Correlation between the grade of tumoral invasion and pain relief in patients with celiac ganglia block

Role of interventional radiology in upper abdominal cancer pain management

Background

The major indication for celiac plexus block is abdominal pain that is nonresponsive to analgesic interventions; often these patients are nonresponsive to high-dose opioid therapies. One of the most common indications for the celiac plexus block is the treatment of abdominal pain associated with pancreatic cancer.

Aim of the work

The differences between two techniques (ultrasound and fluoroscopy guided) are highlighted in terms of effectiveness by means of a Visual Analog Scale (VAS), a percentage reduction in daily morphine consumption and any complications are recorded and evaluated at the time of implementation of each technique from start to finish.

Results

Through the data that have been recorded and statistically analyzed, we found that the mean values of VAS were decreased in the two groups, and there was statistically significant difference between ultrasound and fluoroscopy groups.

Conclusions

It is noticeable and good in conducting this research that there are no major complications that include a large space on the study sample, despite the presence of some minor with no significant differences between ultrasound and fluoroscopy groups. This effective celiac block, regardless of the technique used, produced immediate analgesics that permitted significant opioid decrease in the study sample with a significant improvement in the unwanted adverse effects on account of opioids.

The role of interventional radiology in the treatment of patients with pancreatic cancer

Interventional radiology (IR) provides minimally invasive therapeutic and palliative options for the treatment of pancreatic cancer depending on the stage of the disease. IR plays a critical, and also a very effective role, in both pre- and post-operative care of the patients with early stage resectable disease and also in palliative treatment of the patients with locally advanced or metastatic disease. In this article, we aimed to present the capability and the limitations of IR procedures including: local treatment options of primary and metastatic pancreatic cancer, palliation of biliary and intestinal obstructions, minimally invasive treatment of post-operative complications, and pain management.

Celiac plexus neurolysis for abdominal cancer pain: a systematic review

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.

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.

Relationships between pathology and pain severities: a review

The relationships between pathology severity and pain severity are reviewed using the literature available for humans. The aim is to help veterinary radiologists, physicians and pathologists recognise the disorders in which severity of a lesion is likely to be related to the severity of pain or to incipient pain. Specific features or lesions within the following conditions showed a relationship with pain score, which was usually assessed with a visual analogue scale: inflammation; pancreatitis; ileitis; mucositis; fasciitis; synovitis; arthritis; lower back pain; disc herniation; sciatica; scoliosis; myalgia; cancer; arteriosclerosis; skin ulcers; mastalgia; skin and oral neuropathies; endometriosis; hepatopathy and chronic pulp diseases of the teeth. As experience with magnetic resonance imaging grows, there will be further opportunities to look for quantitative relationships in humans between pathology and pain severities. This information will be useful to veterinarians and other people working with animals in evaluating pain in animals in their care.

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.

Cancer pain: part 2: physical, interventional and complimentary therapies; management in the community; acute, treatment-related and complex cancer pain: a perspective from the British Pain Society endorsed by the UK Association of Palliative Medicine and the Royal College of General Practitioners

OBJECTIVE

This discussion document about the management of cancer pain is written from the pain specialists' perspective in order to provoke thought and interest in a multimodal approach to the management of cancer pain, not just towards the end of life, but pain at diagnosis, as a consequence of cancer therapies, and in cancer survivors. It relates the science of pain to the clinical setting and explains the role of psychological, physical, interventional and complementary therapies in cancer pain.

METHODS

This document has been produced by a consensus group of relevant healthcare professionals in the United Kingdom and patients' representatives making reference to the current body of evidence relating to cancer pain. In the second of two parts, physical, invasive and complementary cancer pain therapies; treatment in the community; acute, treatment-related and complex cancer pain are considered.

CONCLUSIONS

It is recognized that the World Health Organization (WHO) analgesic ladder, whilst providing relief of cancer pain towards the end of life for many sufferers world-wide, may have limitations in the context of longer survival and increasing disease complexity. To complement this, it is suggested that a more comprehensive model of managing cancer pain is needed that is mechanism-based and multimodal, using combination therapies including interventions where appropriate, tailored to the needs of an individual, with the aim to optimize pain relief with minimization of adverse effects.

