Celiac plexus neurolysis in the management of unresectable pancreatic cancer: When and how?

Tissue Ablation: Applications and Perspectives

Tissue ablation techniques have emerged as a critical component of modern medical practice and biomedical research, offering versatile solutions for treating various diseases and disorders. Percutaneous ablation is minimally invasive and offers numerous advantages over traditional surgery, such as shorter recovery times, reduced hospital stays, and decreased healthcare costs. Intra-procedural imaging during ablation also allows precise visualization of the treated tissue while minimizing injury to the surrounding normal tissues, reducing the risk of complications. Here, the mechanisms of tissue ablation and innovative energy delivery systems are explored, highlighting recent advancements that have reshaped the landscape of clinical practice. Current clinical challenges related to tissue ablation are also discussed, underlining unmet clinical needs for more advanced material-based approaches to improve the delivery of energy and pharmacology-based therapeutics.

Best supportive care in advanced pancreas cancer: a systematic review to define a patient-care bundle

BACKGROUND

The majority of patients with pancreatic adenocarcinoma (PDAC) have advanced disease at presentation, preventing treatment with curative intent. Management of these patients is often provided by surgical teams for whom there are a lack of widely accepted strategies for care. The aim of this study was to conduct a systematic review to identify key issues in patients with advanced PDAC and integrate the evidence to form a care bundle checklist for use in surgical clinics.

METHODS

A systematic review of the literature was performed regarding best supportive care for advanced PDAC according to the PRISMA guidelines. Interventions pertaining to supportive care were included whilst preventative and curative treatments were excluded. A narrative review was planned.

RESULTS

Forty-four studies were assessed and four themes were developed: (i) Pain is an undertreated symptom, requiring escalating analgesics and sometimes invasive modalities. (ii) Health-related quality of life necessitates optimisation by involving family, carers and multi-disciplinary teams. (iii) Malnutrition and weight loss can be mitigated with early assessment, replacement therapies and resistance exercise. (iv) Biliary and duodenal obstruction can often be relieved by endoscopic/radiological interventions with surgery rarely required.

CONCLUSION

This is the first systematic review to evaluate the different types of interventions utilized during best supportive care in patients with advanced PDAC. It provides a comprehensive care bundle for surgeons that informs management of the common issues experienced by patients within a multidisciplinary environment.

Efficacy of Endoscopic Ultrasound-guided Celiac Plexus Neurolysis for Abdominal Pain in Patients With Unresectable Pancreatic Cancer: Network Meta-analysis of Randomized Controlled Trials

GOALS

We conducted a systematic review and network meta-analysis to investigate the effect of endoscopic ultrasound-guided celiac plexus neurolysis added to medical management (EUS-CPN+MM) compared with MM, percutaneous CPN (P-CPN)+MM, or intraoperative CPN (I-CPN)+MM for abdominal pain associated with unresectable pancreatic cancer.

BACKGROUND

Many approaches to CPN have been proposed since 1919. EUS-CPN, which is less invasive and safer than traditional procedures, has been preferred recently, but the superiority of EUS-CPN+MM has not been fully investigated.

STUDY

We performed searches of PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) on March 16, 2021. We conducted the network meta-analysis using a frequentist weighted least-squares approach. We used a random-effects model to synthesize the primary outcome, defined as the mean difference between treatment groups in standardized pain intensity scores at 4 and 12 weeks.

RESULTS

We selected 10 RCTs involving 662 individuals. At 4 weeks, the estimated mean difference between the EUS-CPN+MM and MM groups was -1.30 (95% CI: -2.19 to -0.41) in favor of EUS-CPN+MM, and that between the EUS-CPN+MM and P-CPN+MM groups was -0.88 (95% CI: -1.82 to 0.06). At 12 weeks, the estimated mean difference between the EUS-CPN+MM and MM groups was -2.58 (95% CI: -3.68 to -1.48), and that between the EUS-CPN+MM and P-CPN+MM groups was -2.44 (95% CI: -4.03 to -0.84), both in favor of EUS-CPN+MM.

CONCLUSIONS

The combination of EUS-CPN+MM was effective at 4 and 12 weeks, although the risk of bias in synthesized studies was generally high, necessitating careful interpretation.

Evolution of Pancreatic Endotherapy

In the last half century, endotherapy for pancreatic diseases has changed considerably. Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) were introduced initially as diagnostic tools, they quickly evolved into therapeutic tools for preventing and managing complications of pancreatitis. More recently, therapeutic endoscopy has shown potential in palliation and cure of pancreatic neoplasms. This article discusses the changing landscape of pancreatic endotherapy as therapeutic ERCP and EUS were introduced and because they have evolved to treat different diseases.

What can the Interventional Endoscopist Offer in the Management of Upper Gastrointestinal Malignancies?

