[Celiac trunk compression syndrome associated with primary mitral valve prolapse]

A prospective study included 106 patients with celiac trunk compression syndrome (CTCS). Duplex scanning of the celiac trunk and superior mesenteric artery and echocardiography were performed during their examination. The investigation revealed primary mitral valve prolapse (PMVP) in 78 (74%) patients. Operations of decompression of the celiac trunk were made on 101 patients. After operation the symptoms (neurovegetative included) were found to disappear. No authentic distinctions were revealed in the clinical semiology and postoperative course of patients with CTCS and with a combination of CTCS and PMVP.

Celiac Plexus Block: A New Technique Using the Left Lateral Approach

We describe a new celiac plexus block approach in a patient with cholangiocarcinoma who was referred to the Pain Clinic due to uncontrollable abdominal pain. The patient was initially programmed for a neurolytic celiac plexus block using the anterior approach with helical computerized tomography (CT) guidance. The CT scan revealed interposition of the transverse colon in the anterior approach territory, which made the anterior approach technique difficult, and also difficulty to practice the posterior approach without injuring the kidneys. We decided to attempt a left lateral atypical approach because the CT revealed the possibility of using a left lateral window to arrive to the celiac area. The left lateral access allowed us to carry out the neurolytic block using 50% alcohol without injuring any viscera. The patient tolerated the technique and was discharged without pain. No complications regarding either the punction or the block were observed.

Role of endoscopic ultrasound in diagnosis and therapy of pancreatic adenocarcinoma

Since its advent more than 20 years ago, endoscopic ultrasound (EUS) has undergone evolution from an experimental to a diagnostic instrument and is now established as a therapeutic tool for endoscopists. Endoscopic ultrasound cannot accurately distinguish benign from malignant changes in the primary lesion or lymph node on imaging alone. With the introduction of the curved linear array echoendoscope in the 1990s, the indications for EUS have expanded. The curved linear array echoendoscope enables the visualization of a needle as it exits from the biopsy channel in the same plane of ultrasound imaging in real time. This allows the endoscopist to perform a whole range of interventional applications ranging from fine needle aspiration (FNA) of lesions surrounding the gastrointestinal tract to celiac plexus block and drainage of pancreatic pseudocyst. This article reviews the current role of EUS and EUS-FNA in diagnosis, staging and interventional application of solid pancreatic cancer.

Endoscopic ultrasonography guided celiac plexus neurolysis and celiac plexus block in the management of pain due to pancreatic cancer and chronic pancreatitis

Pain is a common symptom of pancreatic disease and is frequently difficult to manage. Pain relief provided by narcotics is often suboptimal and is associated with significant side effects. An alternative approach to pain management in pancreatic disease is the use of celiac plexus block (CPB) or neurolysis (CPN). Originally performed by anesthesiologists and radiologists via a posterior approach, recent advances in endoscopic ultrasonography (EUS) have made this technique an attractive alternative. EUS guided celiac plexus block/neurolysis is simple to perform and avoids serious complications such as paraplegia or pneumothorax that are associated with the posterior approach. EUS guided CPN should be considered first line therapy in patients with pain due to pancreatic cancer. It provides superior pain control compared to traditional management with narcotics. A trend for improved survival in pancreatic cancer patients treated with CPN has been reported, but larger studies are needed to confirm this finding. At this time, the use of EUS guided CPB cannot be recommended as routine therapy for pain in chronic pancreatitis since only one-half of the patients experience pain reduction and the beneficial effect tends to be short lived. EUS guided CPB and CPN should be used as part of a multidisciplinary team approach for pain management.

[A case of intractable chronic abdominal pain caused by hepatomegaly associated with primary amyloidosis, successfully treated with celiac plexus block]

A 51-year-old female previously diagnosed as primary amyloidosis suffered from recurrent abdominal pain. The result of thorough examination indicated that the main cause of the pain was severe hepatomegaly. Continuous venous administration of narcotics and other alternative therapies did not provide symptomatic relief, and thus the patient was treated with celiac plexus block, which resulted in effective pain control and improved ADL level. Though the procedure of celiac plexus block is simple and celiac plexus block is applicable without causing severe complication, it is not widely used. From this case, it is considered that celiac plexus block is one of the most effective means to relieve intractable pain associated with both benign malady and abdominal malignant tumor.

