures may have also contributed.
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Affiliation(s)
- Gonca Oguz
- Department of Anesthesiology, Pain and Palliative Care Clinic, Dr AY Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Gulcin Senel
- Department of Anesthesiology, Pain and Palliative Care Clinic, Dr AY Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Nesteren Kocak
- Department of Anesthesiology, Pain and Palliative Care Clinic, Dr AY Ankara Oncology Education and Research Hospital, Ankara, Turkey
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11
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Ahmed A, Arora D. Fluoroscopy-guided Neurolytic Splanchnic Nerve Block for Intractable Pain from Upper Abdominal Malignancies in Patients with Distorted Celiac Axis Anatomy: An Effective Alternative to Celiac Plexus Neurolysis - A Retrospective Study. Indian J Palliat Care 2017; 23:274-281. [PMID: 28827930 PMCID: PMC5545952 DOI: 10.4103/ijpc.ijpc_28_17] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Introduction: The pain from upper gastrointestinal malignancy leads to considerable morbidity. The celiac plexus and splanchnic nerve neurolysis are good therapeutic options. Although splanchnic nerve neurolysis less frequently performed, but it has an edge over celiac plexus as it can be performed in patients with altered celiac plexus anatomy by enlarged lymph nodes. Methods: The fluoroscopy-guided splanchnic nerve neurolysis was done in about 21 patients with intractable upper abdominal pain with pain intensity of ≥7 in numerical rating scale (NRS) from upper gastrointestinal cancers with distorted celiac plexus anatomy from enlarged celiac lymph nodes as seen by computed tomography scan after positive diagnostic splanchnic nerve neurolysis. The demographic features, pain intensity, daily opioid dose, functional status and quality of life was measured at baseline and 1 week, 1 and 3 months after the procedure. Results: There was a significant improvement in pain intensity, opioid requirement, functional status, and physical components quality of life after the neurolysis (P < 0.05) and this improvement had continued till 3 months. There were also more than 50% reduction in pain intensity and significant decrease in opioid requirement in all the patients after neurolysis. Conclusion: The fluoroscopy-guided splanchnic nerve neurolysis results significant pain relief, decrease in opioid intake, improvement in functional status, and quality of life for up to 3 months in upper abdominal pain from gastrointestinal cancers in patients with distorted celiac lymph node anatomy not amenable to celiac plexus neurolysis.
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Affiliation(s)
- Arif Ahmed
- Department of Anesthesiology and Pain Medicine, Asian Institute of Medical Sciences, Faridabad, India
| | - Divesh Arora
- Department of Anesthesiology and Pain Medicine, Asian Institute of Medical Sciences, Faridabad, India
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Dobosz Ł, Kaczor M, Stefaniak TJ. Pain in pancreatic cancer: review of medical and surgical remedies. ANZ J Surg 2016; 86:756-761. [DOI: 10.1111/ans.13609] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2016] [Indexed: 12/27/2022]
Affiliation(s)
- Łukasz Dobosz
- Department of General, Endocrine and Transplant Surgery; Medical University of Gdansk; Gdansk Poland
| | - Maciej Kaczor
- Department of General, Endocrine and Transplant Surgery; Medical University of Gdansk; Gdansk Poland
| | - Tomasz J. Stefaniak
- Department of General, Endocrine and Transplant Surgery; Medical University of Gdansk; Gdansk Poland
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13
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Dobosz Ł, Stefaniak T, Dobrzycka M, Wieczorek J, Franczak P, Ptaszyńska D, Zasada K, Kanyion P. Invasive treatment of pain associated with pancreatic cancer on different levels of WHO analgesic ladder. BMC Surg 2016; 16:20. [PMID: 27090728 PMCID: PMC4836189 DOI: 10.1186/s12893-016-0136-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 04/08/2016] [Indexed: 01/25/2023] Open
Abstract