The therapeutic possibilities of endoscopy have rapidly increased in the last decades and now allow organ-sparing treatment of early upper gastrointestinal malignancy as well as an increasing number of options for symptom palliation. This review contains an overview of the interventional endoscopic procedures in upper gastrointestinal malignancies. It describes endoscopic treatment of early oesophageal and gastric cancers, and the palliative options in managing dysphagia and gastric outlet obstruction. It also provides an overview of the therapeutic possibilities of biliary endoscopy, such as retrograde stenting and radiofrequency biliary ablation. Endoscopic ultrasound-guided therapeutic options are discussed, including biliary drainage, gastrojejunostomy and coeliac axis block. To aid in clinical decision making, the procedures are described in the context of their indication, efficacy, risks and limitations.

Early Interventional Treatments for Patients with Cancer Pain: A Narrative Review

Between 10% and 20% of patients with cancer-related pain cannot achieve adequate control following the three-step ladder guidelines by the World Health Organization. Therefore, a "fourth step", including interventional approaches, has been suggested for those cases. Systematic reviews support the early use of interventional procedures to treat refractory cancer pain, control symptoms and prevent opioid dose escalation. There is strong evidence of the efficacy of celiac plexus or splanchnic neurolysis, vertebroplasty, kyphoplasty and intrathecal drug delivery. Those procedures have been found to be associated with a decrease in the symptom burden and opioid consumption, improved quality of life, and suggested as having a potentially positive impact on survival. Several studies have recommended using specific interventional techniques at earlier stages, possibly even when opioid treatment is first being considered. Conversely, leaving these options as a last analgesic resource might not be advisable since the burden these procedures might impose on too ill patients is significant. The objective of this review was to collect the available evidence published on the use of interventional treatments for refractory cancer pain with a particular interest in comparing early versus late indications. The results of the search demonstrated a very low number and quality of articles particularly addressing this question. This scarce number of evidence precluded performing a systematic analysis. A detailed and narrative description of the potential benefits of integrating interventional techniques into clinical guidelines at the early stages of the disease is provided.

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.

Pharmacotherapeutic options for pancreatic ductal adenocarcinoma

INTRODUCTION

Pancreatic ductal adenocarcinoma (PDAC) is a lethal malignancy projected to be the 2^nd leading cause of cancer related death in the USA by 2030. This manuscript discusses current and evolving treatment approaches in patients with pancreatic cancer.

AREAS COVERED

PDAC is classified as: a) resectable, b) borderline resectable, c) unresectable (locally advanced and metastatic). The standard of care for patients who present with resectable pancreatic adenocarcinoma is six months of adjuvant modified (m) FOLFIRINOX, gemcitabine plus capecitabine, or single agent gemcitabine. For many reasons, there has been a paradigm shift to employing neoadjuvant chemotherapy. For resectable and borderline resectable patients, we generally start with systemic therapy and reevaluate resectability with subsequent scans specifically when the tumor is located in the head or body of the pancreas. Combined chemoradiation therapy can be employed in select patients. The standard of care for metastatic PDAC is FOLFIRINOX or gemcitabine and nab-paclitaxel. Germline and somatic genomic profiling should be obtained in all patients. Patients with a germline BRCA mutation can receive upfront gemcitabine and cisplatin.

EXPERT OPINION

Thorough understanding of molecular pathogenesis in PDAC has opened various therapeutic avenues. We remain optimistic that future treatment modalities such as targeted therapies, cellular therapies and immunotherapy will further improve survival in PDAC.

Computed tomography-guided single celiac plexus neurolysis analgesic efficacy and safety: a systematic review and meta-analysis

PURPOSE

To perform a systematic review and meta-analysis of published studies to evaluate the analgesic efficacy and safety of computed tomography (CT)-guided single celiac plexus neurolysis (CPN) with the injection of a neurolytic agent into the celiac plexus in one session (CT-guided single CPN).

METHODS

PubMed, the Cochrane Library, and Ichushi-Web were searched for English or Japanese articles published up to February 2022, which reported findings about patients who underwent CT-guided single CPN. The outcome measures assessed in the systematic review and meta-analysis were the pain measurement scales from 0 to 10 before and after the intervention and the rate of minor and major complications.

RESULTS

The pooled pain measurement scales at pre-intervention and 1- or 2-, 7-, 30-, 60-, 90-, and 180-day post-intervention was 6.72 (95% confidence interval [CI], 4.77-9.46, I² = 98%), 2.31 (95% CI 2.31-4.44, I² = 92%), 2.84 (95% CI 1.39-5.79, I² = 95%), 3.36 (95% CI 1.66-6.77, I² = 98%), 3.19 (95% CI 1.44-7.08, I² = 59%), 3.87 (95% CI 1.88-7.97, I² = 0%), and 3.40 (95% CI 3.02-3.83, I² = not applicable), respectively. The pooled minor complication rates of diarrhea, hypotension, nausea or vomiting, and pain associated with the procedure were 18% (95% CI 8-37%, I² = 45%), 16% (95% CI 2-58%, I² = 76%), 6% (95% CI 2-16%, I² = 1%), and 7% (95% CI 2-21%, I² = 17%), respectively. There was no major complication in the included studies.