Celiac plexus block with the long stylet needle technique

Neurolytic celiac plexus block has been used successfully in the treatment of patients with intractable intra-abdominal pain due to malignancy or to benign pain syndromes. A new technique is described here for blocking the celiac plexus through the retrocrural approach with a special long stylet needle inserted under fluoroscopic guidance. Celiac blocks were performed in 2 groups of patients. In the first group (n=7), the classic technique was performed with the use of 2 needles; in the second group (n=5), 1 needle and 2 stylets were used to complete the block through the long guided needle approach. Parameters evaluated in each group consisted of the number of attempts, defined as the number of skin punctures, and fluoroscopy injection time, defined as time from the beginning of fluoroscopy to completion of successful needle insertion into the celiac area. Patients who had abdominal pain resulting from pancreatic cancer underwent celiac plexus block performed by the long guided needle technique. In the classic technique group, fluoroscopy injection time was 13+/-3 min and the number of attempts was 5.3+/-3; values in the long guided needle group were 8.9+/-3 min and 4.9+/-2, respectively. The difference in fluoroscopy injection times was significant (P<.05). The long guided needle technique for celiac plexus block may be an effective and appropriate method for beginners or for practitioners who are not knowledgeable about imaging techniques used in various medical specialties.

Combined neurolytic block of celiac, inferior mesenteric, and superior hypogastric plexuses for incapacitating abdominal and/or pelvic cancer pain

Thirty-five patients with extensive abdominal or pelvic cancer who suffered uncontrolled, diffuse, extensive, and incapacitating pain were treated with a combination of neurolytic celiac plexus block (CPB), inferior mesenteric plexus block (IMPB), and superior hypogastric plexus block (SHGPB). The combination of neurolytic CPB, IMPB, and SHGPB was performed with alcohol, mainly using a transintervetebral disc approach. The combination neurolysis produced effective immediate pain relief in all the patients (visual analog scale (VAS), reduced from 8.8 +/- 0.2 to 0). This pain relief persisted during the first 3 months (VAS, 2.3 +/- 0.5) or until death. Morphine consumption was significantly decreased for the first 1 month (from 96 +/- 29 mg to 31 +/- 10 mg per day) after the neurolysis and thereafter continued to be lower than before the surgery, though not significantly so. No serious complications were observed to have been caused by the neurolytic procedure on the three sympathetic plexuses. Our preliminary clinical results suggest that the combination of neurolytic CPB, IMPB, and SHGPB improves the quality of life of patients who have incapacitating cancer pain, by reducing both the intensity of the pain and their opioid consumption, without serious complications. This combination procedure may provide a new therapeutic option for pain relief in patients with advanced cancer.

EUS-guided celiac block and neurolysis

Abdominal pain related to pancreatic cancer or chronic pancreatitis can be a disabling and difficult symptom to treat for patients, their families, and physicians. Pharmacologic therapy with nonsteroidal anti-inflammatory drugs is usually ineffective. Opiate analgesics may not be well tolerated and can lead to dependence. Endoscopic ultrasound-guided celiac plexus block offers a potential adjunct treatment for pain control.

Ultrasonography of the pancreas. 6. Endoscopic imaging

EUS is a high-resolution technique for pancreatic imaging. EUS has applictions in detecting and staging pancreatic tumors, EUS guided FNA of the pancreas for tissue diagnosis, and evaluation of chronic pancreatitis as well as EUS guided therapy such as celiac plexus block. This is a review of EUS imaging (EUS) of the pancreas covering technical aspects, clinical indications, advantages, and pitfalls as well as emerging trends in the field.