Background Pancreatic cancer is a malignant neoplasm with a high mortality rate, often associated with a delayed diagnosis, the early occurrence of metastasis and an overall, poor response to chemotherapy and radiotherapy. Pain management in pancreatic cancer consists mainly of pharmacological treatment according to the WHO analgesic ladder. Surgical treatment for pain relief, such as splanchnicectomy, is considered amongst the final step of pain management. It has been proven that splanchnicectomy is a safe procedure with a small percentage of complications, nevertheless, it is often used as a last resort, which can significantly decrease its effectiveness. Performance of thoracoscopic splanchnicectomy along the first step of the analgesic ladder may lead to long-lasting protection against the presence and severity of pain. Methods/Design A prospective, open label, 1:1 randomized, controlled trial, conducted at a single institution to determine the effectiveness of invasive treatment of pain via splanchnicectomy, in patients with advanced pancreatic cancer. The size of tested group will consist of 26 participants in each arm of the trial, to evaluate the level of pain relief and its impact on quality of life. To evaluate the influence on patients’ rate of overall survival, a sample size of 105 patients is necessary, in each trial arm. Assessments will not only include the usage of analgesic pharmacotherapy throughout the course of disease, and overall patient survival, but also subjective pain perception at rest, in movement, and after meals (measured by NRS score questionnaire), the patient’s quality of life (measured using the QLQ-C30 and FACIT questionnaires), and any pain-related suffering (measured with the PRISM projection test). The primary endpoint will consist of pain intensity. Questionnaires will be obtained upon the initial visit, the day of surgery, the day after surgery, as well as during long-term follow-up visits, held every two weeks thereafter. Discussion Earlier implementation of invasive treatment, such as thoracoscopic splanchnicectomy, can provide a higher efficacy of pain management, prevent deterioration in the patient’s quality of life, and lengthen their overall survival. Trial registration ClinicalTrials.gov identifier: NCT02424279. Date of registration January 2, 2015.
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Affiliation(s)
- Łukasz Dobosz
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, ul. Smoluchowskiego 17, 80-214, Gdansk, Poland.
| | - Tomasz Stefaniak
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, ul. Smoluchowskiego 17, 80-214, Gdansk, Poland
| | - Małgorzata Dobrzycka
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, ul. Smoluchowskiego 17, 80-214, Gdansk, Poland
| | - Jagoda Wieczorek
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, ul. Smoluchowskiego 17, 80-214, Gdansk, Poland
| | - Paula Franczak
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, ul. Smoluchowskiego 17, 80-214, Gdansk, Poland
| | - Dominika Ptaszyńska
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, ul. Smoluchowskiego 17, 80-214, Gdansk, Poland
| | - Katarzyna Zasada
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, ul. Smoluchowskiego 17, 80-214, Gdansk, Poland
| | - Peter Kanyion
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, ul. Smoluchowskiego 17, 80-214, Gdansk, Poland
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Santoro D, Pellicanò V, Visconti L, Trifirò G, Buemi M, Cernaro V. An overview of experimental and early investigational therapies for the treatment of polycystic kidney disease. Expert Opin Investig Drugs 2015; 24:1199-218. [PMID: 26125126 DOI: 10.1517/13543784.2015.1059421] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION At present, treatment of autosomal dominant polycystic kidney disease (ADPKD) is essentially supportive as there is still no specific therapy. However, recent advances with ADPKD pathophysiology have stimulated research for new therapeutic strategies. AREAS COVERED The aim of this systematic review is to analyze the experimental and early investigational therapies currently under evaluation in this field. Data from completed clinical trials were retrieved from the currently available scientific literature and from the ClinicalTrials.gov website. EXPERT OPINION Among the drugs currently being explored, mammalian target of rapamycin inhibitors reduce kidney volume enlargement but their role remains uncertain. The most promising drug is the V2 receptor antagonist tolvaptan, which reduces the increased rate of total kidney volume and slows down glomerular filtration rate decline. The main candidates for the treatment of cysts growth, both in the kidney and in the liver whenever present, are the somatostatin analogues, such as lanreotide and octreotide and more recently pasireotide. As for other therapies, some favorable results have been achieved but data are still not sufficient to establish if these approaches may be beneficial in slowing ADPKD progression in the future.