CONCLUSION

CT-guided single CPN can be performed safely and provides immediate analgesic efficacy although the amount of heterogeneity is characterized as large. Further investigation of its long-term analgesic efficacy is required.

Celiac Plexus Neurolysis Is Associated With Decreased Survival in Patients With Pancreatic Cancer: A Propensity Score Analysis

OBJECTIVE

The aim of this study was to investigate survival in patients who received celiac plexus neurolysis (CPN) compared with patients who received opioids.

METHODS

The Surveillance, Epidemiology and End Results-Medicare database was used to identify patients older than 65 years diagnosed with pancreatic cancer between 2007 and 2015. We used claims data to identify patients with a history of CPN and opioid use within 1 year of diagnosis, and other demographic, clinical, and treatment variables. Kaplan-Meier analyses and inverse propensity-weighted adjusted Cox proportional hazard ratios were used to evaluate survival.

RESULTS

We identified 648 patients who underwent CPN (19.0%) compared with 2769 patients who received opioids (81.0%). The median survival and interquartile range for patients who received CPN was 4.0 months (2.0-8.0 months) compared with 7.0 months (3.0-12.0 months) for opioid users (P < 0.0001). After adjusting for confounders and propensity score, the patients who received CPN showed worsened survival (hazard ratio, 1.69; 95% confidence interval, 1.59-1.79).

CONCLUSIONS

Pancreatic cancer patients who underwent CPN had decreased survival compared with opioid users. This suggests that opioid sparing methods to reduce pancreatic cancer pain may actually be harmful. Future prospective studies should investigate whether other opioid sparing therapies impact pancreatic cancer survival.

Direct intraoperative versus percutaneous computed tomographyguided celiac plexus neurolysis in non-resectable pancreatic cancer: A randomized, controlled, non-inferiority study

BACKGROUND

Celiac plexus neurolysis (CPN) has been used to control pancreatic cancer (PC) pain, up to our knowledge, there is no study compared intraoperative CPN and computed tomography (CT)-guided techniques.

OBJECTIVES

To compare the effects of intraoperative and CT-guided CPN in unresectable PC on pain intensity and analgesic requirements.

METHODS

A total of 90 patients were enrolled in this prospective, randomized, open label, controlled, non-inferiority study, 20 patients were excluded or lost to follow up. The patients were randomly allocated to either intraoperative or CT-guided CPN group. A mixture of 20 mL ethanol 90%, 100 mg lignocaine and 5 mg dexamethasone was infused on each side of the aorta in both groups. Visual analogue score (VAS) and oral daily tramadol consumption were recorded at day 7, 14, 30, 60, 120 and 180 days after intervention. Occurrence of any intervention related complications were reported.

RESULTS

Median VAS was similar in both intraoperative and CT-guided CPN groups from day 7 up to 180 days after intervention. The median daily analgesic consumption of oral tramadol (mg) was comparable in both intraoperative and CT-guided CPN groups after intervention at day 7 (50 versus 50), day14 (50 versus 50), day 30 (50 versus 50), day 60 (50 versus 50), day 120 (100 versus 75) and day 180 (100 versus 100). The incidence of diarrhea, vomiting, hypotension and back pain was similar in both groups.

CONCLUSION

Intraoperative CPN is non-inferior to CT-guided CPN as both techniques were similarly associated with reduced pain severity and analgesics requirements.

CT-Guided Coeliac Plexus Neurolysis in Patients with Intra-Abdominal Malignancy: A Retrospective Evaluation of 52 Palliative In-Patients

INTRODUCTION

Prevalence rates of chronic abdominal pain (CAP) and breakthrough cancer pain (BTcP) are high in patients with intra-abdominal malignancies. As part of a multimodal approach, CT-guided coeliac plexus blockade (CPB) and CT-guided coeliac plexus neurolysis (CPN) are commonly used pain management strategies. The aim of this study was to evaluate pain outcomes among patients with intra-abdominal malignancies who underwent CPB and/or CPN.

METHODS

Patients with intra-abdominal malignancies who underwent CPB and/or CPN for pain control at the general hospital Klagenfurt am Wörthersee from 2010 to 2019 were enrolled.

