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

Efficacy of botulinum toxin injection using the right-sided unilateral retrocrural approach for celiac plexus in a cancer survivor with persistent abdominal pain: a case report

Cancer survivors often face persistent abdominal pain, necessitating optimal pain management. While celiac plexus block (CPB) and botulinum toxin (BT) injection are viable options, traditional methods may encounter challenges due to patient-specific concerns and anatomical complexities. Here, the case of a cancer survivor in his 70 s experiencing recurrent abdominal pain, who declined conventional percutaneous CPB approaches due to anxiety related to aortic puncture, is presented. Following a pancreaticoduodenectomy, the patient developed chronic abdominal pain attributed to adhesions leading to small bowel obstruction. Concurrently, there was notable psychological distress, including anxiety, depression, and heightened concerns regarding tumor recurrence. Considering the patient's specific concerns, a right-sided unilateral retrocrural single-needle technique was proposed, aimed at alleviating pain, while avoiding conventional CPB approaches. Initial right-sided retrocrural CPB offered short-term relief, prompting a subsequent BT injection using the same approach. Following BT injection, the patient reported significant and sustained pain reduction (from 8 to 1 on an 11-point numerical rating scale) at both 12 and 20 weeks post-procedure. Right-sided retrocrural BT injection offers an alternative approach, addressing patient concerns and demonstrating prolonged pain relief. This may benefit cancer survivors with upper abdominal pain, emphasizing the importance of personalized and innovative pain management strategies.

Role of Endoscopic Ultrasound in Pancreatic Cancer Diagnosis and Management

The emergence of endoscopic ultrasound (EUS) has significantly impacted the diagnosis and management of pancreatic cancer and its associated sequelae. While the definitive role of EUS for pancreatic cancer remains incompletely characterized by currently available guidelines, EUS undoubtedly offers high diagnostic accuracy, the precise staging of pancreatic neoplasms, and the ability to perform therapeutic and palliative interventions. However, current challenges to EUS include limited specialized expertise and variability in operator proficiency. As the technology and techniques continue to evolve and become more refined, EUS is poised to play an increasingly integral role in shaping pancreatic cancer care.

A meta-analysis on the efficacy of endoscopic ultrasonography for treatment of pancreatic cancer

OBJECTIVE

This study aimed to systematically evaluate the efficacy and safety of Endoscopic Ultrasonography (EUS) for the treatment of pancreatic cancer.

METHODS

The PubMed, Embase, Web of Science, and Google Scholar databases were searched from the inception of the databases to June 2022. RevMan 5.3.0 software was utilized for data analysis. In total, 13 self-descriptive studies, which enrolled 382 patients, were finally included.

RESULTS

It was revealed that EUS for the treatment of pancreatic cancer exhibited a lower incidence of adverse reactions (Relative Risk Ration [RR = 0.23], 95 % Confidence interval [95 % CI 0.23-0.23]), a higher success rate (RR = 0.90, 95 % CI 0.90-0.90), and a low failure rate (RR = 0.06, 95 % CI 0.06-0.06). Moreover, EUS-guided Celiac Plexus Neurolysis (EUS-CPN) not only significantly relieved pancreatic cancer patients' pain (RR = 0.83, 95 % CI 0.83-0.83), but also significantly eliminated pain in some patients (RR = 0.09, 95 % CI 0.09-0.09). The effects of EUS on pancreatic cancer treatment were satisfactory, and few adverse reactions were found.

CONCLUSION

Owing to the restricted sample size in this meta-analysis, primarily consisting of descriptive studies, it was imperative to conduct more rigorously designed, multi-center, long-term follow-up, larger sample, and Randomized Controlled Trials (RCTs) to validate the findings.

Clinical efficacy of EUS-guided celiac plexus neurolysis versus EUS-guided celiac ganglion irradiation with iodine-125 seeds for pain relief in advanced pancreatic cancer: A long-term retrospective study

BACKGROUND AND OBJECTIVE

To compare the efficacy of EUS-guided celiac plexus neurolysis (CPN) and celiac plexus irradiation with iodine-125 (125I) seeds with absolute ethanol for relieving pain in patients with advanced pancreatic cancer.

METHODS

We retrospectively analyzed data of 81 patients with advanced pancreatic cancer who underwent EUS-CPN or EUS-125I implantation between January 2017 and December 2020. Postoperative pain was assessed using visual analog scale (VAS) scores; self-assessments of quality of life and the median survival time were compared between the 2 groups.