Percutaneous-guided pain control: exploiting the neural basis of pain sensation

The gastroenterologist deals frequently with painful conditions and suffering patients. Performing regular pain assessments and applying basic pain medicine principles will augment the care of patients in pain. Percutaneous-guided pain therapy techniques play a role in the multidisciplinary approach to pain medicine. Systemic opioid analgesia is the primary means of controlling cancer pain. However, 10% to 15% of cancer patients may need additional interventions to control pain. Sympathetic ganglion nerve blocks with neurolytic agents such as alcohol or phenol are reserved mostly for cancer pain. The efficacy and safety of these tools are validated by several decades of clinical application and published studies. Although the procedures are operator-dependent, in the hands of experienced clinicians, patients achieve sustained relief in the majority of cases. Although these techniques have been attempted in some benign conditions,such as chronic pancreatitis, with limited success, studies of newer imaging localization techniques such as endoscopic ultrasonography may expand future indications. Patients of the gastroenterologist who experience malignant abdominal pain may benefit from referral for percutaneous-guided pain control techniques.

Celiac plexus block for visceral pain

Celiac plexus block has long been used to provide analgesia for upper abdominal pain. In particular, neurolytic celiac plexus block has been advocated for pancreatic cancer pain. In this article, recent advances clarifying the role and limitations of neurolytic celiac plexus block are reviewed. Neurolytic celiac plexus block provides persistent augmented analgesia when used as an adjunct to systemic opiates, but does not reliably decrease opiate requirements. In addition, neurolytic celiac plexus block may prolong survival, but the data supporting this remain controversial. The optimal technique for accomplishing neurolytic celiac plexus block remains undetermined.

Radiation therapy, bypass operation and celiac plexus block in patients with unresectable locally advanced pancreatic cancer

BACKGROUND/AIMS

The great majority of pancreatic cancers are unresectable due to local invasion and/or distant metastasis. The treatment options for such patients include bypass operation, celiac plexus block, radiation therapy (RT), chemotherapy and immunotherapy. RT is divided into intraoperative radiation therapy (IORT) and external radiation therapy (ERT). Appropriate palliative treatment remains controversial.

METHODOLOGY

Our experience with palliative treatments including bypass operation, celiac plexus block and RT (IORT and ERT) was retrospectively reviewed in 31 Japanese patients with unresectable locally advanced pancreatic cancer. The 31 patients consisted of seven with no RT, six with ERT alone, seven with IORT alone and 11 with both IORT and ERT. Gastrojejunostomy was performed in 25 patients and biliary bypass was done in 29 patients for the therapeutic or prophylactic purpose.

RESULTS

No patients developed gastroduodenal obstruction or jaundice until death. Imaging findings after the treatment showed a decrease in tumor size in 11 of the 18 patients examined, an increase in four and no change in the other three. Of 19 patients complaining of back pain before the operation, the pain had disappeared in 12 but persisted in the other seven after the operation. No patients developed back pain after the treatment. Of the 12 patients with pain relief, nine had both RT and celiac plexus block, two RT alone and the other neither RT nor celiac block. Cumulative 0.5-year and 1.0-year survival rates in the group with RT(-), ERT alone, IORT alone IORT and ERT and IORT were 42.9%, 100%, 100%, 100% and 0%, 33.3%, 57.1% and 45.5%, respectively. The survival curve of the RT(-) group was significantly worse than that of the ERT alone group (P = 0.0029), IORT alone group (P = 0.0101) and IORT and ERT group (P = 0.0109). The survival curves of the three RT groups were similar.

CONCLUSIONS

RT significantly prolonged survival of patients with unresectable locally advanced pancreatic cancer and combined palliative treatments including bypass operation, celiac plexus block and RT (ERT or IORT) are recommended for such patients.

Pancreas head carcinoma: frequency of invasion to soft tissue adherent to the superior mesenteric artery

Despite radical extension of surgical procedures, the cure rate of pancreatic head carcinoma patients still remains low. A cause of this concerns unsuccessful locoregional control, which may originate from a positive surgical margin near the superior mesenteric artery (SMA). However, no studies have examined invasion of pancreatic carcinoma around the SMA. En bloc resection of the head of the pancreas and the superior mesenteric vessels was performed on 6 patients who had pancreatic head carcinoma invading the superior mesenteric vein. The specimens were cut perpendicular to the SMA and consecutive serial sections were made. The slices were stained with hematoxylin and eosin or immunohistochemistry for cytokeratin 19 to easily detect carcinoma tissue under a microscope. Nodal metastasis around the SMAs was found in all of the cases. There were no characteristics of the arrangement of the metastatic nodes along the SMA. Lymphatic emboli were often observed close to the metastatic nodes. Neural invasions were detected around the tumors in every case and were continuously connected with the extrapancreatic nerve plexus. The nerve plexus covering the SMA were involved in 4 cases. Involvement was observed mainly behind the SMA, reaching as far as the left side of the SMA in 3 cases. The invasion extended further upwards along the right side of SMA for the celiac nerve plexus. The lymphatics and the nerve plexus in the area around the SMA were frequently involved by pancreatic head carcinoma. This involvement would have been left behind unless the SMA was resected.

