CT-guided celiac ganglion block with alcohol

Single-Center Review of Celiac Plexus/Retrocrural Splanchnic Nerve Block for Non-Cancer Related Pain

RATIONALE AND OBJECTIVES

Celiac plexus and retrocrural splanchnic nerve (CP/RSN) blocks are widely used for cancer-related abdominal pain, but there is limited literature on their efficacy for non-cancer related pain. Our aim was to determine the indications and effectiveness of CT-guided CP/RSN blocks performed on patients with abdominal pain from non-cancer related sources.

MATERIALS AND METHODS

CT-guided CP/RSN blocks for non-cancer related abdominal pain from 2011-2020 were retrospectively reviewed for patient demographics, procedure details, duration of pain relief, and complications. Effective blocks were defined as patient-reported pain relief or decrease in opioid use lasting 2 or more days for temporary blocks and 14 or more days for permanent blocks.

RESULTS

Of 72 CT-guided CP/RSN blocks for non-cancer related abdominal pain, 48 (67%) were effective for a mean of 51 days (median 14, range 2-700). Of the 18 permanent blocks, 9 (50%) were effective for a mean of 111 days (median 90, range 14-390). Of the 54 temporary blocks, 39 (72%) were effective for a mean of 37 days (median 9, range 2-700). Indications included postural orthostatic tachycardia syndrome/dysautonomia (77% effective, 20/26), pancreatitis (86% effective, 12/14), postsurgical pain (62% effective, 8/13), median arcuate ligament syndrome (70% effective, 7/10), chronic pain syndrome (20% effective, 1/5), gastroparesis (80% effective, 4/5), and renal cystic disease (33% effective, 1/3). For postural orthostatic tachycardia syndrome /dysautonomia, pancreatitis, post-surgical pain, and MALS, there were no statistically significant differences in effectiveness between celiac vs. splanchnic blocks in groups matched by indication and intended duration (temporary/permanent).

CONCLUSIONS

CT-guided CP/RSN blocks can effectively manage non-cancer related abdominal pain, though there is discrepancy in efficacy between temporary and permanent blocks.

Clinical Response to Celiac Plexus Block Confirms the Neurogenic Etiology of Median Arcuate Ligament Syndrome

PURPOSE

To evaluate the response of median arcuate ligament syndrome (MALS) symptoms, including postprandial pain, nausea, and vomiting, to celiac plexus block (CPB) and correlate the response with arterial anatomy.

MATERIALS AND METHODS

In a single-institution, retrospective cohort of clinically diagnosed MALS patients, 96 patients (female, 75; male, 21; mean age, 27 years) underwent 103 computed tomography‒guided percutaneous CPB procedures. Imaging, procedural, and clinical reports were reviewed. Primary outcomes evaluated were technical success, change in self-reported pain score, and change in nausea and vomiting.

RESULTS

Computed tomography imaging before the procedure was available for 81 of 96 patients and demonstrated findings of celiac artery compression in 22 of 81 (27%) patients. Technical success was achieved in 102 of 103 cases. No major adverse events and 1 moderate adverse event were reported. The postprandial pain score decreased in 86 (84%) patients, and the mean score decreased from 6.3 to 0.9 points (P < .001). The prevalence of postprandial nausea decreased from 37.9% to 11.6% (P < .001) and that of vomiting decreased from 15.5% to 4.9% (P = .019). No differences were noted in pain relief after CPB between patients with and without celiac artery compression (P = .745).

CONCLUSIONS

In patients with a clinical diagnosis of MALS, a large majority reported pain relief and decreased gastrointestinal symptoms after CPB. Pain relief did not correlate with the presence of celiac arterial abnormalities. This supports neuropathy as the primary etiology of MALS and suggests that the absence of celiac stenosis should not be used as an exclusion criterion.

Use of a steerable needle for CT-guided nerve plexus blockade

PURPOSE

Demonstrate the use of a new steerable needle for CT-guided neural plexus blockade to avoid traversing the kidneys.

MATERIALS AND METHODS

Retrospective evaluation of 23 consecutive CT-guided neural plexus blockade procedures in which a new steerable needle was used in the last 13 and compared with the prior 10 procedures in which a standard needle was used.

RESULTS

Use of the steerable needle was beneficial to reach the target area without traversing a kidney or other organs in 6/13 (46%) procedures; in the other 7 procedures there was no benefit. A kidney was traversed in 0/13 procedures performed with the steerable needle. In contrast, a kidney was traversed in 4/10 (40%) procedures using a standard needle (P = 0.02). There was no significant difference in clinical benefit (P = 1.00) or complications (P = 0.56) between procedures using the steerable needle versus a standard needle. Three complications were observed (1 major and 2 minor) felt to be related to the injection and not the needle type.