RESULTS

EUS-CPN and 125I implantation were performed in 43 and 38 patients, respectively. Postoperative VAS scores were significantly lower than the preoperative levels in both groups. One week after the operation, 26 patients (60.5%) in the EUS-CPN group achieved partial pain relief, whereas no patients in the EUS-125I seed group experienced pain relief. However, after 4 weeks postoperatively, VAS scores had decreased, and the rate of partial pain relief was higher for EUS-125I seeds than for EUS-CPN. Self-assessments of quality of life were similar in both groups during the first 1 month after the procedure.

CONCLUSIONS

Both EUS-CPN and EUS-125I seeds can safely and effectively relieve pain in patients with advanced pancreatic cancer. Although EUS-125I seeds take additional time to show effects, the extent and duration of pain relief are better compared with CPN, and interestingly, the median survival time was different.

Value of Adding Dexmedetomidine in Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis for Treatment of Pancreatic Cancer-Associated Pain

BACKGROUND

Abdominal and back pain is present in up to 80% of patients with pancreatic cancer and represents a significant cause of morbidity. Celiac plexus neurolysis (CPN) demonstrated good results in relief of pain of upper abdominal malignancy. Dexmedetomidine is alpha-2 adrenoceptor highly selective agonist approved for procedural sedation use.

PATIENTS AND METHODS

Fifty patients divided in two groups with locally advanced pancreatic cancer-associated abdominal pain underwent endoscopic ultrasound (EUS)-guided CPN using bupivacaine 0.5% alone with alcohol for the first group and bupivacaine 0.5% plus dexmedetomidine in the second. Patients scored their pain according to the Numeric Rating Scale (NRS-11) before, 2, 4, 6, 8, 12, 16, and 24 week after the procedure.

RESULTS

The study has included 50 patient in two groups. There was no significant difference between the two groups as regards medical, laboratory, or tumor characters. The median pain score decreases from 8.32 ± 0.75 before the procedure to 3.75 ± 3.72 24 week after the procedure in group 1 and from 8.08 ± 0.86 before to 1.67 ± 2.3 24 week after the procedure in group 2. However, there was no significant difference between the two groups in the median pain score during the first 4 weeks. There was no statistically significant difference between the two groups as regards the median survival time.

CONCLUSION

The addition of dexmedetomidine to bupivacaine 0.5% in EUS-CPN demonstrated beneficial effects as regards the degree and duration of pain relieve with negligible effect on the patient survival.

Effectiveness of Percutaneous Celiac Plexus Ablation in the Treatment of Severe Cancer Pain in Upper Abdomen and Evaluation of Health Economics

Objective:

To compare the effectiveness, adverse effects, and cost-effectiveness of percutaneous neurolytic celiac plexus block (NCPB) versus traditional medication strategies for the treatment of patients with advanced cancer having severe upper abdominal cancer pain.

Methods:

This retrospective study included 81 patients with advanced upper abdominal cancer admitted to The Sixth People’s Hospital Affiliated to Shanghai Jiaotong University between January 2013 and July 2014. The patients were divided into percutaneous NCPB (treatment) and medication for pain (control) groups. The outcomes were measured in terms of Numeric Rating Scale (NRS) score and Karnofsky Performance Status (KPS) score before treatment and on the 3rd, 7th, 14th, and 28th days posttreatment. The effectiveness and cost-effectiveness of the therapy were assessed using analysis of the health economics.

Results:

The improvements in NRS score (1.42 ± 1.09 vs 4.03 ± 0.96, P < .01) and KPS score (65.55 ± 9.09 vs 63.03 ± 8.961, P < .01) in the treatment group were significantly superior compared to the control group on the 7th day of treatment, followed by no significant difference between the 2 groups on the 14th and the 28th day of treatment. Health economics evaluation revealed that the medicine-specific costs and total health care costs were significantly reduced in the treatment group compared to the control group ( P < .05), but no significant differences between the 2 groups ( P > .05) were seen in the costs of hospitalization, examinations, and treatment.

Conclusion:

The percutaneous NCPB method shows promising results and better cost-effectiveness for treating patients with advanced cancer having severe upper abdominal pain.

[Celiac block in paediatric patients using endoscopic ultrasound for management of severe pain due to chronic pancreatitis. Review of the technique in 2 cases]

BACKGROUND

Pancreatic diseases such as cancer, idiopathic recurrent pancreatitis, and chronic pancreatitis, can cause pain that is difficult to control. Pain is one of the most debilitating symptoms and demands increasing doses of analgesics and narcotics, as well as the number of hospital admissions, with a direct implication in the costs of medical treatments.

OBJECTIVE

To describe the experience with 2 paediatric patients who were subjected to an ultrasound-guided endoscopic celiac ganglion block for difficult pain management, secondary to chronic pancreatitis disease.

