Thoracoscopic splanchnicolysis for the relief of chronic pancreatitis pain: experience of a group of pneumologists

Percutaneous splanchnic nerve neurolysis analgesic efficacy and safety for cancer-related pain: a systematic review and meta-analysis

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.

Geographical variance in reporting of elective surgery for chronic pancreatitis

The selection of optimum surgical procedure from the range of reported operations for chronic pancreatitis (CP) can be difficult. The aim of this study is to explore geographical variation in reporting of elective surgery for CP. A systematic search of the literature was performed using the Scopus database for reports of five selected procedures for CP: duodenum-preserving pancreatic head resection, total pancreatectomy with islet autotransplantation (TPIAT), Frey pancreaticojejunostomy, thoracoscopic splanchnotomy and the Izbicki V-shaped resection. The keyword and MESH heading 'chronic pancreatitis' was used. Overall, 144 papers met inclusion criteria and were utilized for data extraction. There were 33 reports of duodenum-preserving pancreatic head resection. Twenty-one (64%) were from Germany. There were 60 reports of TPIAT, 53 (88%) from the USA. There are only two reports of TPIAT from outwith the USA and UK. The 34 reports of the Frey pancreaticojejunostomy originate from 12 countries. There were 20 reports of thoracoscopic splanchnotomy originating from nine countries. All three reports of the Izbicki 'V' procedure are from Germany. There is geographical variation in reporting of surgery for CP. There is a need for greater standardization in the selection and reporting of surgery for patients with painful CP.

[Vascular relationships of the right great splanchnic nerve in the thorax]

AIM

The surgical assumption of responsibility of the pancreatic pain requires either a truncular coelioscopic or radicular neurectomy of greater splanchnic nerves (gsn). The goal of our work is to describe the way and relations of the right gsn which are variable and rarely described. This constitutes an undeniable peroperational hemorrhagic risk during splanchnicectomy.

MATERIAL AND METHODS

After a double side thoracotomy and a bilateral sterno-clavicular desarticulation on 15 adult cadaveric subjects preserved by method of Winckler we removed the sterno-costal drill plate as well as the ventral rib arch and proceeded to a mediastinal evisceration of the thorax. Then we respected only the thoracic aorta and the oesophagus, the azygos venous system, the thoracic duct and the thoracic sympathetic chain. In some of the subjects, the azygos vein was injected (after catheterization of its stick) using gelatine coloured with blue paint. We studied the way and vascular relations of the right gsn. We measured the transverse distances between the origin of the gsn on one hand and the longitudinal axes of the azygos vein and the thoracic duct on the other hand.

RESULTS

The relations of the right gsn trunk during its way related to the azygos vein in particular its constitutive origin and its affluents: ascending lumbar vein and twelfth intercostal vein. Sometimes the thoracic duct even a lymphatic node was near the gsn in the posterior infra-mediastinal space. A classification of the way and vascular relations of the right gsn in the thorax identified 3 anatomical types. The average distances separating the right gsn on one hand from the azygos vein and the thoracic duct on the other hand were respectively 5.7 mm and 11.2 mm.

CONCLUSION

The vascular relations of the right gsn are very variable from one subject to another but primarily venous, sometimes lymphatic. They concerned the great thoracic vessels whose respect is essential in particular at the time of mini-invasive access procedure for a cœlioscopic splanchnicectomy.

Preoperative opioid use and the outcome of thoracoscopic splanchnicectomy in chronic pancreatitis: a systematic review

BACKGROUND

Thoracoscopic splanchnicectomy (TS) is a minimally invasive intervention to relieve pain in patients with chronic pancreatitis (CP) with equivocal results. Preoperative opioid use seems to impair TS outcome but this has not been investigated in a systematic matter.

METHODS

We searched PubMed, EMBASE, and The Cochrane Library for studies on the outcome of TS in CP patients. Studies with ≥5 patients and a follow-up of ≥12 months were included. Success was defined as the proportion of patients free of opioids or who had a reduction of ≥4 points on a pain scale. The effect of opioid use on the success rate of TS was analyzed by uni- and multivariate regression.

RESULTS

Sixteen studies with 484 patients were included in our review. The mean (±SD) age of the patients was 44 ± 4.3 years and 66 % were male. Median follow-up period was 21 months (IQR 14-35). Median preoperative opioid use was 85 % (IQR 54-100 %). After TS, a median of 49 % (IQR 22-75 %) of patients were free of opioids at end of follow-up. The median success rate was 62 % (IQR 48-86 %). Mean success rate in studies in which ≤50 % of the patients used opioids preoperatively was 81 % (SD ± 21) compared to 60 % (SD ± 15) for other studies (p = 0.049). Higher age, male gender, and lower rates of preoperative opioid use were associated with a higher success rate (p = 0.003, 0.047, and 0.017, respectively). Multivariate regression, including age, gender, preoperative opioid use, and duration of follow-up, identified age and preoperative opioid use as independent predictors of success after TS (both p = 0.002).