RESULTS

A total of 84 procedures (24 CPB and 60 CPN) were performed on 52 patients; 62% of these patients had pancreatic cancer. CPN led to significant pain reduction and decreased BTcP intensity. Patients receiving repeated CPN showed higher individual pain reduction. Higher pre-procedural pain intensity was correlated with higher pain reduction. No difference in pain reduction in patients receiving a diagnostic CPB prior to CPN compared to patients without a diagnostic CPB was found. Higher pain reduction after CPN led to longer-lasting pain relief. The time frame from diagnosis to CPN was 472 (± 416) days. Patients experienced a mean duration of pain prior to CPN of 330 (± 53) days. The time frame from diagnosis to CPN was shorter in patients with pancreatic cancer compared to other intra-abdominal malignancies. In 58% of patients pain medication was stable or was reduced after CPN; 16% of patients complained about pain during the procedure; no major complications occurred. There was no correlation between median survival after CPN and pain outcomes.

CONCLUSIONS

In patients with intra-abdominal malignancy-related CAP, CPN is a safe and effective procedure which can provide long-lasting significant relief of background pain and BTcP. As part of a multimodal approach, CPN should be considered as an earlier option for pain management in these patients.

Endoscopic ultrasound-guided neurolysis in advanced pancreatic cancer: current status

Pancreatic cancer has a very poor prognosis with patients often presenting with locally advanced, inoperable or metastatic disease. A significant proportion of patients have visceral pain due to perineural infiltration or coeliac plexus involvement by the tumour. This pain is difficult to control and may become refractory to conventional pain management. Therefore, coeliac plexus neurolysis (CPN) has been proposed to ablate the neuronal transmission pathway of pain permanently. CPN is recommended for those who have uncontrolled pain, are experiencing unacceptable opioid adverse effects or are receiving escalating doses of analgesics. It is not known whether CPN performed at diagnosis as the first-line treatment ('early') would impact short-term and long-term pain control and quality of life. NICE has recommended (2018) a randomised trial comparing early endoscopic ultrasound-guided coeliac plexus neurolysis (EUS-CPN) with on-demand EUS-CPN in pancreatic cancer. In this context, we will review the current evidence on its clinical benefits.

Neurolytic Splanchnic Nerve Block and Pain Relief, Survival, and Quality of Life in Unresectable Pancreatic Cancer: A Randomized Controlled Trial

BACKGROUND

Neurolytic splanchnic nerve block is used to manage pancreatic cancer pain. However, its impact on survival and quality of life remains controversial. The authors' primary hypothesis was that pain relief would be better with a nerve block. Secondarily, they hypothesized that analgesic use, survival, and quality of life might be affected.

METHODS

This randomized, double-blind, parallel-armed trial was conducted in five Chinese centers. Eligible patients suffering from moderate to severe pain conditions were randomly assigned to receive splanchnic nerve block with either absolute alcohol (neurolysis) or normal saline (control). The primary outcome was pain relief measured on a visual analogue scale. Opioid consumption, survival, quality of life, and adverse effects were also documented. Analgesics were managed using a protocol common to all centers. Patients were followed up for 8 months or until death.

RESULTS

Ninety-six patients (48 for each group) were included in the analysis. Pain relief with neurolysis was greater for the first 3 months (largest at the first month; mean difference, 0.7 [95% CI, 0.3 to 1.0]; adjusted P < 0.001) compared with placebo injection. Opioid consumption with neurolysis was lower for the first 5 months (largest at the first month; mean difference, 95.8 [95% CI, 67.4 to 124.1]; adjusted P < 0.001) compared with placebo injection. There was a significant difference in survival (hazard ratio, 1.56 [95% CI, 1.03 to 2.35]; P = 0.036) between groups. A significant reduction in survival in neurolysis was found for stage IV patients (hazard ratio, 1.94 [95% CI, 1.29 to 2.93]; P = 0.001), but not for stage III patients (hazard ratio, 1.08 [95% CI, 0.59 to 1.97]; P = 0.809). No differences in quality of life were observed.

CONCLUSIONS

Neurolytic splanchnic nerve block appears to be an effective option for controlling pain and reducing opioid requirements in patients with unresectable pancreatic cancer.

EDITOR’S PERSPECTIVE

Direct intraoperative versus percutaneous computed tomographyguided celiac plexus neurolysis in non-resectable pancreatic cancer: A randomized, controlled, non-inferiority study

BACKGROUND

Celiac plexus neurolysis (CPN) has been used to control pancreatic cancer (PC) pain, up to our knowledge, there is no study compared intraoperative CPN and computed tomography (CT)-guided techniques.

OBJECTIVES

To compare the effects of intraoperative and CT-guided CPN in unresectable PC on pain intensity and analgesic requirements.

