The effects of early or late neurolytic sympathetic plexus block on the management of abdominal or pelvic cancer pain

Neurolytic sympathetic plexus block (NSPB) has been proposed to prevent the development of pain and improve the quality of life of patients with cancer, thus questioning the WHO protocol that proposes the use of invasive methods only as a final resort. This study evaluates the pain relief, opioid consumption and quality of life provided by the use of NSPB in two different phases of cancer pain and compares them with that provided by pharmacological therapy only. Sixty patients with abdominal or pelvic cancer pain were divided into three groups and observed for 8 weeks. In group I, neurolytic celiac (NCPB) or superior hypogastric plexus block (SHPB), or lumbar sympathetic ganglion chain block (LSGCB) was performed with alcohol in patients using NSAID and a weak oral opioid or morphine (dose</=90 mg/day) and reporting VAS>/=4. In group II, NCPB, SHPB or LSGCB were performed on patients using NSAID and morphine (dose>/=90 mg/day) and reporting VAS>/=4. The patients of group III received pharmacological therapy only. The patients of groups I and II had a significant reduction of pain (P < 0.004), opioid consumption (P < 0.02) and a better quality of life (P < 0.006) than those of group III, but no significant differences between groups I and II were seen in these aspects. Opioid-related adverse effects were significantly greater in group III (P < 0.05). The occasional neurolysis-related complications were transitory. The results suggest NSPB for the management of cancer pain should be considered earlier in the disease.

[The transintervertebral disc approach for educational practice of the neurolytic celiac plexus block]

BACKGROUND

The transintervertebral disc approach was proposed recently for percutaneous neurolytic celiac plexus block (NCPB). Its superior simplicity, reliability, as well as safety potentially overcome the technical hurdles of NCPB that may interfere with the practical use of this validated analgesic intervention for abdominal cancer pain. The present study was conducted to evaluate the effectiveness of the use of this approach in a resident education program for NCPB.

METHODS

The clinical results of NCPBs conducted from January 2001 to September 2002 were examined comparing that performed by institutional residents with that by specialized physicians authorized by the Japanese Society of Pain Clinicians. The transintervertebral disc approach was used in all cases. Each resident completed NCPB under close supervision of the specialists.

RESULTS

Twenty-four patients received NCPB during the study period. Seven residents randomly completed 12 procedures and 4 specialists did others. The duration of fluoroscopy to complete the procedure was 256+/-109 sec in the resident group and 392+/-194 sec in the specialist group (ns). Significant pain reduction was obtained immediately after NCPB in all patients without any intergroup difference. No critical complication was observed in each group.

CONCLUSIONS

The transintervertebral disc approach can be used effectively and safely in educational practice of NCPB for less-trained physicians.

Angioplasty/stenting of the superior mesenteric artery and celiac trunk: early and late outcomes

PURPOSE

To analyze the early results and durability of angioplasty/stenting of the superior mesenteric artery (SMA) and celiac trunk (CT).

METHODS

Twenty-two patients (19 women; mean age 69.2 years, range 52-88) with 24 symptomatic SMA or CT stenotic lesions were treated with dilation/stenting over a recent 4.5-year period. Two patients had lesions in both the SMA and CT treated. Clinical follow-up and duplex exams were done to evaluate long-term patency. Kaplan-Meier life-table analyses estimated the freedom from recurrent stenosis and recurrent symptoms, as well as survival rates.

RESULTS

The initial technical and clinical success rates were 96% (23/24) and 95% (21/22), respectively, with no perioperative mortality or major morbidity. During a mean follow-up of 26 months (range 1-54), the primary late clinical success rate was 61% (11/18; 4 lost to follow-up), and freedom from recurrent stenosis (> or =70%) was 30% (6/20). The freedom from recurrent stenosis at 1, 2, 3, and 4 years were 65%, 47%, 39%, and 13%; freedom from recurrent symptoms was 67% at all 4 intervals. The survival rates were 93%, 93%, 80%, and 53% at 1 to 4 years, respectively.

CONCLUSIONS

Angioplasty/stenting of SMA and CT stenoses has a high initial technical success rate and acceptable early and late clinical outcomes; however, it is associated with a high incidence of late restenosis based on strict Doppler criteria.

Effect of neurolytic celiac plexus block on pain relief, quality of life, and survival in patients with unresectable pancreatic cancer: a randomized controlled trial

CONTEXT

Pancreatic cancer is an aggressive tumor associated with high mortality. Optimal pain control may improve quality of life (QOL) for these patients.