CONCLUSION

Preoperative opioid use is associated with a worse outcome after TS in CP patients. To optimize outcome, use of TS may be considered at an earlier stage in the treatment of patients with CP before prolonged opioid therapy.

Medical pleuroscopy

There has been an exciting expansion in the practice of medical pleuroscopy in recent years. As technology has become more available and confidence in the use of equipment has grown, medical thoracoscopy has become a core diagnostic and therapeutic tool in pleural disease care. Despite this, many areas of medical pleuroscopy practice remain conspicuously devoid of well-established evidence. More knowledge is needed in those areas where there is currently a degree of equipoise. Many areas where pleuroscopy currently has a marginal role require high-quality randomized trials be undertaken with a view to informing future practice and guidelines.

Video-assisted thoracoscopic splanchnicectomy for pain control in chronic pancreatitis

BACKGROUND

: Management of pain in patients with chronic pancreatitis can be frustrating. The authors retrospectively evaluated their experience with video-assisted thoracoscopic surgery (VATS) for pain secondary to chronic pancreatitis.

METHODS

: From September 1999 to August 2004, 16 patients underwent VATS for pain associated with chronic pancreatitis. Data were collected retrospectively.

RESULTS

: Eight patients were female and 8 were male. Their ages ranged from 17 to 81 years, with a mean age of 40 years. There were 22 VATS splanchnicectomies performed: 7 right, 10 left, and 5 bilateral. The average operative time was 75 minutes for right VATS splanchnicectomy, 86 minutes for left VATS splanchnicectomy, and 88 minutes for bilateral VATS splanchnicectomies. The average length of stay (LOS) was 2.6 days after right VATS splanchnicectomy, 2.2 days after left VATS splanchnicectomy, and 1 day after bilateral VATS splanchnicectomies. Two cases were nonelective and not included in the determination of LOS. No postoperative complications occurred in any of the patients admitted for elective operations. Postoperative mortality was zero. Complete resolution of pain occurred in 4 patients (25%): 1 right splanchnicectomy, 1 left splanchnicectomy, and 2 bilateral splanchnicectomies. Total pancreatectomy with islet cell transplant was subsequently performed in 5 patients (31%), who improved but then had recurrent pain. Continued chronic pain managed with nonsteroidal antiinflammatory drugs and narcotic analgesics was the result in 7 patients (44%)

CONCLUSIONS

: Video-assisted thoracoscopic splanchnicectomy surgery may alleviate pain in patients with chronic pancreatitis. It can be performed with minimal morbidity and mortality, and has been safe and useful in the workup, evaluation, and management of pain associated with chronic pancreatitis.

A review of the thoracic splanchnic nerves and celiac ganglia

Anatomical variation of the thoracic splanchnic nerves is as diverse as any structure in the body. Thoracic splanchnic nerves are derived from medial branches of the lower seven thoracic sympathetic ganglia, with the greater splanchnic nerve comprising the more cranial contributions, the lesser the middle branches, and the least splanchnic nerve usually T11 and/or T12. Much of the early anatomical research of the thoracic splanchnic nerves revolved around elucidating the nerve root level contributing to each of these nerves. The celiac plexus is a major interchange for autonomic fibers, receiving many of the thoracic splanchnic nerve fibers as they course toward the organs of the abdomen. The location of the celiac ganglia are usually described in relation to surrounding structures, and also show variation in size and general morphology. Clinically, the thoracic splanchnic nerves and celiac ganglia play a major role in pain management for upper abdominal disorders, particularly chronic pancreatitis and pancreatic cancer. Splanchnicectomy has been a treatment option since Mallet-Guy became a major proponent of the procedure in the 1940s. Splanchnic nerve dissection and thermocoagulation are two common derivatives of splanchnicectomy that are commonly used today. Celiac plexus block is also a treatment option to compliment splanchnicectomy in pain management. Endoscopic ultrasonography (EUS)-guided celiac injection and percutaneous methods of celiac plexus block have been heavily studied and are two important methods used today. For both splanchnicectomies and celiac plexus block, the innovation of ultrasonographic imaging technology has improved efficacy and accuracy of these procedures and continues to make pain management for these diseases more successful.

Current status of medical pleuroscopy

Medical pleuroscopy (MP) offers a safe and minimally invasive tool for interventional pulmonologists. It allows diagnosis of unexplained effusion, while at the same time allowing drainage and pleurodesis. It can also help in the diagnosis of diffuse interstitial disease or associated peripheral lung abnormality in the presence of effusion. It can have a therapeutic role in pneumothorax and hyperhidrosis or chronic pancreatic pain. This article reviews the technical aspects and range of applications of MP.