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Affiliation(s)
- Domenico Santoro
- University of Messina, AOU G. Martino PAD C, Department of Internal Medicine and Pharmacology , Via Consolare Valeria, 98100 Messina , Italy +39 090 2212331 ; +39 090 2212331 ;
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Abstract
BACKGROUND Pain originating from the organs of the upper abdomen, especially in patients suffering from inoperable carcinoma of the pancreas or advanced inflammatory conditions, is difficult to treat in a significant number of patients. STANDARD RADIOLOGICAL PROCEDURES Computed tomography (CT) guided neurolysis is the most commonly used technique for neurolysis of the celiac plexus. Ethanol is used to destroy the nociceptive fibers passing through the plexus and provides an effective means of diminishing pain arising from the upper abdomen. METHODS Using either an anterior or posterior approach, a 22 G Chiba needle is advanced to the antecrural space and neurolysis is achieved by injecting a volume of 20-50 ml of ethanol together with a local anesthetic and contrast medium. PERFORMANCE In up to 80% of patients suffering from tumors of the upper abdomen, CT-guided celiac plexus neurolysis diminishes pain or allows a reduction of analgesic medication; however, in some patients the effect may only be temporary necessitating a second intervention. In inflammatory conditions, celiac neurolysis is often less effective in reducing abdominal pain. PRACTICAL RECOMMENDATIONS The CT-guided procedure for neurolysis of the celiac plexus is safe and effective in diminishing pain especially in patients suffering from tumors of the upper abdomen. The procedure can be repeated if the effect is only temporary.
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Shwita AH, Amr YM, Okab MI. Comparative Study of the Effects of the Retrocrural Celiac Plexus Block Versus Splanchnic Nerve Block, C-arm Guided, for Upper Gastrointestinal Tract Tumors on Pain Relief and the Quality of Life at a Six-month Follow Up. Korean J Pain 2015; 28:22-31. [PMID: 25589943 PMCID: PMC4293503 DOI: 10.3344/kjp.2015.28.1.22] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 11/06/2014] [Accepted: 11/17/2014] [Indexed: 12/20/2022] Open
Abstract
Background The celiac plexus and splanchnic nerves are targets for neurolytic blocks for pain relief from pain caused by upper gastrointestinal tumors. Therefore, we investigated the analgesic effect of a celiac plexus block versus a splanchnic nerve block and the effects of these blocks on the quality of life six months post-intervention for patients with upper GIT tumors. Methods Seventy-nine patients with inoperable upper GIT tumors and with severe uncontrolled visceral pain were randomized into two groups. These were Group I, for whom a celiac plexus block was used with a bilateral needle retrocrural technique, and Group II, for whom a splanchnic nerve block with a bilateral needle technique was used. The visual analogue scale for pain (0 to 100), the quality of life via the QLQ-C30 questionnaire, and survival rates were assessed. Results Pain scores were comparable in both groups in the first week after the block. Significantly more patients retained good analgesia with tramadol in the splanchnic group from 16 weeks onwards (P = 0.005, 0.001, 0.005, 0.001, 0.01). Social and cognitive scales improved significantly from the second week onwards in the splanchnic group. Survival of both groups was comparable. Conclusions The results of this study demonstrate that the efficacy of the splanchnic nerve block technique appears to be clinically comparable to a celiac block. All statistically significant differences are of little clinical value.
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Affiliation(s)
- Amera H Shwita
- Department of Anesthesia and Pain Relief, Tanta Cancer Institute, Tanta, Egypt
| | - Yasser M Amr
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mohammad I Okab
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt
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Splanchnicectomy for pancreatic cancer pain. BIOMED RESEARCH INTERNATIONAL 2014; 2014:941726. [PMID: 24868557 PMCID: PMC4017796 DOI: 10.1155/2014/941726] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 04/05/2014] [Indexed: 12/20/2022]
Abstract
Persistent pain is a serious problem that often contributes to a poor quality of life in pancreatic cancer patients. Medical management by opioid analgesics is often accompanied by side effects and incomplete pain relief. A celiac plexus block is a simple treatment which relieves pain, but the procedure demands a certain degree of proficiency and the duration of the effects obtained can be rather limited. Transhiatal bilateral splanchnicectomy achieves a certain denervation of splanchnic nerves, but it requires a laparotomy. Unilateral thoracoscopic splanchnicectomy is a minimally invasive procedure to cause definite denervation. Bilateral thoracoscopic splanchnicectomy is recommended for unsatisfactory cases or recurrent pain occurring after the initial unilateral splanchnicectomy. It is important to select the most suitable treatment depending on patients' actual medical state and the predicted outcomes.
