Percutaneous neurolytic celiac plexus block

Hepatic Hilar Nerve Block for Adjunctive Analgesia in Thermal Ablation of Liver Tumors: A Prospective Randomized Controlled Trial

To determine whether performing a temporary hepatic hilar nerve block in patients undergoing microwave or radiofrequency ablation of primary or secondary hepatic malignancies reduces the requirement for intravenous conscious procedural sedation and analgesia.Fifty patients undergoing percutaneous image-guided liver thermal ablation were included in this single-center prospective randomized controlled trial. The experimental arm received a hepatic hilar nerve block in addition to intravenous medication directly before thermal ablation, whereas the control group underwent thermal ablation solely under intravenous medication, with the possibility of crossover. Student's t-test and analysis of covariance were performed to determine the block's efficacy regarding the intraoperative medication requirement.50 patients (22 females, 28 males) were randomly allocated to two groups without significant differences between the cohorts' baseline patient, clinical, and tumor characteristics. Three control group patients underwent crossover. Initial analysis using Student's t-test revealed no significant intravenous medication reduction in the control group vs. the test group (190 µg vs. 189 µg fentanyl, P = 0.96 and 1.34 mg vs. 1.60 mg Midazolam, P = 0.19). Thus, ANCOVA was performed to accommodate for heterogeneous ablation conditions (ablation time, total energy applied, affected liver capsule area). The adjusted mean fentanyl dosage was 206 µg vs. 184 µg (control group vs. test group), yielding a significant reduction after block (P = 0.020). None of the patients who received a hepatic hilar nerve block experienced any adverse events during a mean follow-up of nearly six months (range: 0-17 months).This prospective randomized trial confirms that a hepatic hilar nerve block can be safely performed before liver tumor thermal ablation as an adjunct to intravenous medication to reduce opioid consumption and manage pain. · First randomized study evaluating hepatic hilar nerve block (HHNB) for liver tumor ablation.. · HHNB significantly reduced opioid use after adjusting for heterogeneous ablation conditions.. · The effect is less pronounced than in retrospective studies. Larger trials are needed.. · Georgiades M, March C, Barajas Ordonez F et al. Hepatic Hilar Nerve Block for Adjunctive Analgesia in Thermal Ablation of Liver Tumors: A Prospective Randomized Controlled Trial. Rofo 2025; DOI 10.1055/a-2528-7037.

Nerve Injury and Regeneration after Neurolysis: Ethanol Combined with Iodine-125 Radioactive Seed versus Ethanol Alone in Rabbits

PURPOSE

This study aimed to prove the hypothesis that neurolysis based on ethanol injection in combination with iodine-125 (¹²⁵I) radioactive seed implantation could prolong nerve regeneration time compared with ethanol injection alone. Moreover, we assessed the grade of nerve injury using both methods.

MATERIALS AND METHODS

Twenty female rabbits (mean 2.8 ± 0.2 kg) were randomly assigned to group A (neurolysis of the left brachial plexus nerve based on ethanol injection in combination with ¹²⁵I radioactive seed implantation, n=10) and group B (neurolysis using ethanol injection alone, n=10). The right brachial plexus nerve was used as a blank control. Injury and regeneration of the brachial plexus nerve were analyzed using electromyography (EMG). Statistical tests were performed using the Mann-Whitney U test and repeated-measures analysis of variance. The results were verified with histopathological examinations.

RESULTS

The overall postprocedural amplitude was significantly lower in group A than in group B (P=0.01), particularly in the second month after the procedure (P=0.036). However, no statistical difference in latency was observed between the two groups (P=0.103). Histopathological examination of both groups revealed Sunderland's third-degree peripheral nerve injury (PNI), mainly characterized by axon disintegration. The degree of nerve regeneration was significantly lower in group A than in group B.

CONCLUSION

Neurolysis based on ethanol injection in combination with ¹²⁵I radioactive seed implantation can prolong the time of nerve regeneration compared to ethanol injection alone, although both methods resulted in Sunderland's third-degree PNI.