CONCLUSIONS

The utility of a steerable 21-gauge needle during neural plexus blockades was found to allow for avoidance of the kidneys when compared to a standard (non-steerable) needle. Interventional radiologists may find this needle and its future iterations useful for neural blockades, as well as other procedures, when intervening structures need to be avoided.

LEVEL OF EVIDENCE

Level 3, Non-randomized controlled cohort.

CT-guided celiac plexus neurolysis: a review of anatomy, indications, technique, and tips for successful treatment

The celiac plexus is the largest visceral plexus and is located deep in the retroperitoneum, over the anterolateral surface of the aorta and around the origin of the celiac trunk. It serves as a relay center for nociceptive impulses that originate from the upper abdominal viscera, from the stomach to the proximal transverse colon. Celiac plexus neurolysis, with agents such as ethanol, is an effective means of diminishing pain that arises from these structures. Percutaneous imaging-guided celiac plexus neurolysis has been established as an invaluable therapeutic option in the management of intractable abdominal pain in patients with upper abdominal malignancy. The use of multidetector computed tomography (CT) for imaging guidance has superseded other modalities and allows direct visualization of the spread of the neurolytic agent in the antecrural space. Accurate depiction of the retroperitoneal anatomy and the position of the needle tip helps avoid crucial anatomic structures such as the pancreas, aorta, celiac artery, and superior mesenteric artery. Proper patient education, meticulous preprocedure planning, use of optimal multidetector CT techniques, adjunctive CT maneuvers, and postprocedure care are integral to successful celiac plexus neurolysis. Celiac plexus neurolysis does not completely abolish pain; rather, it diminishes pain, helping to reduce opioid requirements and their related side effects and improving survival in patients with upper abdominal malignancy.

Palliative interventions for pain in cancer patients

Pain is a debilitating problem that is common to most patients with cancer at some time during the course of their disease. Conventional therapies such as opiate analgesics and radiation therapy provide suboptimal and limited relief. Novel image-guided interventions have made a significant impact in the management of this difficult problem. This article reviews some of the most promising image-guided techniques for relieving bone and visceral pain in patients suffering from cancer.

Interventional endoscopic ultrasound: Therapeutic capability and potential

The linear echoendoscope, introduced in the 1990s, opened the era of interventional endoscopic ultrasound (IEUS). The linear echoendoscope enabled EUS guided Fine Needle Aspiration (EUS-FNA) allowing the path of the needle to be traced during the puncture process. After EUS-FNA, other interventional procedures were introduced in clinical practice. Tissue acquisition was the first EUS-guided interventional procedure and its higher diagnostic quality has undoubtedly been established. After EUS-FNA, Celiac plexus neurolysis (CPN) and block (CPB), pancreatic pseudocyst drainage, abdominal and mediastinal collections/abscesses drainage, and in selected cases, pancreatic and biliary ductal system drainage, were introduced in clinical practice. EUS-guided fine needle injection with local delivery of antitumor agents is considered a promising modality. We have reviewed published data on EUS guided interventional procedures with the object of summarizing the diagnostic capability of endoscopic ultrasound and elaborates in detail its therapeutic capability and potential.

Managing nonmalignant chronic abdominal pain and malignant bowel obstruction

Evaluation of abdominal pain requires an understanding of the possible causes(benign or malignant) and recognition of typical patterns and clinical presentation. Abdominal pain has multiple causes; associated signs and symptoms may aid in the diagnosis. Remember that some patients will not have a textbook presentation, and unusual causes for pain must be considered. Those with chronic pancreatitis with structural complications should be operated on early, whereas those with other types of chronic pancreatitis should receive medical therapy focusing on alleviating symptoms. Control of the most troublesome symptoms will provide the best management for IBS. Pharmacologic success in bowel obstruction depends on the level and degree of obstruction. Decision making is based on reasonable expectations of survival, treatment-related success, performance status, and goals of care. Quality of life will be enhanced by appropriate symptom management.