OBJECTIVE

To test the hypothesis that neurolytic celiac plexus block (NCPB) vs opioids alone improves pain relief, QOL, and survival in patients with unresectable pancreatic cancer.

DESIGN, SETTING, AND PATIENTS

Double-blind, randomized clinical trial conducted at Mayo Clinic, Rochester, Minn. Enrolled (October 1997 and January 2001) were 100 eligible patients with unresectable pancreatic cancer experiencing pain. Patients were followed up for at least 1 year or until death.

INTERVENTION

Patients were randomly assigned to receive either NCPB or systemic analgesic therapy alone with a sham injection. All patients could receive additional opioids managed by a clinician blinded to the treatment assignment.

MAIN OUTCOME MEASURES

Pain intensity (0-10 numerical rating scale), QOL, opioid consumption and related adverse effects, and survival time were assessed weekly by a blinded observer.

RESULTS

Mean (SD) baseline pain was 4.4 (1.7) for NCPB vs 4.1 (1.8) for opioids alone. The first week after randomization, pain intensity and QOL scores were improved (pain intensity, P< or =.01 for both groups; QOL, P<.001 for both groups), with a larger decrease in pain for the NCPB group (P =.005). From repeated measures analysis, pain was also lower for NCPB over time (P =.01). However, opioid consumption (P =.93), frequency of opioid adverse effects (all P>.10), and QOL (P =.46) were not significantly different between groups. In the first 6 weeks, fewer NCPB patients reported moderate or severe pain (pain intensity rating of > or =5/10) vs opioid-only patients (14% vs 40%, P =.005). At 1 year, 16% of NCPB patients and 6% of opioid-only patients were alive. However, survival did not differ significantly between groups (P =.26, proportional hazards regression).

CONCLUSION

Although NCPB improves pain relief in patients with pancreatic cancer vs optimized systemic analgesic therapy alone, it does not affect QOL or survival.

Celiac plexus block for pancreatic cancer pain: factors influencing pain, symptoms and quality of life

Neurolytic celiac plexus block (NCPB) is claimed to be an effective method of pain control for pancreatic cancer pain. However, the factors that may influence long-term analgesia, adverse effects, and quality of life after performing NCPB have never been determined. In a prospective multicenter study, 22 patients who underwent NCPB were followed until death. Numerous parameters other than pain and symptom intensity were evaluated, including age, gender, initial site of cancer, sites of pain, possible peritoneal involvement, technique, and oncologic interventions. Indices were calculated to determine the opioid consumption ratio (EAS) and the trend of opioid escalation (OEI). NCPB was effective in reducing opioid consumption and gastrointestinal adverse effects for at least 4 weeks. In the last four weeks prior to death, there was the typical trend of increasing symptom intensity common to the terminal cancer population. None of the factors studied influenced the analgesic effectiveness of NPCB. NPCB, performed by skilled clinicians, regardless of the technique chosen, is a safe and useful means that should be considered as an adjuvant to common analgesic regimens at any stage, as it may allow the reduction of the visceral component of pancreatic pain that may prevail in certain phases of the illness. The analgesic and symptomatic effect of NCPB is presumably advantageous for about four weeks. A possible factor interfering with long-term outcome includes the capacity of cancer to involve the celiac axis, which can distort the anatomy and prevent neurolytic spread, or modify the pain mechanisms. Outcomes are strongly based on individual variation.

Endoscopic ultrasound-guided injection: a close look at celiac plexus block and celiac plexus neurolysis

This article describes the use of interventional endoscopic ultrasonography, namely, endoscopic ultrasound-guided injection therapy for the treatment of pain. With the assistance of endoscopic ultrasonography, it is now possible to safely inject the celiac plexus with pharmacological agents to provide analgesia in painful pancreatic conditions such as cancer and chronic pancreatitis. The indications for celiac plexus injection, the procedure, required accessories, complications, and nursing care are discussed.

Celiac plexus block: evaluation of injectate spread by three-dimensional computed tomography

We describe a case of pancreatic cancer in which the spread pattern of injectate during neurolytic celiac plexus block was evaluated by three-dimensional helical computed tomography. Three-dimensional images provide excellent visualization of the spread patterns of injectate in a target site, which appears to provide patients with effective relief from intractable pain.