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Abstract
Pain is the most feared symptom of cancer. New oncological cancer treatments are improving survival, but advanced cancer presents challenges that have not been seen before, often with pain that is very difficult to manage because of a recurrent tumour that is invading the central nervous system. In some of the older interventional techniques of destroying nerve pathways, expertise has diminished or has been deemed unnecessary with the development of specialist palliative care. Not all pain is managed adequately with the analgesic ladder. Knowledge of pain mechanisms, careful assessment and selection of the right technique at the right time will enhance cancer pain management. New techniques include intrathecal drug therapy, vertebroplasty, cordotomy, ultra-sound guided nerve blocks, neuromodulation and advances in drug therapies.
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Affiliation(s)
- James Wilson
- Department of AnaestheticsSt George's Hospital, Blackshaw Road, Tooting, London SW17 0QTUK
| | - Catherine Stack
- Department of AnaestheticsKing's College Hospital, Denmark Hill, London SE5 9RSUK
| | - Joan Hester
- Department of AnaestheticsKing's College Hospital, Denmark Hill, London SE5 9RSUK
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A randomized clinical trial of nerve block to manage end-stage pancreatic cancerous pain. Tumour Biol 2013; 35:2297-301. [DOI: 10.1007/s13277-013-1304-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 10/08/2013] [Indexed: 01/29/2023] Open
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Nagels W, Pease N, Bekkering G, Cools F, Dobbels P. Celiac plexus neurolysis for abdominal cancer pain: a systematic review. PAIN MEDICINE 2013; 14:1140-63. [PMID: 23802777 DOI: 10.1111/pme.12176] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE This systematic review assesses the effectiveness and side effects of celiac plexus neurolysis (CPN) in the treatment of upper abdominal cancer pain, and evaluates whether there are any differences between the percutaneous and endoscopic ultrasound-guided (EUS) denervation techniques. METHODS Five databases were searched, expanded by assessing the reference lists of all retrieved papers. Sixty-six publications fulfilled the inclusion/exclusion criteria and were included in the systematic review. Randomized controlled trials were available for the percutaneous CPN, and therefore meta-analyses were performed for pain, opioid consumption, and specific side effects. The quality of life data were too heterogeneous to be assessed by a meta-analysis, and evidence for EUS CPN could only be evaluated by observational studies. RESULTS Meta-analyses show that percutaneous CPN significantly improves pain in patients with upper abdominal cancer, with a decrease in opioid consumption and side effects. It is unclear whether there is any change in quality of life. Case series suggest that EUS CPN improves pain. No conclusion can be made about EUS CPN's influence on opioid consumption. Although CPN is a safe procedure, side effects and complications can occur with both the percutaneous and EUS techniques. CONCLUSIONS Following this review, evidence suggests that CPN should be considered in patients with upper abdominal cancer where the pain is not adequately controlled with systemic analgesics or when significant opioid-induced side effects are present. The percutaneous approach remains the standard technique as robust evidence for EUS CPN is lacking.
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Affiliation(s)
- Werner Nagels
- Department of Anesthesiology and Pain Management, Heilig-Hart Hospital Roeselare-Menen, Roeselare, Belgium.