Interventional applications of endoscopic ultrasound

Endoscopic ultrasound, which was developed more than 20 years ago, is currently a valuable investigative tool for endoscopists. It began as a diagnostic instrument and in the short span of a decade made a clinical impact as a therapeutic tool with a promising potential for various interventional applications. The introduction of the curved linear array echoendoscope in the 1990s enabled a whole range of interventional applications of endoscopic ultrasound ranging from fine needle aspiration of lesions surrounding the gastrointestinal tract to celiac plexus block and drainage of pancreatic pseudocyst. This review article outlines the current interventional applications of endoscopic ultrasound and discusses potential future procedures. These procedures include endoscopic ultrasound guided creation of communication between the gastrointestinal tract and adjacent organs, such as hepaticogastrostomy and choledochoduodenostomy.

Celiac ganglia block

Pain occurs frequently in patients with advanced cancers. Tumors originating from upper abdominal viscera such as pancreas, stomach, duodenum, proximal small bowel, liver and biliary tract and from compressing enlarged lymph nodes can cause severe abdominal pain, which do not respond satisfactorily to medical treatment or radiotherapy. Percutaneous celiac ganglia block (CGB) can be performed with high success and low complication rates under imaging guidance to obtain pain relief in patients with upper abdominal malignancies. A significant relationship between pain relief and degree of tumoral celiac ganglia invasion according to CT features was described in the literature. Performing the procedure in the early grades of celiac ganglia invasion on CT can increase the effectiveness of the CGB, which is contrary to World Health Organization criteria stating that CGB must be performed in patients with advanced stage cancer. CGB may also be effectively performed in patients with chronic pancreatitis for pain palliation.

Coeliac plexus block: utility of the anterior approach and the real time colour ultrasound guidance in cancer patient

AIMS

The aim of our study was to demonstrate the efficacy of ultrasound-guidance compared with computed tomography (CT) guidance for coeliac plexus block in cancer patients.

METHODS

Coeliac plexus block (30 ml ethanol) was performed in 34 cancer patients (sex ratio: 10F, 24M), mean age: 54.8 years (range 26-67) under CT (n=21) and ultrasound-guidance (n=13). All patients had excruciating epigastric and generalized abdominal pain caused by cancer of the pancreas (n=13) or upper abdominal viscera (n=9) or a malignancy of extra-digestive origin (n=12). Feasibility and complication rates were analysed.

RESULTS

Notable pain relief was obtained in 27 (79%) of the patients. The technical success rate was 100% for CT-guidance and 93% (13/14) for ultrasound guidance. There were six minor complications (17%): chemical peritonitis (n=2), orthostatic arterial hypotension (n=2) and transient left shoulder pain (n=2), no major complications occurred. The target route was transhepatic in 6/13 of the ultrasound cases and mean length was 6 cm (range 3-12 cm). Colour Doppler sonography improved visualization of the 21 Gauge Chiba needle when the needle shaft was vibrated. Echogenic foci were observed around the origin of the coeliac trunk and superior mesenteric artery in all cases. CT coeliac block was successfully performed after failure of ultrasound guidance in one patient.

CONCLUSION

Ultrasound guidance is safe and effective and should be attempted for coeliac plexus block whenever possible.

Endoscopic ultrasound-guided (neurolytic) celiac plexus block

Celiac plexus neurolysis is an established technique for relieving pain in cancers of the upper abdomen. This article reviews the novel technique of endoscopic ultrasound (EUS)-guided neurolytic celiac plexus block. This recently described procedure is a therapeutic extension of curvilinear array endosonographic fine needle aspiration. The indications, patient preparation, and technical aspects of the procedure are described in detail. The potential complications are mentioned and the results of the published studies are reviewed. We believe that where the expertise is available, this procedure can be integrated into the diagnostic EUS of patients with inoperable upper abdominal malignancy. As such, this would be the safest and most cost-effective approach for celiac plexus neurolysis in these patients. The role of EUS-guided celiac plexus block in patients with chronic pancreatitis may be emerging and needs further study.

Endosonography-guided celiac plexus neurolysis

BACKGROUND

We have evaluated the safety and efficacy of performing endosonography-guided celiac plexus neurolysis (EUS CPN) in patients with pain due to intra-abdominal malignancies.

METHODS

Thirty patients with upper abdominal pain requiring narcotic analgesia and suspected or known intra-abdominal malignancy were selected for EUS CPN. This group included 25 patients with pancreas carcinoma and 5 patients with intra-abdominal metastases. Using the linear array ultrasound endoscope and a prototype needle catheter, transgastric injection of the celiac plexus with bupivacaine and 98% dehydrated absolute alcohol was accomplished.