[Intraoperative neurolysis of the celiac plexus in patients with unresectable pancreatic cancer]

BACKGROUND

The analgetic treatment of inoperable pancreatic cancer patients is of paramount importance. The relative ineffectiveness of pharmacological agents has led many investigators to recommend chemical neurolysis of the celiac ganglions for pain control. However, the assessment of the results and the effectiveness of the block carried out during laparotomy have been unclear.

PATIENTS AND METHODS

After 41 intraoperative celiac neurolytic blocks pain intensity was retrospectively analysed in 38 patients suffering from unresectable pancreatic carcinoma. The mean age of the patients was 59 years, the observation period after neurolysis ranged to 6 months. All patients underwent definitive neurolysis using 50 % ethanol in 0.5 % prilocaine. Immediate and long-term efficacy, analgetic consumption and mortality were evaluated at follow-up. The calculated parenteral equivalent morphine dosage (mg per day) was evaluated before as well as at different time points after treatment as an objective parameter to describe pain intensity.

RESULTS

7 to 34 days (at discharge from the hospital) after block pain intensity was statistically highly significant reduced (p=0.016). Long-term results were obtained from 17 (10 to 12 weeks after intervention) and 9 (up to 20 weeks after intervention) patients respectively, demonstrating a long-lasting effect of the neurolysis. A statistical analysis was not possible because of the small patient 's number.

CONCLUSIONS

Intraoperative celiac neurolytic block is a safe and effective method of pain treatment in patients with unresectable pancreatic carcinoma. However, it alone provides complete pain relief until death only in a few cases. Therefore, it should be considered as an adjuvant treatment in the analgesic strategy. Combined palliative therapy is necessary in most of the cases.

[Splenic necrosis after percutaneous celiac plexus block guided by ultrasonography]

Celiac plexus block guided by ultrasonography is an efficient technique for treatment of pain due to solar syndrome. Neurological complication of this therapeutic method can be avoided using an anterior route. We report the occurrence of splenic necrosis after celiac plexus block, which represents an exceptional complication of the therapeutic procedure.

A comparison of intraoperative celiac plexus block with pharmacological therapy as a treatment for pain of unresectable pancreatic cancer

BACKGROUND/PURPOSE

The efficacy of intraoperative celiac plexus block was compared with that of pharmacological therapy in the treatment of pain caused by unresectable pancreatic cancer.

METHODS

Twenty-one patients were included in the study: 15 patients underwent intraoperative celiac plexus block (group 1) and 6 received pharmacological therapy (group 2). The effectiveness at 1 week after treatment and from treatment to death was evaluated at follow-up by looking at mean analgesic consumption, mortality and morbidity, and any postoperative complications. Statistical analysis was performed using unpaired t-tests.

RESULTS

One week after the operation, the analgesic consumption of 14 patients in group 1 was the same as that before treatment, and 1 patient's consumption had decreased. Pain in 4 patients in group 2 did not change, but in 2 patients it increased. Mean opioid consumption was significantly lower in group 1. Complications related to the block were transient diarrhea and hypotension ( P not significant between groups). There was no operative mortality or major complication related to the block. The incidence of adverse drug-related effects, such as constipation, nausea, and vomiting, was significantly lower in group 1 than in group 2.

CONCLUSIONS

Intraoperative celiac plexus block made pain control possible with reduced opioid consumption, representing an effective, safe, and simple tool for the treatment of pain caused by unresectable pancreatic cancer.

Metastatic pancreatic cancer

Metastatic pancreatic cancer is one of the leading causes of cancer-related deaths in North America and Europe. In the past, patients with metastatic pancreatic cancer have had few treatment options. However, recently, several effective palliative therapies and procedures have become available. The systemic administration of gemcitabine has been shown to result in clinical benefit and in a prolongation of median survival, and is now established as the standard first-line treatment for patients with metastatic pancreatic cancer. Clinical trials are exploring whether the use of gemcitabine-based chemotherapy combinations will result in further benefit. Several novel chemotherapeutic and biologic agents appear promising, and are likely to play a role in the treatment of patients with pancreatic cancer in the future. Palliative procedures, such as biliary or duodenal stenting and celiac plexus blockade, should be considered in conjunction with systemic therapy in patients with specific complications from pancreatic cancer.