METHODS

A total of 90 patients were enrolled in this prospective, randomized, open label, controlled, non-inferiority study, 20 patients were excluded or lost to follow up. The patients were randomly allocated to either intraoperative or CT-guided CPN group. A mixture of 20ml ethanol 90%, 100mg lignocaine and 5mg dexamethasone was infused on each side of the aorta in both groups. Visual analogue score (VAS) and oral daily tramadol consumption were recorded at day 7, 14, 30, 60, 120 and 180 days after intervention. Occurrence of any intervention related complications were reported.

RESULTS

Median VAS was similar in both intraoperative and CT-guided CPN groups from day 7 up to 180 days after intervention. The median daily analgesic consumption of oral tramadol (mg) was comparable in both intraoperative and CT-guided CPN groups after intervention at day 7 (50 versus 50), day14 (50 versus 50), day 30 (50 versus 50), day 60 (50 versus 50), day 120 (100 versus 75) and day 180 (100 versus 100). The incidence of diarrhea, vomiting, hypotension and back pain was similar in both groups.

CONCLUSION

Intraoperative CPN is non-inferior to CT-guided CPN as both techniques were similarly associated with reduced pain severity and analgesics requirements.

Symptom Management in Pancreatic Cancer

OPINION STATEMENT

Despite extensive research that has identified new risk factors, genetic mutations, and therapeutic options, pancreatic ductal adenocarcinoma continues to be a leading cause of cancer related death. Patients with pancreatic cancer, along with their clinicians, must balance realistic hope alongside a life-threatening diagnosis. As the search for treatments to reduce the morbidity and mortality continues, symptom management and quality of life remain the focus of our efforts. In addition to side effects of cancer-directed therapy, patients are at risk for malnutrition, pain, and fatigue. These factors are often overlooked in practice, so a multidisciplinary team is critical in optimizing the care of patients.

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.

A retrospective case series of patients who have undergone coeliac plexus blocks for the purpose of alleviating pain due to intra-abdominal malignancy

BACKGROUND

Coeliac plexus block (CPB) is an interventional pain management option for patients with pancreatic or other upper abdominal malignancy.

AIMS

To assess the safety, utilization, and outcomes of CPBs in the local context.

METHODS AND RESULTS

We conducted a retrospective case series of all patients with cancer who underwent CPB at 4 Sydney teaching hospitals from March 2010 to February 2016. We recorded baseline demographic data, details of the injectate, procedural approach and survival, as well as pain scores and analgesic use at 4 time points of interest. Thirty-nine procedures were performed during the study period. Twenty-four were performed endoscopically, 14 were performed via a bilateral percutaneous posterior approach by Pain Specialists or Radiologists and 1 was performed intraoperatively by a Surgeon. Patients had experienced pain for a mean of 17 weeks prior to CPB. Prior to CPB, the mean pain score was 8.8 out of 10. The mean pain score was reduced at 48 hours, 2 weeks, and 4 weeks following CPB (P < .01). The mean oral morphine equivalent daily dose prior to CPB was 362 mg which was reduced at 48 hours and 2 weeks but increased at the 4 weeks following CPB. One patient developed a bacteremia but otherwise no complications were observed.

CONCLUSION

CPB is performed by a number of approaches and is well tolerated. The approach selected appears to depend on patient anatomy, preference, and availability of local expertise. Local clinicians could consider CPB earlier in the management of malignant epigastric pain.

A Comprehensive Review of the Celiac Plexus Block for the Management of Chronic Abdominal Pain

PURPOSE OF REVIEW

Chronic abdominal pain (CAP) is a significant health problem that can dramatically affect quality of life and survival. Pancreatic cancer is recognized as one of the most painful malignancies with 70-80% suffering from substantial pain, often unresponsive to typical medical management. Celiac plexus neurolysis and celiac plexus block (CPB) can be performed to mitigate pain through direct destruction or blockade of visceral afferent nerves. The objective of this manuscript is to provide a comprehensive review of the CPB as it pertains to CAP with a focus on the associated anatomy, indications, techniques, neurolysis/blocking agents, and complications observed in patients who undergo CPB for the treatment of CAP.

RECENT FINDINGS

The CAP is difficult to manage due to lack of precision in diagnosis and limited evidence from available treatments. CAP can arise from both benign and malignant causes. Treatment options include pharmacologic, interventional, and biopsychosocial treatments. Opioid therapy is typically utilized for the treatment of CAP; however, opioid therapy is associated with multiple complications. CPB has successfully been used to treat a variety of conditions resulting in CAP. The majority of the literature specifically related to CPB is surrounding chronic pain associated with pancreatic cancer. The literature shows emerging evidence in managing CAP with CPB, specifically in pancreatic cancer. This review provides multiple aspects of CAP and CPB, including anatomy, medical necessity, indications, technical considerations, available evidence, and finally complications related to the management.