Celiac Plexus Cryoneurolysis

Intractable, chronic abdominal pain from upper abdominal malignant and benign diseases is a significant challenge for healthcare providers and burden on the healthcare system. While opioid analgesics are commonly used to provide pain relief, the adverse effects of chronic opioid use cannot be overlooked. Celiac plexus neurolysis via chemical or thermal means represents an alternative minimally invasive approach to provide palliative pain relief and increase patients' quality of life. Through the use of computed tomography guidance, celiac plexus neurolysis can be performed by accurately targeting the celiac plexus, while minimizing risks to adjacent structures. Historically, celiac plexus neurolysis was performed via instillation of ethanol or phenol; however, within the past decade cryoablation has gained increasing use with potentially fewer side effects.

Interventional Therapies for Pain in Cancer Patients: a Narrative Review

PURPOSE OF REVIEW

Pain is a prevalent symptom in the lives of patients with cancer. In light of the ongoing opioid epidemic and increasing awareness of the potential for opioid abuse and addiction, clinicians are progressively turning to interventional therapies. This article reviews the interventional techniques available to mitigate the debilitating effects that untreated or poorly treated pain have in this population.

RECENT FINDINGS

A range of interventional therapies and technical approaches are available for the treatment of cancer-related pain. Many of the techniques described may offer effective analgesia with less systemic toxicity and dependency than first- and second-line oral and parenteral agents. Neuromodulatory techniques including dorsal root ganglion stimulation and peripheral nerve stimulation are increasingly finding roles in the management of oncologic pain. The goal of this pragmatic narrative review is to discuss interventional approaches to cancer-related pain and the potential of such therapies to improve the quality of life of cancer patients.

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.

Renal Auto-Transplantation for Loin Pain Hematuria Syndrome Using a Multidisciplinary Team Model: Intermediate-Term Results

Background

Patients with loin pain hematuria syndrome (LPHS) can find relief via multiple modalities, few provide long-term pain control like renal auto-transplantation (RAT). This study evaluates the intermediate effectiveness of the RAT procedure’s ability to achieve long-term pain control and quality of life improvement.

Methods

All patients with suspected LPHS were seen by a multi-disciplinary team (MDT) composed of urologists, interventional radiologists, and transplant surgeons. Clinical history and physical exam, lab values, imaging findings, and response to renal hilar block (RHB) were used to determine LPHS and candidacy for potential RAT. Preoperative, one-year, three-year, and five-year postoperative pain assessment scores and quality of life surveys were administered to each LPHS and potential RAT patient.

Results

Eighty-four LPHS patients were referred for the evaluation of and consultation for the option of RAT. Sixty-four of these patients underwent RHB of which 60 (93.8%) had a positive response, defined as a temporary reduction of pain score by >50%. Forty-six of the 60 patients who responded favorably proceeded to RAT. At the one-year follow-up, there was a 75% reduction in pain with 88.9% of patients experiencing a 50% reduction in pain. At one year, the mean Beck Depression Inventory (BDI) decreased by 65.4%, from an average of 23.7 to 8.2. Similarly, at three years (n = 5) and five years (n = 3), the mean pain scores were 2 and 1.

Conclusions

The MDT evaluation of potential LPHS patients with our protocol and treatment results in an improvement in pain and depression scores in these selected patients.

Time-dependent change in pain threshold following neurolytic celiac plexus block

Aim: To determine the long-term effect of ethanol relative to the re-occurrence of pain in postneurolytic celiac plexus block (NCPB) patients. Patients & methods: A noninterventional study on 31 patients who had undergone NCPB to illustrate the average change of pain score over time. Results: All NCPB patients reported a pain score decrease of 83.8% right after the procedure. 73% of patients reported 50-66% decrease in pain 80-100 days postprocedure. The temporal threshold for the return of pain scores to average preblock level was determined to be 103 post-NCPB procedure days. Conclusion: In this study, NCPB patients demonstrate return of pain to baseline subsequent to the analgesic effects of ethanol after a mean 103 days.

[Single needle versus double needle celiac trunk neurolysis in abdominal malignancy pain management: a randomized controlled trial]

BACKGROUND

Computerized tomography-guided celiac plexus neurolysis has become almost a safe technique to alleviate abdominal malignancy pain. We compared the single needle technique with changing patients' position and the double needle technique using posterior anterocrural approach.

METHODS

In Double Needles Celiac Neurolysis Group (n = 17), we used two needles posterior anterocrural technique injecting 12.5 mL phenol 10% on each side in prone position. In Single Needle Celiac Neurolysis Group (n = 17), we used single needle posterior anterocrural approach. 25 mL of phenol 10% was injected from left side while patients were in left lateral position then turned to right side. The monitoring parameters were failure block rate and duration of patient positioning, technique time, Visual Analog Scale, complications (hypotension, diarrhea, vomiting, hemorrhage, neurological damage and infection) and rescue analgesia.