RESULTS

Pain scores were significantly lower compared with baseline at 2, 4, 8, and 12 weeks after EUS CPN (median follow-up: 10 weeks). At these follow-up intervals, 82% to 91% of patients required the same or less pain medication and 79% to 88% of patients had persistent improvement in their pain score. Comparison of patients with TXNXM1 versus TXNXMO pancreatic carcinoma revealed higher initial pain scores (7.9 +/- 1.92 versus 5.8 +/- 2.0, p = .02) and a greater decline in pain scores (decrease of 6.1 +/- 3.1 versus 4.8 +/- 2.0, p = .004). Complications were minor and consisted of transient diarrhea in four patients.

CONCLUSION

EUS CPN is a safe and effective means for improving pain control in patients with intra-abdominal malignancy. The technique may be performed as an outpatient at the same setting as the EUS staging examination.

Pancreatic adenocarcinoma

Pancreatic carcinoma is one of the most enigmatic and aggressive malignant disease facing oncologists. A precocious propensity to spread along peripancreatic neurons and lymphatic channels conspires with the limited activity of standard chemotherapeutic agents and the inability to deliver large doses of radiotherapy to the upper abdomen, leaving radical surgical resection as the primary treatment capable of influencing long-term survival. Theoretically, when the tumor is small and confined to the pancreas, adequate locoregional control is possible by radical resection of the tumor, lymph nodes, peripancreatic neurons, and surrounding soft tissue. Realistically, at the time of initial diagnosis, 50% of patients have distant metastases to the liver or peritoneal surface, and more than 80% of the remaining patients have locally advanced tumors. Fewer than 10% of all patients with a small pancreatic adenocarcinoma confined to the pancreas are candidates for cure by use of radical resection as the sole treatment modality. Given these sobering statistics on the late presentation of this tumor, it is not surprising that, even after radical resection, the overall median survival time is only 18 to 20 months and the overall 5-year survival is approximately 10%. These dismal results led to a call in the early 1970s for abandonment of radical therapy in this disease and for treatment of all patients with palliative care only. These statistics are discouraging, but over the last 10 years a therapeutic renaissance has erupted. This resurgence has been driven by surgeons performing pancreaticoduodenectomy with low perioperative mortality rates and excellent functional results. It has been fueled by the use of adjuvant and neoadjuvant chemoradiotherapy protocols. Improved radiographic imaging techniques such as endoscopic retrograde cholangiopancreatography, helical computed tomography scan, and endoscopic ultrasonography are beginning to show promise in facilitating an earlier diagnosis and in providing highly accurate tumor staging without operation. It is hoped that recent observations on the molecular genetics of pancreatic adenocarcinoma will lead to a better understanding of tumor biology, which in turn should result in a more rational application of new diagnostic and therapeutic strategies. Effective percutaneous, endoscopic, and laparoscopic techniques have been developed concomitant with the recent advances in radiographic and endoscopic imaging. These minimally invasive options can now provide meaningful, long-lasting palliation and improved quality of life for the large number of patients with unresectable or metastatic disease who have no other treatment options. The therapeutic nihilism so pervasive in previous decades has no place in the contemporary treatment of patients with pancreatic adenocarcinoma. True long-term survival seems possible for a growing proportion of patients, and minimally invasive, effective palliation is achievable in the vast majority of patients. It is only through aggressive recruitment of patients for treatment, application of novel diagnostic and therapeutic protocols, and further laboratory investigation into the biology of pancreatic cancer that the momentum of the last decade toward improved outcome and quality of life can be sustained.

Retrocrural splanchnic nerve alcohol neurolysis with a CT-guided anterior transaortic approach

Retrocrural splanchnic nerve alcohol neurolysis with a CT-guided anterior transortic approach, a new method for splanchnic block alleviation of chronic abdominal pain, is described. Ten patients with chronic abdominal pain requiring narcotic treatment, six with pancreatic carcinoma, one with gastric carcinoma, two with chronic pancreatitis, and one with pain of unknown etiology, were referred for splanchnic nerve neurolysis. With CT guidance, a 20 gauge needle was placed through the aorta into the retrocrural space at T11-T12, and 5-15 ml 96% alcohol was injected into the retrocrural space. Following the procedure, 6 of 10 patients were pain free, 2 patients had temporary pain relief, and 2 patients were without response. There were no significant complications. CT-guided anterior transaortic retrocrural splanchnic nerve alcohol neurolysis is technically feasible, easier to perform than the classic posterolateral approach, and may have less risk of complications. The success rate in this initial trial was reasonable and, therefore, this technique provides an additional method for the treatment of abdominal pain.