Classification of pain in cancer patients--a systematic literature review

One of the aims of the European Palliative Care Research Collaborative (EPCRC) is to achieve consensus on a classification system for cancer pain. We performed a systematic literature review to identify existing classification systems and domains/items used to classify cancer patients with pain. In a systematic search in the databases Medline and Embase, covering 1986-2006, 692 hits were obtained. 92 papers were evaluated to address pain classification. Six standardised classification systems were identified; three of them systematically developed and partially validated. Both pain characteristics and patient characteristics relevant for cancer pain classification were included in the classification systems. All but one of the standardised systems aim at predicting treatment response or adequacy of treatment. Several domains and items used to describe cancer pain but not formally described as part of a classification system were also identified and systematized. The existing approaches to pain classification in cancer patients are different, mostly not thoroughly validated, and none is widely applied. An internationally accepted classification system for cancer pain could improve research and cancer pain management. This systematic review suggests a need for developing an international consensus on how to classify pain in cancer patients.

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.

Long-term results of celiac Ganglia block: correlation of grade of tumoral invasion and pain relief

OBJECTIVE

We evaluated the long-term results and response rates of celiac ganglia block to the level of tumor invasion of the celiac region. SUBJECTS AND METHODS. Forty-one patients each with an inoperable intraabdominal carcinoma who were referred to our department for celiac ganglia block were included in this study. Tumor invasion of the celiac ganglia region was graded on a four-point scale according to CT features (grade I = no invasion, grade II = invasion < 50%, grade III = invasion > 50%, and grade IV = complete invasion). Subjective pain levels (0 = no pain, 10 = worst pain) were obtained from the patients, and objective criteria (change in daily analgesic doses) were noted before the procedure and during the follow-up to determine effectiveness of the celiac ganglia block.

RESULTS

Celiac ganglia block was successfully performed in all 41 patients (100%). In 39 (95%) of 41 patients, pain decreased significantly after the procedure, and the pain level did not change in the remaining two patients. Major complications were not encountered in any of the patients. Minor complications were observed in 35 patients (85%). Mean pain intensity and mean daily analgesic consumption significantly decreased after the procedure in all four groups. The amount of pain decrease for these two parameters was inversely related to degree of invasion. Responses of the patients were obtained at the end of the first week after the procedure and remained unchanged during long-term follow-up.

CONCLUSION

Percutaneous celiac ganglia block, particularly when performed in earlier stages of ganglia invasion, is an effective, easy, and safe procedure with successful long-term results.

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.

Common nerve blocks in chronic pain management

Anesthesiologists have become increasingly involved with the management of chronic pain patients in the operating room, on the surgical floor, and in the outpatient pain facility setting (often interdisciplinary). Based upon the authors' practice of regional anesthesia, the most specific contribution to chronic pain management arguably remains the practice of diagnostic, prognostic, and therapeutic injections of the neuraxis, peripheral nerves, and the autonomic nervous system.

MR imaging-guided radio-frequency thermal ablation in the pancreas in a porcine model with a modified clinical C-arm system

PURPOSE

To test the hypotheses that (a) magnetic resonance (MR) imaging-guided radio-frequency (RF) thermal ablation in the pancreas is safe and feasible in a porcine model and (b) induced thermal lesion size can be predicted with MR imaging monitoring.

MATERIALS AND METHODS

MR imaging-guided RF ablation was performed in the pancreas of six pigs. A 17-gauge monopolar RF probe was inserted into the pancreas with MR imaging guidance, and RF was applied for 10 minutes. After postprocedural imaging (T2-weighted, short inversion time inversion-recovery [STIR], and T1-weighted imaging before and after intravenous administration of gadodiamide), the pigs were observed for 7 days and follow-up MR images were acquired. The pigs were sacrificed, and pathologic examination was performed.

RESULTS

Successful RF probe placement was accomplished in all pigs; the interventional procedure took 46-80 minutes. Thermal lesions were 12-15 mm perpendicular to the probe track and were best seen on STIR and contrast material-enhanced T1-weighted images with a radiologic and/or pathologic mean difference in RF lesion diameter of 1.7 mm +/- 1.0 (SD) and 0.8 mm +/- 1.2, respectively. Diarrhea was the only side effect during the 1-week follow-up; no clinical signs of pancreatitis occurred.

CONCLUSION

MR imaging-guided RF thermal ablation in the pancreas is feasible and safe. Induced thermal lesion size can best be monitored with STIR and contrast-enhanced T1-weighted images. In the future, RF ablation may offer an alternative treatment option for pancreatic cancer.