RESULTS

The failure block rate and duration of patient positioning significantly increased in double needles celiac neurolysis vs. single needle celiac neurolysis (30.8% vs. 0.13.8±1.2 vs. 8.9 ± 1; p = 0.046, p ≤ 0.001 respectively). Also, the technique time increased significantly in double needles celiac neurolysis than single needle celiac neurolysis (24.5 ± 5.1 vs. 15.4 ± 1.8; p ≤ 0.001). No significant differences existed as regards visual analogue scale: double needles celiac neurolysis = 2 (0-5), 2 (0-4), 3 (0-6), 3 (2-6) and single needle celiac neurolysis = 3 (0-5), 2 (0-5), 2 (0-4), 4 (2-6) after 1 day, 1 week, 1 and 3 months respectively. However, visual analogue scale in each group reduced significantly compared with basal values (p ≤ 0.001). There were no statistically significant differences as regards rescue analgesia and complications (p > 0.05).

CONCLUSION

Single needle celiac neurolysis with changing patients' position has less failure block rate, less procedure time, shorter duration of patient positioning than double needles celiac neurolysis in abdominal malignancy.

Single needle versus double needle celiac trunk neurolysis in abdominal malignancy pain management: a randomized controlled trial

Background

Methods

Results

Conclusion

Renal hilar block predicts long-term success of renal auto-transplantation for loin pain hematuria syndrome

PURPOSE

In patients with loin pain hematuria syndrome (LPHS), a response to percutaneous renal hilar blockade (RHB) and a multidisciplinary team (MDT) evaluation predicts patient's potential renal auto-transplantation (RAT) success.

METHODS

A pain assessment was performed using a 0-10 numeric pain rating scale prior to a percutaneous RHB under CT guidance. If the pain score was reduced > 50% immediately after the RHB, patients were evaluated for RAT by a MDT. Pre-operative and 1-year post-operative quality-of-life surveys were administered to each RAT patient.

RESULTS

43 LPHS patients were referred for RHB. Of the 38 patients who received a RHB, 31 had > 50% reduction in pain scores. Pre- and post-RHB mean pain scores were 6/10 and 0.7/10, respectively, in patients who had > 50% reduction in pain. 22 of the patients who responded favorably then proceeded to RAT. Twelve patients had at least 1-year follow-up after RAT. All patients had a meaningful decrease in their pain. Mean pain score at 1 year was 0.8/10 for an 85% overall reduction in pain. 92% of patients experienced a ≥ 50% reduction in pain at 1 year. Mean Beck Depression Inventory (BDI) score (0-66) 1 year after RAT decreased from 25.2 pre-op (moderate depression) to 12.8 post-op (minimal depression).

CONCLUSIONS

A MDT approach utilizing a RHB should be considered as a tool to select appropriate LPHS patients for RAT to achieve long-term success in reducing chronic pain and depression while increasing quality of life.

An overview of interventional strategies for the management of oncologic pain

Pain is a ubiquitous part of the cancer experience. Often the presenting symptom of malignancy, pain becomes more prevalent in advanced or metastatic disease and often persists despite curative treatment. Although management of cancer pain improved following publication of the WHO's analgesic ladder, when used in isolation, conservative approaches often fail to control pain and are limited by intolerable side effects. Interventional strategies provide an option for managing cancer pain that remains refractory to pharmacologic therapy. The purpose of this review is to investigate these strategies and discuss the risks and benefits which must be weighed when considering their use. Therapies anticipated to have an increasingly important role in the future of cancer pain management are also discussed.

CT guided neurolytic blockade of the coeliac plexus in patients with advanced and intractably painful pancreatic cancer

Background and aims:

Pain caused by infiltrating pancreatic cancer is complex in nature and may therefore be difficult to treat. In addition to conventional analgesics, neurolytic blockade of the coeliac plexus is often recommended. However, different techniques are advocated, and procedures vary, and the results may therefore be difficult to compare. Therefore strong evidence for the effect of this treatment is still lacking, and more studies are encouraged. Our aim was to describe our technique and procedures using a Computer Tomograph (CT) guided procedure with a dorsal approach and present the results.