Celiac plexus block increases quality of life in patients with pancreatic cancer

Background

Pancreatic cancer is a malignant disease with a high mortality rate and severe pain that is challenging to manage. To reduce the excruciating abdominal pain, opioids and adjuvant agents are conventionally used.

Objectives

PRNCPB is a treatment of neural therapy. The number of studies assessing the effect on patients' QoL is limited and inconsistent. With this study, we intended to address this issue.

Study design

A prospective nonrandomized study with a series of cases of unresectable pancreatic cancer was conducted.

Setting

The study was performed at our pain clinic under real life conditions.

Materials and methods

A total number of 16 patients with severe abdominal pain were enrolled in the study all of whom had responded to combined systemic analgesic therapy inadequately and had intolerable side effects contraindicating further increase in dose. The efficacy of this invasive, palliative analgesic procedure was evaluated 35 days after PRNCPB was performed. Primary outcomes were changed in pain intensity using the VAS questionnaire. Secondary outcomes were improved in QoL using the SF-36 questionnaire. Changes in pain medications and adverse reactions were monitored.

Results

After PRNCPB patients experienced a significant decrease (P=0.002) in pain intensity as shown by the VAS score, and a decreased opiate demand. Their QoL scores considering effect sizes also improved (P<0.001). No complications attributable to PRNCPB were observed during the study period. Additionally, no adverse drug reactions were observed.

Limitations

Detection, observation, and reporting bias can be estimated as moderate. Selection bias was not detected.

Conclusion

Our results give preliminary evidence that PRNCPB might be helpful as an additional treatment to conventional pain management in end-stage pancreatic cancer patients. PRNCPB seems to improve QoL in these patients in a time frame of at least 5 weeks after intervention.

Effect of Early Management on Pain and Depression in Patients with Pancreatobiliary Cancer: A Randomized Clinical Trial

Background: The present study assessed whether early palliative care (EPC) targeting pain and depression and automated symptom monitoring could improve symptoms in patients with advanced pancreatobiliary cancer. Methods: Patients diagnosed with pathologically confirmed locally advanced or metastatic pancreatic or biliary tract cancer who had cancer-related pain (brief pain inventory (BPI) worst pain score >3) and/or depression (Center for Epidemiological Studies-Depression Scale (CES-D) >16) were randomized within 8 weeks after diagnosis to receive EPC or on-demand palliative care (n = 144 each). EPC included (1) nursing assessment of pain and depression, (2) pain control based on National Comprehensive Cancer Network guidelines, (3) depression control by psychoeducation and/or consultation with a psychiatric specialist, and (4) patient education. The primary end points were ≥50% reductions from baseline to week 4 in pain and depression scores. Results: The proportion of patients in the EPC and usual care groups with ≥50% reductions in pain (29.5% vs. 25.2%; p = 0.4194) and depression (30.8% vs. 36.8%; p = 0.5732) scores from baseline to week 4 did not differ significantly. The proportion of patients with BPI worst pain score ≤3 was significantly higher (51.1% vs. 38.9%, p = 0.0404) and the reduction in pain intensity score significantly greater (1.5 vs. 1.0 points, p = 0.0318) in the EPC than in the usual care group. At 4 weeks, patients in the EPC group reported significant increases in global health status, role of functioning, nausea and vomiting, and pain scores on the European Organization for Research and Treatment of Cancer Core Quality of Life questionnaire (EORTC QLQ-C30) general questionnaire. Conclusions: Although the primary outcome was not met, this trial indicates that EPC may improve early pain relief in patients with advanced pancreatobiliary cancers.

Management and supportive treatment of frail patients with metastatic pancreatic cancer

Data regarding management of frail patients with pancreatic ductal adenocarcinoma practice is currently very scarce. Randomized clinical trials usually exclude these subgroup of patients and the majority of the publications only consider chronological age and ECOG performance status for their classification. Therefore, the current available data do not reflect daily clinical practice. Only data from a phase two study (FRAGANCE study), designed to select a tolerable dose-schedule of nab-placitaxel + gemcitabine (Phase one) and to evaluate the efficacy of the selected regimen (Phase two) in patients with ECOG-2 and previously untreated advanced PDAC, are currently available. Management of these particular patients is exceedingly complex and requires collaboration of multidisciplinary teams and intensive support treatment. This article reviews the literature available regarding the management of the so-called frail patients and provide guidance for chemotherapy as well as supportive care treatments.

Laparoscopic versus open approach to neurolytic celiac plexus block in inoperable pancreatic cancer

BACKGROUND

Neurolytic celiac plexus block (NCPB) is an effective method of palliative pain control. The purpose of this study was to evaluate the feasibility and effectiveness of the laparoscopic NCPB versus open approach.