An Objective Study of Pain Relief in Chronic Pancreatitis from Bilateral Thoracoscopic Splanchnicectomy

Pain from chronic pancreatitis leads to disability, malnutrition, and narcotic dependence. This study demonstrates the efficacy of bilateral thoracoscopic splanchnicectomy in reducing pain associated with chronic pancreatitis. This study reviews results from this procedure between 1998 and 2006. Data included pain levels, hospital admissions, nutritional status, and the duration between splanchnicectomy and pancreatic resection. Narcotic use was determined from the Kentucky All Schedule Prescription Electronic Reporting system. Fifty-four patients underwent splanchnicectomy with technical success in 98 per cent and immediate symptom relief in 43 per cent. Additional surgery occurred in 44 per cent (average time to surgery was 26 months). Failure of pain relief occurred in 17 per cent, early recurrence (6–12 months) occurred in 15 per cent, and 68 per cent had over a year of relief. Admissions decreased from 5.8 to 2.9 post surgery. Average pain levels decreased from 8.7 to 6.1 post surgery ( P < 0.001). Kentucky All Schedule Prescription Electronic Reporting demonstrated decreased or stable narcotic use in half of the patients. Over half (55%) maintained or gained weight, whereas 39 per cent experienced weight loss. Discharge occurred 24-hours after surgery. Bilateral thoracoscopic splanchnicectomy demonstrates a positive impact on pain control, hospital admissions, nutritional status, and narcotic use. Thoracoscopic splanchnicectomy is an effective and safe option in the treatment of pain from chronic pancreatitis.

Video-assisted thoracoscopic surgery

Video-assisted thoracoscopic surgery is finding an ever-increasing role in the diagnosis and treatment of a wide range of thoracic disorders that previously required sternotomy or open thoracotomy. The potential advantages of video-assisted thoracoscopic surgery include less postoperative pain, fewer operative complications, shortened hospital stay and reduced costs. The following review examines the surgical and anesthetic considerations of video-assisted thoracoscopic surgery, with an emphasis on recently published articles.

Video-assisted thoracic surgery--the past, present status and the future

Video-assisted thoracic surgery (VATS) has developed very rapidly in these two decades, and has replaced conventional open thoracotomy as a standard procedure for some simple thoracic operations as well as an option or a complementary procedure for some other more complex operations. In this paper we will review its development history, the present status and the future perspectives.

Bilateral Thoracoscopic Splanchnicectomy for Pain Control in Chronic Pancreatitis

The purpose of this study was to evaluate prospectively the efficacy of bilateral thoracoscopic splanchnicectomy (TS) for pain due to chronic pancreatitis. Pain is invariably a major debilitating factor in the course of chronic pancreatitis. This study was performed to evaluate the effect of bilateral TS on pain intensity, hospital admissions, and daily functions in patients with debilitating pain due to chronic pancreatitis. Twenty bilateral TS were performed in 20 patients. Follow-up was obtained in all patients and averaged 15 months (6 months to 3 years). To evaluate efficacy of the procedure, all 20 patients were personally interviewed after TS regarding impact of pain and change in lifestyle. Using the 0–10 numeric rating scale, patients ranked pre- and postoperative pain level and overall mood. A KASPER report was obtained for 17 of 20 patients from the Kentucky Drug Control and Professional Practices to obtain accurate information on all narcotic prescriptions filled for 1 year prior to surgery until today. Information from the KASPER report provided very objective information on pain medication use before and after TS. Thirteen patients (65%) had a decreased pain level, and 12 patients (55%) also developed an improved overall mood. The number of hospital admissions for chronic pancreatitis pain decreased in 19 patients (95%), and the days spent in the hospital decreased for 15 patients (75%). Overall, 12 patients (60%) indicated pain symptom relief during a mean duration of 14.8 months after the procedure. KASPER reports indicated a decrease in pain medication prescriptions filled for 9 patients (53%), 3 of which were able to discontinue completely use of opioids for pain associated with chronic pancreatitis. TS is a minimally invasive procedure that appears to offer pain relief, improve quality of life, and reduce narcotic dependence in patients with pain from chronic pancreatitis. The decrease in hospital admissions represents further quality of life improvement in this difficult to treat group of patients.

Auto-islet transplantation after pancreatectomy

Chronic pancreatitis (CP) is an inflammatory disease that causes progressive and irreversible structural changes to the pancreas, resulting in permanent impairment of both endocrine and exocrine functions. In advanced cases of CP, pain can be relieved only with pancreatic resection. However, even partial resection of the pancreas in this setting may cause diabetes. Furthermore, postsurgical diabetes (PSD) always occurs after total or near-total pancreatectomy, which is commonly performed for CP. Auto transplantation of pancreatic islets into the portal vein after pancreatic resection can prevent PSD. The results of this strategy, which are already encouraging, are likely to improve in the near future because of significant progress in the isolation and preservation of pancreatic islets. This review discusses the current status and future prospects for auto-islet transplantation after pancreatic resection for CP.