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Basiński A, Stefaniak T, Stadnyk M, Sheikh A, Vingerhoets AJJM. Influence of religiosity on the quality of life and on pain intensity in chronic pancreatitis patients after neurolytic celiac plexus block: case-controlled study. JOURNAL OF RELIGION AND HEALTH 2013; 52:276-84. [PMID: 21286817 PMCID: PMC3560951 DOI: 10.1007/s10943-011-9454-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
The quality of life in patients with chronic pancreatitis (CP) is reduced due to their suffering of high levels of pain. It has been presented that quality of life can also be linked to religiosity and/or spirituality. The aim of this study is to assess the influence of religious practices on the quality of life and on the subjective level of pain in CP patients. Ninety-two patients (37 women and 55 men) with chronic pancreatitis were treated invasively for pain with neurolytic celiac plexus block (NCPB). The religiosity of the patients was recorded and served as a dichotomizer. Group 1 was for patients who claimed to have no contact with the church or to have very sporadic contact (N = 35 patients). Group 2 was for patients who claimed to have deep faith and were regular participants at church activities (N = 57 patients). Visual analogue scale was used to assess pain, while the quality of life was measured by using QLQ C-30 questionnaire adapted for chronic pancreatitis patients in Polish population. The patients were assessed prior to the pain-relieving intervention and subsequently 2 and 8 weeks after it. The intensity of pain was reduced in both groups significantly after performing the NCPB. Patients who declared a deep faith reported higher level of pain on the VAS scale prior to intervention than non-religious patients. Quality of life in both groups of patients significantly improved after NCPB. Following NCPB, global quality of life in patients who declared higher religiosity/church attendance was significantly higher (79.88) than for those patients who have no contact or sporadic contact with the church (44.21, P < 0.05). NCPB resulted in significant reduction of pain and increase in quality of life in both groups of patients with CP. Nevertheless, in the group declaring higher religiosity/church attendance, reported pain was higher, but, despite that, quality of life better. It may be concluded that religious practices might serve as an additional factor improving quality of life and coping in patients suffering from chronic pancreatitis.
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Affiliation(s)
- Andrzej Basiński
- Department of Emergency Medicine, Medical University of Gdansk, Gdansk, Poland
| | - Tomasz Stefaniak
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, 7 Debinki Str., PL-80-210 Gdansk, Poland
- Laboratory of Psychology of Surgery and Psychosomatics, Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Gdansk, Poland
| | - Magdalena Stadnyk
- Laboratory of Psychology of Surgery and Psychosomatics, Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Gdansk, Poland
| | - Arfan Sheikh
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, 7 Debinki Str., PL-80-210 Gdansk, Poland
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Saw CLL, Chew L, Goh C. Recent Non-Interventional Advances in Cancer Pain Among Singapore Patients. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2012. [DOI: 10.47102/annals-acadmedsg.v41n9p407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: Pain is a common symptom in cancer patients, but very little information about the prevalence, severity, and treatment of pain in cancer patients in Singapore is available. Therefore, our prospective survey in the National Cancer Centre (NCC) outpatients is incorporated in this report. In addition, a review concerning the recent advances on non-interventional pain management in cancer treatment, which is relevant in the context, is discussed. Materials and Methods: For the prospective survey, a questionnaire was distributed for self-administration by patients while waiting for consultation at the NCC outpatient departments. Literature searches on advances in pain management were conducted, reviewed and discussed. Results: In the last decade, there have been advances in pain pharmacology ranging from wider therapeutic options and management approaches to novel delivery techniques. Acupuncture and massage therapy became increasingly popular among cancer patients. Some clinical trials of acupuncture show benefits in palliation of cancer pain. From the prospective survey, 41.2% of the responders reported pain in the past week, and only 70.8% talked to their doctors about their pain. One third of the patients received analgesics. Of these, 86.5% said that they were taking the prescribed medications, however, 37.4% admitted to having difficulties taking them. Non-drug methods were used by 25.4% of the patients. Medicated oil, cream or gel was used by 49.3%; only 2.6% reported use of Chinese herbs. Conclusion: Pain is a significant symptom in outpatients attending a cancer centre, affecting 41.2% of the patients. Although majority of patients who suffered from pain reported this to doctors, much more medical effort is needed to help patients to relieve their pain and proper complementary therapy could be considered.