METHODS

Eight patients (Group A) underwent diagnostic laparoscopy which revealed an inoperable pancreatic cancer. Forty millilitres of solution (20 mL of 95% ethanol mixed with 20 mL of xylocaine) was injected into either side of para-aortic soft tissue. The same solution was injected in 10 patients (Group B), with inoperable pancreatic body cancer diagnosed during laparotomy.

RESULTS

There were no intraoperative or post-operative, NCPB related, complications. Patients in both groups, reported significant pain relief in the early post-operative period. Using the visual analogue scale preoperatively, in second post-operative day, first and third post-operative month, no significant different was observed between the two groups. The mean hospital stay in both groups was 2.1 versus 5.2 (P = 0.0005) and the mean survival 8.1 versus 7.9 months (ns).

CONCLUSIONS

The NCPB is feasible method for palliation in inoperable pancreatic cancer. Laparoscopic NCPB gives excellent results and could still be considered in selected cases, as an effective alternative during staging laparoscopy.

Onsite evaluation of endoscopic ultrasound fine needle aspiration: the endosonographer, the cytotechnologist and the cytopathologist

Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) has become an essential tool in the management of multiple diseases. Its accuracy is related to different aspects of the technique, one of the most important being the experience and interaction of the endosonographer and pathologist. Certain studies over the past years have highlighted the importance of having rapid on-site evaluation (ROSE) of samples obtained at the time of EUS-FNA. We have reviewed the role of ROSE, performed by the same endosonographer, a cytotechnologist and an expert cytopathologist. The available data suggest that ROSE (either by the endosonographer, the cytotechnologist, or the cytopathologist) improves sample adequacy and diagnostic yield, with the best option to have ROSE performed by an expert cytopathologist. However, if non-ROSE accuracy is already very high, any improvement is harder to achieve.

SEOM clinical guideline for treatment of cancer pain (2017)

Pain is a highly prevalent symptom in patients with cancer. Despite therapeutic advances and well-accepted treatment guidelines, a percentage of patients with pain are under-treated. Currently, it has been recognized that several barriers in pain management still exist and, in addition, there are new challenges surrounding complex subtypes of pain, such as breakthrough and neuropathic pain, requiring further reviews and recommendations. This is an update of the guide our society previously published and represents the continued commitment of SEOM to move forward and improve supportive care of cancer patients.

[Recommendations for the diagnosis, staging and treatment of pre-malignant lesions and pancreatic adenocarcinoma]

BACKGROUND AND OBJECTIVE

Clinical management of adenocarcinoma of the pancreas is complex, and requires a multidisciplinary approach. The same applies for the premalignant lesions that are increasingly being diagnosed. The current document is an update on the diagnosis and management of premalignant lesions and adenocarcinoma of the pancreas.

PATIENTS AND METHODS

A conference to establish the basis of the literature review and manuscript redaction was organized by the Grupo Español Multidisciplinar en Cáncer Digestivo. Experts in the field from different specialties (Gastroenterology, Surgery, Radiology, Pathology, Medical Oncology and Radiation Oncology) met to prepare the present document.

RESULTS

The current literature was reviewed and discussed, with subsequent deliberation on the evidence.

CONCLUSIONS

Final recommendations were established in view of all the above.

Pain Outcomes in Patients Undergoing CT-Guided Celiac Plexus Neurolysis for Intractable Abdominal Visceral Pain

The purpose of this study was to assess outcomes in patients who have undergone celiac plexus neurolysis (CPN) as treatment for refractory abdominal visceral pain at a tertiary care medical center. This study involved retrospective analysis of all patients who had undergone computed tomography (CT)-guided CPN over a 7-year period, as identified in the medical record. Cases were categorized into 1 of 3 groups-group 1: patients getting at least moderate improvement in pain but with improvements subsiding within 2 days; group 2: patients with some sustained pain relief but still requiring heavy doses of narcotics; group 3: patients with major or complete sustained reduction in pain where the narcotic dose was able to be reduced. One hundred thirty-eight cases were identified, 51 of which had no or insufficient follow-up, leaving 87 cases for analysis. Of the 87 cases, 31 (36%) were categorized as group 1, 21 (24%) as group 2, and 35 (40%) as group 3. There were no statistical differences in outcomes based on patient age, gender, time since diagnosis, or type of cancer. Documented postoperative complications were diarrhea (11 cases) and 1 case each of obtundation, hypotension, and presyncopal event. We conclude that patients undergoing CT-guided CPN for abdominal visceral pain achieve moderate or major short-term pain relief in a majority of cases. The procedure is safe with minimal complications.