State of the art in thoracospic surgery: a personal experience of 2000 videothoracoscopic procedures and an overview of the literature

BACKGROUND

Herein we compare our personal experience with a series of > 2000 videothoracoscopic procedures with those reported in the literature to identify the procedures now accepted as the gold standard, those still regarded as investigational, and those considered unacceptable.

METHODS

Between June 1991 and December 2000, we performed 2068 videothoracoscopic procedures, including lung cancer staging (n = 910), wedge resections (n = 261), lobectomies (n = 221), pneumonectomies (n = 6), the diagnosis and treatment of pleural diseases (n = 200), the treatment of pneumothorax (n = 170), giant bullae (n = 57), lung volume reduction surgery (LVRS) for emphysema (n = 41), the diagnosis and treatment of mediastinal diseases (n = 133), the treatment of esophageal diseases (n = 39), and 30 other miscellaneous procedures.

RESULTS

A review of the literature indicates that videothoracoscopy is usually considered the preferred approach for the treatment of spontaneous pneumothorax, the diagnosis of indeterminate pleural effusions, the treatment of malignant pleural effusions, sympathectomy, and the diagnosis and treatment of benign esophageal or mediastinal diseases. The videoendoscopic approach to LVRS for emphysema is still under evaluation. Videothoracoscopic wedge resections for the diagnosis of indeterminate nodules and the treatment of primary lung cancer, metastases, and other malignancies are still controversial due to oncologic concerns. Videoendoscopic major pulmonary resections are usually considered investigational or even unacceptable due to oncologic concerns, technical difficulties, and the risk of complications.

CONCLUSIONS

Although we generally agree with the foregoing recommendations, we consider videoendoscopy the best approach for LVRS and particularly useful for the staging of lung cancer, where we always perform it as the first step of the operation. We widely perform videoendoscopic major pulmonary resections, but we believe that these procedures should only be used in strictly selected cases and at specialized centers.

Video-assisted thoracoscopic sympathectomy-splanchnicectomy for pancreatic cancer pain

Patients with unresectable pancreatic cancer often suffer severe pain. Various techniques are available for pain control. We present a patient with pancreatic cancer who underwent unilateral video-assisted thoracoscopic sympathectomy-splanchnicectomy and had complete pain relief. This minimally invasive procedure offers promise in carefully selected patients with severe pain from pancreatic cancer and other conditions which are not amenable to conventional interventions.

Palliative strategies for locally advanced unresectable and metastatic pancreatic cancer

Technical improvement in perioperative morbidity and mortality with improved long-term survival associated with pancreaticoduodenectomy for patients with pancreatic carcinoma has clearly established a role for this operation when performed with curative intent. Most patients with pancreatic adenocarcinoma will not be candidates for surgical resection of their disease. These patients will experience significant symptoms potentially requiring surgical and nonsurgical palliative interventions to treat unrelieved cancer-associated pain, obstructive jaundice, or the development of GOO. The primary goal for palliative interventions should be to relieve symptoms with minimal morbidity and to maintain or improve the quality of life for patients with an expected limited survival.

Current practice in thoracic sympathectomy

Thoracic sympathectomy has been performed for many years. With the recent development of video assisted thoracic surgical techniques the indications for surgery have increased, and the outcome is much better.

Management of chylothorax after thoracoscopic splanchnicectomy

Thoracoscopic splanchnicectomy is a minimally invasive procedure used in the treatment of recalcitrant abdominal pain in patients with chronic pancreatitis or pancreatic carcinoma. Chylothorax, an uncommon complication of thoracoscopic splanchnicectomy, may lead to a protracted, costly hospital course of treatment usually consisting of central venous hyperalimentation, restricted oral intake, and tube thoracostomy. In our series of 25 patients who underwent thoracoscopic splanchnicectomy, 2 developed postoperative chylothorax. Both patients failed conservative management and ultimately underwent operative reintervention, at which time, leaking lymphatics were easily identified and closed using minimally invasive techniques. On the basis of this experience, we advocate early thoracoscopic reintervention in patients with chylothorax after thoracoscopic splanchnicectomy.

Video-assisted thoracic surgery: a renaissance in surgical therapy

Within a few years, video-assisted thoracic surgery (VATS) has become the accepted or preferred approach over a wide range of thoracic procedures. The authors review the development of this technique, the basic operative strategies and the current surgical indications. Technical pitfalls and future developments are also discussed.