Key words: Cancer outpatients, Complementary therapies, Non-pharmacological pain treatments, Pain prevalence
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Demir IE, Friess H, Ceyhan GO. Nerve-cancer interactions in the stromal biology of pancreatic cancer. Front Physiol 2012; 3:97. [PMID: 22529816 PMCID: PMC3327893 DOI: 10.3389/fphys.2012.00097] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Accepted: 03/28/2012] [Indexed: 12/21/2022] Open
Abstract
Interaction of cancer cells with diverse cell types in the tumor stroma is today recognized to have a fate-determining role for the progression and outcome of human cancers. Despite the well-described interactions of cancer cells with several stromal components, i.e., inflammatory cells, cancer-associated fibroblasts, endothelial cells, and pericytes, the investigation of their peculiar relationship with neural cells is still at its first footsteps. Pancreatic cancer (PCa) with its abundant stroma represents one of the best-studied examples of a malignant tumor with a mutually trophic interaction between cancer cells and the intratumoral nerves embedded in the desmoplastic stroma. Nerves in PCa are a rich source of neurotrophic factors like nerve growth factor (NGF), glial-cell-derived neurotrophic factor (GDNF), artemin; of neuronal chemokines like fractalkine; and of autonomic neurotransmitters like norepinephrine which can all enhance the invasiveness of PCa cells via matrix-metalloproteinase (MMP) upregulation, trigger neural invasion (NI), and activate pro-survival signaling pathways. Similarly, PCa cells themselves provide intrapancreatic nerves with abundant trophic agents which entail a remarkable neuroplasticity, leading to emergence of more routes for NI and cancer spread, to augmented local neuro-surveillance, neural sensitization, and neuropathic pain. The strong correlation of NI with PCa-associated desmoplasia suggests the potential presence of a triangular relationship between nerves, PCa cells, and other stromal partners like myofibroblasts and pancreatic stellate cells which generate tumor desmoplasia. Hence, although not a classical hallmark of human cancers, nerve-cancer interactions can be considered as an indispensable sub-class of cancer-stroma interactions in PCa. The present article provides an overview of the so far known nerve-cancer interactions in PCa and illustrates their ominous role in the stromal biology of human PCa.
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Affiliation(s)
- Ihsan Ekin Demir
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München Munich, Germany
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Rizk MK, Tolba R, Kapural L, Mitchell J, Lopez R, Mahboobi R, Vrooman B, Mekhail N. Differential epidural block predicts the success of visceral block in patients with chronic visceral abdominal pain. Pain Pract 2012; 12:595-601. [PMID: 22471927 DOI: 10.1111/j.1533-2500.2012.00548.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIMS Differential thoracic epidural regional block, also known as a differential neural block (DNB), involves the placement of an epidural catheter placed in the thoracic epidural space to achieve appropriate anesthesia in a dermatomal distribution. This is a retrospective case series evaluating how well a DNB may predict success of subsequent visceral blockade in patients with chronic abdominal pain of visceral origin. METHODS Of 402 patients who had a DNB performed for unexplained abdominal pain from January 2000 to January 2009, 81 patients were found to have results consistent with visceral pain and thus underwent subsequent visceral blockade. Basic demographic data, years of chronic pain, history of psychosocial issues, initial visual analog scale (VAS) pain score, pain location, and medication usage were documented in our electronic medical record database. Parameters regarding DNB and visceral blocks also were documented. Descriptive statistics were computed for all variables. The positive predictive value (PPV) for DNB for whom visceral block was successful (at least a 50% reduction in VAS) was calculated. Additionally, subjects with successful visceral blocks were compared to those with unsuccessful visceral blocks. PARTICIPANTS All patients with chronic abdominal pain with normal gastrointestinal studies who underwent DNB. SETTING Tertiary Outpatient Pain Management Clinic. DESIGN Retrospective Cohort Study. RESULTS Mean age of patients was 46 (± 15) years, 73% were female, and median duration of pain was 5 years. 67% of subjects were taking opioid analgesics. PPV of DNB was 70.4%. Only factor found to be statistically significant with visceral block success was baseline VAS with higher scores associated with DNB predictive success (6.8 ± 1.7 vs. 5.5, 1.8; P = 0.004). Use of membrane stabilizing medications was significantly more common in subjects for whom visceral block was not successful (46% vs. 25%; P = 0.058). Area underneath curve (AUC) for VAS was found to be 0.70 (95% CI: 0.57, 0.82), which signifies fair discrimination. CONCLUSION Differential neural block is fairly predictive of subsequent visceral block success in patients with chronic abdominal pain of visceral origin. An initial VAS ≥ 5 provides a sensitivity of 93%, which implies that VAS < 5 may predict unsuccessful visceral block. Contrarily, a value of ≥ 8 would provide a specificity of 92% and may be used to predict success of subsequent visceral block.