Palliation by coeliac plexus block for upper abdominal visceral cancer pain

Palliation of cancer related pain is one of the major concerns of patients suffering from cancer of the upper abdominal organs. The non-availability of imaging techniques to guide needle placement prompted us to use a blind technique of neurolytic coeliac plexus block. Thirty consecutive patients with intractable pain, due to documented inoperable upper abdominal visceral cancers, underwent neurolytic coeliac plexus block by blind percutaneous retrocrural unilateral neurolysis. The severity of pain was documented on a 0-10 visual analogue scale (VAS) performed pre-block and post-block at 1 day, 1 week, 1 month and 3 months. Pain relief was graded as excellent if the score was 0-2, good when VAS was 3-5, satisfactory whenVAS was 6-7 and unsatisfactory if VAS was 8-10. Excellent pain relief was obtained in 26/30 patients (86.6%). Relief from pain diminished with time and after 3 months, 16/30 patients (53.35) graded their pain relief as excellent. Transient but severe hypotension complicated 73% of blocks. Despite the proximity of vital structures, blind unilateral retrocrural neurolytic coeliac plexus blockade is a safe and effective means to relieve the terminal pain associated with upper abdominal visceral cancer. It deserves more widespread use in patients with upper abdominal cancer. Results of the present study are encouraging and relevant for clinicians working in developing countries.

Neurolytic celiac plexus block for visceral abdominal malignancy: is prior diagnostic block warranted?

Neurolytic celiac plexus block is a recognised treatment for visceral abdominal pain due to malignancy. The need for a diagnostic celiac plexus block prior to neurolytic blockade is of questionable value, as it may not predict a positive response and may incorrectly predict a lack of response. Our objective is to evaluate the efficacy of diagnostic celiac plexus block. The records of 59 patients treated with celiac plexus block during 1994-2000 were retrospectively reviewed. Diagnostic block was performed on 32 patients prior to the decision for subsequent neurolytic block (Group 1). Another 27 patients were directly treated with a neurolytic celiac plexus block (Group 2). Response of Group 1 to diagnostic and neurolytic blocks was compared. Data from Group 2 was used to project the response of Group 1 should those patients with negative response to diagnostic block proceeded to neurolytic block. A two-by-two table was then constructed. The diagnostic celiac plexus block predicted a positive response with a sensitivity of 93% and a specificity of 37%. The positive predictive value was 85% and the negative predictive value was 58%. The estimated "number needed to test" before a "true" nonrespondent to lytic block to be detected was 16.7. Therefore, a positive response to diagnostic block correlates positively with neurolytic celiac plexus block for abdominal visceral pain due to malignancy. However, diagnostic block is a poor predictor when the response is negative. Hence, its clinical role is questionable and may not be warranted for patients with terminal malignancy.

Pain management of patients with unresectable peripancreatic carcinoma

In patients with unresectable peripancreatic carcinoma, pain is generally treated with pain medication or with a celiac plexus blockade. Radiotherapy has also been reported to reduce pain. The efficacy of these treatment modalities is still under discussion. The aim of this study was to analyze the effects of the various types of pain management on patients who underwent palliative bypass surgery for unresectable peripancreatic carcinoma. During the period January 1995 to December 1998 a series of 98 patients underwent palliative bypass surgery, mostly for unresectable disease found during exploration. Patients were divided into three groups: palliative bypass surgery (BP), palliative bypass surgery with an intraoperative celiac plexus blockade (CPB), and palliative bypass surgery with or without celiac plexus blockade followed by high-dose conformal radiotherapy (RT). Radiotherapy was performed only in selected patients with locally advanced disease and without metastases, implying a better prognosis of the last group. The pain medication consumption, pain medication-free survival, hospital-free survival, and overall survival were analyzed. The preoperative consumption of pain medication was significantly higher in the CPB group than in the BP or RT group. The postoperative consumption of pain medication in the CPB, BP, and RT groups increased during follow-up from 15%, 17%, and 13% before surgery to 52%, 57%, and 46%, respectively, at three-fourths of the survival time (NS). This increase in consumption of pain medication was not different in the three groups. In the RT group the median pain medication-free survival was significantly longer than in the BP or CPB group (9.3 vs. 3.1 and 3.3 months; p = 0.02). The median hospital-free survival and median overall survival were significantly longer in the RT group than in the CPB group (10.3 vs. 6.8 months, p = 0.01; and 7.1 vs. 10.8 months, p = 0.01). Celiac plexus blockade as pain management did not result in an increase of the pain medication-free survival or overall survival. Therefore a positive effect of a celiac plexus blockade on pain could not be confirmed in the present study. Radiotherapy resulted in increased pain-medication survival, hospital-free survival, and overall survival compared to celiac plexus blockade. These effects are probably partly related to patient selection.