Thermoablation of Liver Metastases: Efficacy of Temporary Celiac Plexus Block

PURPOSE

To determine the efficacy of celiac plexus block during thermoablation of liver metastases.

METHODS

Fifty-five consecutive patients underwent thermoablation therapy of liver tumors by laser-induced thermotherapy. Twenty-nine patients received a temporary celiac plexus block, 26 patients acted as control group. In both groups fentanyl and midazolam were administered intravenously upon request of the patient. The duration of the intervention, consumption of opiates, and individual pain sensations were documented.

RESULTS

No complications resulting from the celiac plexus block were recorded. Celiac plexus block significantly reduced the amount of pain medication used during thermoablation therapy of liver tumors (with block, 2.45 mug fentanyl per kg body weight; without block, 3.58 mug fentanyl per kg body weight, p < 0.05; midazolam consumption was not reduced) in patients with metastases < or = 5 mm from the liver capsule. For metastases farther away from the capsule no significant differences in opiate consumption were seen. Celiac plexus block reduced the time for thermoablation significantly (178 min versus 147 min, p < 0.05) no matter how far the metastases were from the liver capsule. Average time needed to set the block was 12 min (range 9-15 min); additional costs for the block were marginal. As expected (as pain medications were given according to individual patients' needs) pain indices did not differ significantly between the two groups.

CONCLUSION

In patients with liver metastases < or = 5 mm from the liver capsule, celiac plexus block reduces the amount of opiates necessary, simplifying patient monitoring. In addition celiac plexus block reduces intervention time, with positive effects on overall workflow for all patients.

Palliative gastroenterology

Continuous improvements in endoscopic imaging and accessories have opened up a field of interventional endoscopy. This highly technical offshoot of gastroenterology uses not just standard endoscopic techniques but also newer endoscopic ultrasound (EUS) imaging or fluoroscopic monitoring to facilitate procedures that were once performed either surgically or percutaneously, if at all. This review will update the role of these novel procedures that can be used to assist in the palliative care of patients whose malignancies involve the gastrointestinal tract. The emphasis will be on those palliative interventions that are used to overcome intestinal obstruction in the gastrointestinal tract and restore luminal patency. The role of EUS-guided celiac plexus neurolysis to assist in pain control, especially in patients with pancreatic malignancies, will also be detailed.

Efficacy of coeliac plexus and splanchnic nerve blockades in body and tail located pancreatic cancer pain

Palliative treatment, pain therapy and quality of life (QOL) are very important in pancreatic cancer patients. We evaluated the pain relieving efficacy, side effects and effects on QOL of neurolytic coeliac plexus blockade (NCPB) and splanchnic nerves neurolytic blockade (SNB) in body and tail located pancreatic cancer. The study protocol was approved by the local ethics committee. Patients were randomly divided into two groups. Coeliac group; GC, N = 19 were treated with coeliac plexus blockade, whereas the patients in splanchnic group; GS, N = 20 were treated with bilateral splanchnic nerve blockade. The VAS values, opioid consumption and QOL (Patient satisfaction scale=PSS, performance status scale=PS) were evaluated prior to the procedure and at 2 weeks intervals after the procedure with the survival rates. The demographic features were found to be similar. The VAS differences (difference of every control's value with baseline value) in GS were significantly higher than the VAS differences in GC on every control meaning that VAS values in GS decreased more than the VAS values in GC. GS patients were found to decrease the opioid consumption significantly more than GC till the 6th control. GS patients had significant improvement in PS values at the first control. The mean survival rate was found to be significantly lower in GC. Two patients had severe pain during injection in GC and 5 patients had intractable diarrhoea in GC. Comparing the ease, pain relieving efficacy, QOL-effects of the methods, splanchnic nerve blocks may be an alternative to coeliac plexus blockade in patients with advanced body and tail located pancreatic cancer.