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Affiliation(s)
- Maged K Rizk
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA.
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Hameed M, Hameed H, Erdek M. Pain management in pancreatic cancer. Cancers (Basel) 2010; 3:43-60. [PMID: 24212605 PMCID: PMC3756348 DOI: 10.3390/cancers3010043] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 11/25/2010] [Accepted: 12/20/2010] [Indexed: 12/15/2022] Open
Abstract
A majority of pancreatic cancer patients present with pain at the time of diagnosis. Pain management can be challenging in light of the aggressive nature of this cancer. Apart from conventional pharmacotherapy, timely treatment with neurolytic celiac plexus block (NCPB) has been shown to be of benefit. NCPB has demonstrated efficacious pain control in high quality studies with analgesic effects lasting one to two months. NCPB has also shown to decrease the requirements of narcotics, and thus decrease opioid related side effects. Another option for the control of moderate to severe pain is intrathecal therapy (IT). Delivery of analgesic medications intrathecally allows for lower dosages of medications and thus reduced toxicity. Both of the above mentioned interventional procedures have been shown to have low complication rates, and be safe and effective. Ultimately, comprehensive pancreatic cancer pain management necessitates understanding of pain mechanisms and delivery of sequential validated therapeutic interventions within a multidisciplinary patient care model.
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Affiliation(s)
- Mariam Hameed
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, 600 N. Wolfe St., Phipps 160, Baltimore, MD 21287, USA; E-Mails: (M.H.); (H.H.)
| | - Haroon Hameed
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, 600 N. Wolfe St., Phipps 160, Baltimore, MD 21287, USA; E-Mails: (M.H.); (H.H.)
| | - Michael Erdek
- Division of Pain Medicine, Department of Anesthesia and Critical Care Medicine, Johns Hopkins University, School of Medicine, 550 North Broadway St., Suite 301, Baltimore, MD 21205, USA
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Ceyhan GO, Demir IE, Maak M, Friess H. Fate of nerves in chronic pancreatitis: Neural remodeling and pancreatic neuropathy. Best Pract Res Clin Gastroenterol 2010; 24:311-22. [PMID: 20510831 DOI: 10.1016/j.bpg.2010.03.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Accepted: 03/07/2010] [Indexed: 01/31/2023]
Abstract
There is probably no other gastrointestinal disorder which is as much characterized by concomitant local, intra-organ and central neuropathic and neuroplastic alterations as chronic pancreatitis (CP). While some key features of this neuropathy have recently been elucidated, there is still no satisfying pathophysiological explanation for the generation of neuropathic pain in CP. It is becoming increasingly clear that an effective pain treatment in CP can probably not be achieved without consideration of the exact fate of intrapancreatic nerves and central neuroplastic alterations. This review is intended to illustrate the temporal and spatial alterations of intrapancreatic nerves in the course of CP. At the same time, it depicts the reciprocal relationship between these plastic changes and thus underlines the notion of a 'common fate' for all these alterations. Moreover, it points out numerous aspects of this fate that are yet to be unveiled and should therefore be subject to future investigation.
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Affiliation(s)
- Güralp O Ceyhan
- Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany.
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New aspects in performing interventional techniques for chronic pain. Curr Opin Support Palliat Care 2007; 1:132-6. [DOI: 10.1097/spc.0b013e3282eeb44e] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Michaels AJ, Draganov PV. Endoscopic ultrasonography guided celiac plexus neurolysis and celiac plexus block in the management of pain due to pancreatic cancer and chronic pancreatitis. World J Gastroenterol 2007; 13:3575-80. [PMID: 17659707 PMCID: PMC4146796 DOI: 10.3748/wjg.v13.i26.3575] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Pain is a common symptom of pancreatic disease and is frequently difficult to manage. Pain relief provided by narcotics is often suboptimal and is associated with significant side effects. An alternative approach to pain management in pancreatic disease is the use of celiac plexus block (CPB) or neurolysis (CPN). Originally performed by anesthesiologists and radiologists via a posterior approach, recent advances in endoscopic ultrasonography (EUS) have made this technique an attractive alternative. EUS guided celiac plexus block/neurolysis is simple to perform and avoids serious complications such as paraplegia or pneumothorax that are associated with the posterior approach. EUS guided CPN should be considered first line therapy in patients with pain due to pancreatic cancer. It provides superior pain control compared to traditional management with narcotics. A trend for improved survival in pancreatic cancer patients treated with CPN has been reported, but larger studies are needed to confirm this finding. At this time, the use of EUS guided CPB cannot be recommended as routine therapy for pain in chronic pancreatitis since only one-half of the patients experience pain reduction and the beneficial effect tends to be short lived. EUS guided CPB and CPN should be used as part of a multidisciplinary team approach for pain management.