CLINICAL CASES

The first case concerns a 9-year-old male with a diagnosis of chronic pancreatitis, and the second case is a 12-year-old female who developed episodes of intermittent acute pancreatitis. Both cases suffered from chronic abdominal pain, which was difficult to control with stronger painkillers, such as opioids. The pain decreased after patients were subjected to an ultrasound-guided endoscopic celiac ganglion block.

CONCLUSIONS

This technique showed that both patients obtained satisfactory pain relief, with significant improvements in general symptomatology and the stopping of almost all analgesic medication. The authors suggest that celiac ganglion block must be considered, and implemented early before the usual complications, such as a consumption syndrome that is frequent in paediatric patients with chronic pancreatitis.

Long-Term Blood Pressure Control Effect of Celiac Plexus Block with Botulinum Toxin

Celiac plexus block (CPB) is one of the main treatment options for patients resistant to conventional antihypertensive drugs. We present a case of resistant hypertension (RHTN) that was treated with CPB using botulinum toxin. An 18-year-old male patient with RHTN, who suffered from persistent hypertension even after combination therapy and a renal denervation procedure, was referred to our pain center for CPB. CPB using botulinum toxin following the use of only local anesthetics resulted in control of systolic blood pressure (BP) at ~150 mmHg for at least three months.

Celiac plexus neurolysis in pancreatic cancer: the endoscopic ultrasound approach

Pain in pancreatic cancer is often a major problem of treatment. Administration of opioids is frequently limited by side effects or insufficient analgesia. Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) represents an alternative for the palliative treatment of visceral pain in patients with pancreatic cancer. This review focuses on the indications, technique, outcomes of EUS-CPN and predictors of pain relief. EUS-CPN should be considered as the adjunct method to standard pain management. It moderately reduces pain in pancreatic cancer, without eliminating it. Nearly all patients need to continue opioid use, often at a constant dose. The effect on quality of life is controversial and survival is not influenced. The approach could be done in the central position of the celiac axis, which is easy to perform, or in the bilateral position of the celiac axis, with similar results in terms of pain alleviation. The EUS-CPN with multiple intraganglia injection approach seems to have better results, although extended studies are still needed. Further trials are required to enable more confident conclusions regarding timing, quantity of alcohol injected and the method of choice. Severe complications have rarely been reported, and great care should be taken in choosing the site of alcohol injection.

EUS-guided celiac ganglion irradiation with iodine-125 seeds for pain control in pancreatic carcinoma: a prospective pilot study

BACKGROUND

Celiac plexus neurolysis for the palliative reduction of pain in unresectable pancreatic carcinoma (PC) is safe but provides limited relief. In a previous study, we found that EUS-guided implantation of iodine-125 ((125)I) around the celiac ganglia is a safe procedure and can induce apoptosis of local neurons in a porcine model.

OBJECTIVE

To evaluate the safety and efficacy of direct celiac ganglion irradiation with (125)I seeds for the relief of moderate to severe pain secondary to unresectable PC.

DESIGN

Prospective study.

SETTING

Single, tertiary care referral center.

PATIENTS

This study enrolled consecutive patients who had moderate to severe pain resulting from biopsy-proven unresectable PC.

INTERVENTION

All patients underwent EUS-guided direct celiac ganglion irradiation with (125)I seeds. Follow-up was conducted at least once weekly until death.

MAIN OUTCOME MEASUREMENTS

Blood parameters, Visual Analog Scale (VAS) score, mean analgesic (MS Contin [morphine sulfate]) consumption, and complications were evaluated during follow-up.

RESULTS

Twenty-three patients with unresectable PC underwent the procedure. The mean number of seeds implanted in the celiac ganglion per patient was 4 (range 2-6). Immediately after the procedure, pain relief and analgesic consumption showed no significant changes compared with preoperative values. Six patients (26%) reported pain exacerbation. Two weeks later, the VAS score and mean analgesic consumption were significantly less than preoperative values. No procedure-related deaths or major complications occurred.

LIMITATIONS

Uncontrolled study.

CONCLUSIONS

EUS-guided direct celiac ganglion irradiation with (125)I seeds can reduce the VAS score and analgesic drug consumption in patients with unresectable PC.