Neurolytic celiac plexus block: a better alternative to opioid treatment in upper abdominal malignancies: an Indian experience

The majority of patients with advanced upper abdominal malignancies suffer from moderate to severe pain due to unavailability of morphine in developing world. This study was undertaken to evaluate the role of neurolytic celiac plexus block on pain and quality of life in this patient subpopulation. One hundred consecutive patients receiving opioids for their pain relief were divided in two groups. Group I (control) patients received oral morphine & NSAIDS and group II (study) patients underwent neurolytic celiac plexus block (NCPB) to compare their effects on pain relief, morphine consumption, quality of life (QOL), Karnofsky and performance scores up to one month. NCPB provided statistically significant better pain relief and reduced morphine consumption at one month (P = 0.000). Superior Karnofsky and performance scores also favored NCPB group (P = 0.000); however the difference in overall QOL was not statistically significant (P = 0.24). Patients in oral morphine group had more side effects (94% vs. 58%) as compared to NCPB (P = 0.000). NCPB is an effective tool to reduce opioid requirement and the drug-related adverse effects. It is a rewarding technique, especially when morphine availability and its easy accessibility to the deserving patient is poor.

[Aneurysms of the pancreaticoduodenal artery in association with stenosis or occlusion of the celiac trunk]

On the basis of an analysis of 69 patients including 2 personal observations the authors discuss the questions of pathogenesis, clinical picture, diagnosis and treatment of aneurysms of the pancreaticoduodenal artery in association with stenosis or occlusion of the celiac trunk (CT). A description of 2 cases with a true not broken aneurysms of the inferior pancreaticoduodenal artery and subocclusion of the celiac trunk is given which was caused by compression of the latter by the median arcuate ligament of the diaphragm and neurofibrous tissue of the celiac plexus. These patients were detected as a result of examinations and operative treatment of 556 patients with compressive stenosis of the celiac trunk for the period from 1982 through 2002. In one case a transcatheter embolization of the aneurysm was fulfilled followed in 3 months by a compression of the celiac trunk, in the other case a compression of the celiac trunk was made first and then in 5 months it was followed by resection of the aneurysm with a favorable outcome.

Celiac ganglion block

The percutaneus blockade of the celiac plexus is being performed nearly for a century. The aim of performing celiac plexus and splancnic nerve blocks was surgical anesthesia at the beginning. But because of the technical demands and variable results of celiac plexus and splanchnic nerve blocks as a surgical anesthetic, over time, these techniques were supplanted by spinal anesthesia and segmental blockade of the somatic paravertebral nerves. As celiac plexus and splanchnic nerve blocks were falling into disuse for surgical anesthesia, the clinical utility of these techniques was becoming apparent in the new specialty of pain management. Celiac plexus and splancnic nerve blocks are effective in relieving chronic abdominal pain, especially originating from the malignancies of the pancreas, liver, gallbladder, omentum, mesentery, and alimentary tract from the stomach to the transverse portion of the large colon. The relevant anatomy, indications, cotraindications, different application techniques and results of celiac blockade is reviewed in this paper.

Endoscopic ultrasound-guided fine-needle injection

With the development of linear array echoendoscopes and the ability to perform endoscopic ultrasound (EUS)-guided fine-needle aspiration, the delivery of therapeutic agents with fine-needle injection (FNI) emerged. EUS-guided FNI is an attractive delivery system because of its minimal invasiveness and low complication rate. This approach is effective in performing celiac plexus neurolysis for pain relief in patients with pancreatic cancer. The most exciting area of interest involves the delivery of antitumor agents in patients with locally advanced cancer, such as cancer of the pancreas or esophagus. The involvement of EUS-guided FNI in tumor therapy adds a host of potential new applications that continue to swing the pendulum of EUS from a diagnostic to a therapeutic modality.