Methods:

The procedures were performed in collaboration between a radiologist and an anaesthesiologist. All patients had advanced pancreatic cancer. The patients were placed in prone position on pillows, awake and monitored. Optimal placement of injection needles was guided by CT, and the radiologist injected a small dose of contrast as a control. When optimal needle position, the anaesthesiologist took over and completed the procedure. At first 40 mg methylprednisolone was injected to prevent inflammation. Thereafter a mixture of 99% ethanol diluted to 50% by ropivacaine 7.5 mg/mL to a total amount of 20–30 mL per needle was slowly injected. Repeated aspiration was performed during injection to avoid intravasal injection. Pain treatment and pain score was recorded and compared before and after the treatment.

Results:

Eleven procedures in 10 patients were performed. Age 49–75, mean 59 years. Median rest life time was 36 days (11–140). Significant reduction of analgesics was observed 1 week after the procedure, and most patients also reported reduction of pain. No serious side effects were observed.

Conclusions:

CT guided neurolytic celiac plexus blockade is a safe and effective treatment for intractable pain caused by advanced pancreatic cancer. Not all patients experience a significant effect, but the side effects are minor, and the procedure should therefore be offered patients experiencing intractable cancer related pain.

Ganglion blocks as a treatment of pain: current perspectives

The inputs from sympathetic ganglia have been known to be involved in the pathophysiology of various painful conditions such as complex regional pain syndrome, cancer pain of different origin, and coccygodynia. Sympathetic ganglia blocks are used to relieve patients who suffer from these conditions for over a century. Many numbers of local anesthetics such as bupivacaine or neurolytic agents such as alcohol can be chosen for a successful block. The agent is selected according to its duration of effect and the purpose of the injection. Most commonly used sympathetic blocks are stellate ganglion block, lumbar sympathetic block, celiac plexus block, superior hypogastric block, and ganglion Impar block. In this review, indications, methods, effectiveness, and complications of these blocks are discussed based on the data from the current literature.

A Review of Therapeutic Ablation Modalities

Understanding basic science and technical aspects is essential for scientists and engineers to develop and enhance ablative modalities, and for clinicians to effectively apply therapeutic ablative techniques. An overview of ablative modalities, anatomical locations, and indications for which ablations are performed is presented. Specifically, basic concepts, parameter selection, and underlying biophysics of tissue injury of five currently used therapeutic ablative modalities are reviewed: radiofrequency ablation (RFA), cryoablation (CRA), microwave ablation (MWA), high-intensity focused ultrasound (HIFU), and chemical ablation (CHA) (ablative agents: acetic acid, ethanol, hypertonic sodium chloride, and urea). Each ablative modality could be refined for expanding applications, either independently or in combination, for future therapeutic use.

CT-guided microinvasive intervention in treating refractory carcinous pain

OBJECTIVE

To evaluate the analgesic effect of CT-guided microinvasive intervention on refractory carcinous pain.

METHODS

A total of 23 patients with poor response to drug therapy for carcinous pain were selected: 6 patients underwent CT-guided neurolytic celiac plexus block (NCPB), 5 patients underwent CT-guided(125)I implantation and 12 patients underwent combined CT-guided NCPB and CT-guided(125)I implantation.

RESULTS

After 1 week of treatment, 6 patients exhibited complete remission, 13 patients exhibited partial remission and 4 patients exhibited no changes in condition. The treatment efficiency rate was 82.6%. After 1 month of treatment, 5 patients exhibited complete remission, 14 patients exhibited partial remission and 4 patients exhibited no changes in condition. Treatment efficiency rate was 82.6%. After 3 months of treatment, 4 patients exhibited complete remission, 9 patients exhibited partial remission, 5 patients exhibited no changes in condition and 5 patients died. Treatment efficiency rate was 72.2%. After 6 months of treatment, 3 patients exhibited complete remission, 6 patients exhibited partial remission, 3 patients exhibited no changes in condition and 11 patients died. The treatment efficiency rate was 75.0%. No severe postoperative severe complications, such as bleeding, biliary fistula and pancreatic fistula, were reported.

CONCLUSION

CT-guided microinvasive intervention clearly demonstrated an analgesic effect on refractory carcinous pain with less trauma and few complications. Therefore, this method provides effective relief for carcinous pain.