The efficacy and safety of endoscopic ultrasound-guided celiac plexus neurolysis for treatment of pain in patients with pancreatic cancer

Introduction. Celiac plexus neurolysis is used in pain management of patients with advanced and unresectable pancreatic cancer. We retrospectively analyzed efficacy and safety of endoscopic ultrasound- (EUS-) guided celiac plexus neurolysis in patients treated in our unit. Methods. Twenty nine subjects with unresectable pancreatic cancer and severe pain despite pharmacological treatment underwent EUS-guided celiac plexus neurolysis with 98% ethanol. Patients scored their pain according to a 0-10 point scale and were interviewed 1-2 weeks and 2-3 months after the procedure. Results. Twenty five (86%) patients reported improvement in their pain at 1-2 weeks following the procedure. Of these, 7 (24%) reported substantial improvement (decrease in pain by more than 50%) and 4 (14%) complete disappearance of pain. Pain relief was still present in 76% of patients after 2-3 months. Treatment-related side effects included hypotonia in 1 patient, severe pain immediately postprocedure in 2 patients, and short episodes of diarrhea in 3 patients. Conclusion. Endoscopic ultrasound- (EUS-) guided celiac plexus neurolysis is a safe and effective treatment of severe pain from advanced pancreatic cancer.

Pain management in pancreatic cancer

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.

Regional Cancer Pain Syndromes

Cancer pain often presents in a body region. This review summarizes articles from 1999-2004 relevant to cancer pain syndromes in the head and neck, chest, back, abdomen, pelvis, and limbs. Although the evidence is limited, progress is being made in further development of the evidence base to support and guide current practice.

Percutaneous-guided pain control: exploiting the neural basis of pain sensation

The gastroenterologist deals frequently with painful conditions and suffering patients. Performing regular pain assessments and applying basic pain medicine principles will augment the care of patients in pain. Percutaneous-guided pain therapy techniques play a role in the multidisciplinary approach to pain medicine. Systemic opioid analgesia is the primary means of controlling cancer pain. However, 10% to 15% of cancer patients may need additional interventions to control pain. Sympathetic ganglion nerve blocks with neurolytic agents such as alcohol or phenol are reserved mostly for cancer pain. The efficacy and safety of these tools are validated by several decades of clinical application and published studies. Although the procedures are operator-dependent, in the hands of experienced clinicians, patients achieve sustained relief in the majority of cases. Although these techniques have been attempted in some benign conditions,such as chronic pancreatitis, with limited success, studies of newer imaging localization techniques such as endoscopic ultrasonography may expand future indications. Patients of the gastroenterologist who experience malignant abdominal pain may benefit from referral for percutaneous-guided pain control techniques.

A comparison of two invasive techniques in the management of intractable pain due to inoperable pancreatic cancer: neurolytic celiac plexus block and videothoracoscopic splanchnicectomy

BACKGROUND AND AIMS

Pancreatic cancer is characterized by a constant deterioration in quality of life, excruciating pain and progressive cachexia. The aim of this study was to compare the effectiveness of two invasive methods of pain treatment in these patients: neurolytic coeliac plexus block (NCPB) and videothoracoscopic splanchnicectomy (VSPL) to a conservatively treated control group concerning pain, quality of life and opiates' consumption.

PATIENTS AND METHODS

Fifty nine patients suffering from pain due to inoperable pancreatic cancer were treated invasively with NCPB (N=35) or VSPL (N=24) in two non-randomised, prospective, case-controlled protocols. Intensity of pain (VAS-pain), quality of life (FACIT and QLQ C30) and opioid intake were compared between the groups and to a control group of patients treated conservatively before the procedure and after 2 and 8 weeks of follow-up. The analysis was performed retrospectively using meta-analysis statistics.

RESULTS

Both methods of invasive pain treatment resulted in significant reduction of pain (VSPL effect size=11.27, NCPB effect size=7.29) and fatigue (effect sizes, respectively, 1.23 and 3.37). NCPB improved also significantly physical, emotional and social well-being (effect sizes, respectively, 2.37, 4.13 and 7.51) which was not observed after VSPL. No influence on ailments characteristic for the disease was demonstrated. Mean daily opioid consumption was significantly decreased after both procedures. There was no perioperative mortality and no major morbidity.

CONCLUSION

Both NCPB and VSPL provide significant reduction of pain and improvement of quality of life in inoperable pancreatic cancer patients. They present rather similar efficacy, but lower invasiveness of NCPB, in combination with its more positive effect on quality of life, pre-disposes it as being the preferred method.

Neurolytic Approaches for the Treatment of Pain in Patients with Chronic Pancreatitis

In large part, treatment options for patients with painful chronic pancreatitis remain empirical because of our limited understanding of the pathobiology of pancreatic pain. The procedures of neural block/ablation exemplify these limitations, which include the lack of a clear biologic rationale for various approaches, as well as unequivocal data on long-term outcomes and efficacy. Although the techniques themselves appear to be well established, controlled trials of various medical, endoscopic, radiologic, and surgical options to define the best treatment are clearly needed. In addition, the lack of uniform improvement with any technique underscores the need for applying a multidisciplinary approach to these patients, as should be the case for any chronic pain disorder.