Increasing the efficacy of a celiac plexus block in patients with severe pancreatic cancer pain

The purpose of this study was to evaluate the technical possibilities of placing a catheter near the celiac plexus for performance of a celiac plexus block, and to study the efficacy of repeated neurolytic celiac plexus blocks with alcohol in patients with advanced pancreatic cancer pain resistant to opioid treatment. In 12 patients, a neurolytic celiac plexus block with alcohol, administered via an indwelling celiac catheter, was performed. To evaluate the efficacy, visual analog scale scores were recorded every day. Quality of life scores were registered before and 4 weeks following the procedure. Alterations in opioid consumption, and the time between the diagnosis of pancreatic cancer and the performance of the block, were registered. All patients were followed until they died. Two patients remained without pain after the first neurolytic celiac plexus block. In all other patients a second block was administered which provided only temporary relief. Additional intermittent administration of bupivacaine through the catheter was necessary to provide adequate pain relief in these patients. Quality of life increased significantly during the treatment. Opioid consumption decreased significantly in all patients. Our study indicates that a neurolytic celiac plexus blockade with alcohol results in a significant but short-lasting analgesic effect. The use of a celiac catheter improves the long-term management of pancreatic cancer pain.

A prospective study of EUS-guided celiac plexus neurolysis for pancreatic cancer pain

BACKGROUND

Celiac plexus neurolysis, a chemical splanchnicectomy of the celiac plexus, is used to treat pain caused by pancreatic cancer. Most commonly, celiac plexus neurolysis is performed percutaneously under CT or fluoroscopic guidance, but can also be performed with EUS. The aim of this study was to prospectively assess the efficacy of EUS celiac plexus neurolysis in the management of pain caused by pancreatic cancer.

METHODS

In this prospective study conducted in a community-based referral hospital, 58 patients with painful and inoperable pancreatic cancer were evaluated at 8 observation points before and after EUS celiac plexus neurolysis for up to 6 months. The following data were collected: age, gender, tumor location, vascular invasion, adjuvant therapy, and laboratory tests including prothrombin time, and complete blood counts were obtained at baseline (before EUS celiac plexus neurolysis); pain scores, morphine use, and adjuvant therapy were assessed at each observation.

RESULTS

Pain scores were lower (p = 0.0001) 2 weeks after EUS celiac plexus neurolysis, an effect that was sustained for 24 weeks when adjusted for morphine use and adjuvant therapy. Forty-five of the 58 patients (78%) experienced a decline in pain scores after EUS celiac plexus neurolysis. Chemotherapy with and without radiation also decreased pain after EUS celiac plexus neurolysis (p = 0.002). Procedure-related transient abdominal pain was noted in 5 patients; there were no major complications.

CONCLUSIONS

EUS celiac plexus neurolysis is safe and controls pain caused by unresectable pancreatic cancer.

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.

[Analgesic effect of neurolytic celiac plexus block guided by ultrasonography in advanced malignancies]

OBJECTIVE

To investigate the analgesic effect of celiac plexus block with anhydrous alcohol in patients suffering form advanced abdominal malignancies.

METHODS

Ultrasonographically demonstrated and guided, 20 to 50 ml of anhydrous alcohol is injected into the celiac plexus and superior mesenteric plexus by fine needle of 22G. The injecting angle between the needle and the aorta is 20 to 30 degree. The injecting fields mainly located around the celiac plexus and the dorsal part of tumor are also injected. Sometimes if the tumor is rather large, an appropriate amount of alcohol was injected inside too.

RESULTS

Twenty-eight cases of advanced abdominal malignancies were treated, among whom 96.4% achieved analgesic effect of different degree, 53.6% (15 cases) achieved the period of pain relief over three days, and 42.8% (12 cases) achieved partial relief. The analgesic effect is correlated with the amount of alcohol injected, i.e. no complete relief was observed in the four patients who received less than 12 ml, while two out of six could get transient complete relief in those who received 15 to 28 ml. In the group of 30 to 50 ml, 72.2% (13 cases) could get complete pain relief. Nine cases with big tumor received injection in side the tumor, with six tumors resulting in shrinkage or necrosis, significant pain relief also achieved in these cases. Complications occurred in nine cases (32.1%), with four cases of postural hypotension, two cases of vomiting, two cases of hiccup and one case of diarrhea.

CONCLUSION

Neurolytic celiac plexus block guided by ultrasonography is a safe and effective modality in the management of intractable pain resulted from advanced abdominal malignancies.