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Affiliation(s)
- Anthony J Michaels
- University of Florida, Department of Gastroenterology, Hepatology and Nutrition, PO Box 100214, Gainesville, FL 32610-0214, USA
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Stefaniak T, Vingerhoets A, Makarewicz W, Kaska L, Kobiela J, Kwiecińska B, Stanek A, Lachinski AJ, Sledziński Z. Opioid use determines success of videothoracoscopic splanchnicectomy in chronic pancreatic pain patients. Langenbecks Arch Surg 2007; 393:213-8. [PMID: 17436011 DOI: 10.1007/s00423-007-0177-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2006] [Accepted: 02/14/2007] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Videoscopic splanchnicectomy (VSPL) is a method of pain relief in chronic pancreatitis patients. Because this method is not equally effective in all patients, this study was designed to identify the factors determining the unfavorable results of VSPL. MATERIALS AND METHODS This is a non-randomized prospective case-controlled study designed to compare a group of patients suffering from chronic pancreatitis treated with VSPL (N = 48) versus a group of patients treated symptomatically (N = 42). The outcome was measured as the intensity of pain ailments [visual analog scale (VAS)-pain scale] and subjective satisfaction of the patients from the surgical treatment [Functional Assessment of Chronic Illness Therapy-Treatment Satisfaction (FACIT-TS)]. The predictive variables considered in this study were: age, sex, emotional status, social support (the two last variables were measured by subscales of quality-of-life questionnaire from the group of FACIT), history of previous surgical treatment, and opioid use for at least 3 months before VSPL. The follow-up was 18 months. Logistic regression was performed using dichotomized pain as outcome variable: high score more than 66.7 on VAS scale and low under 50 points on VAS scale 18 months after VSPL. RESULTS VSPL significantly reduced the pain ailments at all points of the study when compared to the control. However, the pain intensity at the end of the study was higher than directly after the surgery. In the patients treated with opioids before the surgery, the pain intensity was significantly higher than in the patients not using this group of drugs. Logistic regression revealed that opioid administration before VSPL was the most important predictor of high pain scores 18 months after the surgery. CONCLUSION When planning the VSPL in the treatment of pain in patients suffering from chronic pancreatitis, it is necessary to take into consideration the previous chronic use of opioids, as this variable can significantly influence poorer results of this surgical pain management.
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Affiliation(s)
- Tomasz Stefaniak
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Gdansk, Poland.
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Videothoracoscopic Simultaneous Bilateral Posterior Splanchnicectomy - Initial Report. POLISH JOURNAL OF SURGERY 2007. [DOI: 10.2478/v10035-007-0039-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Many diseases of the biliary tract and pancreas preferentially effect the elderly. Recent innovations in the evaluation and management of these disorders have directly impacted the lives of many seniors. Improved outcomes of pancreatic surgery is a good example of a positive impact in quality of life, especially when these surgeries are performed in centers of excellence. Evaluation and treatment strategies are presented for complicated calculous biliary disease, pancreatic carcinoma, and pancreatic cystic neoplasms.
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Affiliation(s)
- R Matthew Walsh
- Department of General Surgery, The Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Kim DH, Shim JK, Moon JC, Yoon KB, Kim WO, Yoon DM. A Case of Thoracoscopic Splanchnicectomy for Relief of Intractable Pain in Pancreatic Cancer -A case report-. Korean J Pain 2006. [DOI: 10.3344/kjp.2006.19.1.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Do Hyung Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Je Kwang Shim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Chun Moon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Bong Yoon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Won Oak Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Duck Mi Yoon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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