A New Perspective of Neuromyopathy to Explain Intractable Pancreatic Cancer Pains; Dry Needling as an Effective Adjunct to Neurolytic Blocks

We present a new perspective of neuromyopathy in pancreatic cancer pain (PCP) referral to bodywall; proposal of new rationale to include ultrasound guided dry needling (USGDN) of body wall muscles as an effective adjunct to neurolytic coeliac plexus block (NCPB) or splanchnic nerve radiofrequency ablation (SRF) for comprehensive interventional management. Methods: PCP response to SRF in 2 patients and NCPB in 3 patients was documented on numerical rating scale (NRS) on post procedure days 3 and 15. If the residual pain was >5 NRS on day 15, USGDN of abdominal and back muscles was started on a thrice weekly basis. The response to USGDN documented on day 30 after approximately 6 sessions of DN, showed a significant pain reduction (0-2 NRS) with 50% reduction of pre-treatment opioid consumption. This was sustained at 6 months or till their demise. Convergence of visceral and somatic nerves at the dorsal horn (viscerosomatic neurons) causes referral of visceral pain to the back and abdominal muscles. This leads to formation of myofascial trigger points (MTrPs) in the muscles which sets up a parallel network of sensitized peripheral and central motor nociceptive processing (neuromyopathy). USGDN specifically addressed the MTrPs that develop as an epiphenomenon of self-perpetuating neuromyopathy while SRF/NCPB, analgesics and neuromodulators could address only visceral nociceptive afferents (pain mediated through celiac plexus) which forms a meagre 10% of the total spinal cord afferent input. Thus, we conclude that combination of neuromyopathy and viscerosomatic convergence in PCP indicate a specific role for DN as an adjunct to SRF/NCPB in our patients

Management of pancreatic cancer in the elderly

Currently, pancreatic adenocarcinoma mainly occurs after 60 years of age, and its prognosis remains poor despite modest improvements in recent decades. The aging of the population will result in a rise in the incidence of pancreatic adenocarcinoma within the next years. Thus, the management of pancreatic cancer in the elderly population is gaining increasing relevance. Older cancer patients represent a heterogeneous group with different biological, functional and psychosocial characteristics that can modify the usual management of this disease, including pharmacokinetic and pharmacodynamic changes, polypharmacy, performance status, comorbidities and organ dysfunction. However, the biological age, not the chronological age, of the patient should be the limiting factor in determining the most appropriate treatment for these patients. Unfortunately, despite the increased incidence of this pathology in older patients, there is an underrepresentation of these patients in clinical trials, and the management of older patients is thus determined by extrapolation from the results of studies performed in younger patients. In this review, the special characteristics of the elderly, the multidisciplinary management of localized and advanced ductal adenocarcinoma of the pancreas and the most recent advances in the management of this condition will be discussed, focusing on surgery, chemotherapy, radiation and palliative care.

Diagnosis, Preoperative Evaluation, and Assessment of Resectability of Pancreatic and Periampullary Cancer

Periampullary region encircles a radius of 2 cm around the ampulla of Vater; accordingly, four distinct neoplasias with overlapping imaging features originate in the region. Each of these lesions has a different long-term prognosis; hence, imaging evaluation to characterize the lesion is important. Further certain specific features pertaining to the vascular invasion and systemic spread may decide about the treatment as well as surgical approach. An understanding of the advances in imaging and image processing technology as well as in the methods of image acquisition, for the purpose, is quite relevant towards etching out a rational pre-treatment evaluation protocol. Further, an evidence-based decision as to the choice of optimum modality for answering specific clinical question is of prime importance in achieving a reasonable post-treatment outcome. Pancreatic adenocarcinoma is the fourth most common cancer and a malignancy with one of the least 5-year survival rates (ranging from 6.8 to 15 % depending on peripancreatic extensions, dropping to 1.8 % for metastatic disease). A survival rate of 15-27 % can be achieved if the lesion is resectable but unfortunately, only 10-15 % of patients are eligible for resection. Cystic tumors of pancreas are a rarer variety of pancreatic neoplasia (5-15 % of pancreatic cysts and 1 % of all pancreatic cancers) which have a much better outcome and chances of resection. Being mostly incidentalomas, a timely differentiation of this lesion from the much more common pseudocyst (which would mandate a medical management and a different surgical protocol) is the key for curability. Lastly, the neuroendocrine tumors of pancreas are equally rare (1 % of all pancreatic tumors), but importantly due to associated clinical syndromes and their capability to metastasize early in the course of disease, a timely detection may hence be the key for successful treatment of these lesions. Imaging plays a vital role in the initial detection and characterization as well as in determination of resectability of each of these pancreatic neoplasias. Further, the differentiation of pancreatic head tumors from other periampullary neoplasias is important; the fact that most recurrences are as a result of surgical intervention in an otherwise inoperable disease while most treatment failures are due to improper characterization of the lesion is notable.