Endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience

OBJECTIVE

In our previous randomized trial, we suggested a possible role for endoscopic ultrasound (EUS) guided celiac plexus block in the treatment of abdominal pain associated with chronic pancreatitis. The purpose of this study was to evaluate our prospective experience with EUS-guided celiac plexus block for controlling pain attributed to chronic pancreatitis, including follow-up on response rates and complications.

METHODS

All subjects enrolled had documented chronic pancreatitis by ERCP and EUS criteria and presented with chronic abdominal pain unresponsive to current treatment options. All were treated with EUS-guided celiac plexus block under the guidance of linear array endosonography using a 22-gauge FNA needle (GIP, Mediglobe Inc., Tempe, AZ) inserted on each side of the celiac area, followed by injection of 10 cc bupivacaine (0.25%) and 3 cc (40 mg) triamcinolone on each side of the celiac plexus. Individual pain scores, based on a visual analog scale (0-10), were determined preblock and postblock by a nurse at 2, 7, 14 days and monthly thereafter. Subjects also rated their overall comfort level during the EUS procedure.

RESULTS

EUS-guided celiac plexus block was performed in 90 subjects (40 males, 50 females) having a mean age of 45 yr (range 17-76 yr) between July 1, 1995 and December 30, 1996. A significant improvement in overall pain scores occurred in 55% (50/90) of patients. The mean pain score decreased from 8 to 2 post EUS celiac block at both 4 and 8 wk follow-up (p < 0.05). In 26% of patients there was persistent benefit beyond 12 wk, and 10% still had persistent benefit at 24 wk, including three patients who were pain-free between 35 and 48 wk. Younger patients (<45 yr of age) and those having previous pancreatic surgery for chronic pancreatitis were unlikely to respond to the EUS-guided celiac block. Three patients experienced diarrhea post EUS celiac block, which resolved in 7-10 days; however, it is unclear whether this diarrhea was due to the block or to refractory disease. A cost comparison between the EUS ($1200) and CT ($1400) techniques shows the EUS celiac block to be less costly and perhaps more cost efficient in a subset of subjects.

CONCLUSIONS

EUS-guided celiac plexus block appears to be safe, effective, and economical for controlling pain in some patients with chronic pancreatitis. Younger patients (<45 yr) and those having prior pancreatic surgery for chronic pancreatitis do not appear to benefit from this technique. Prophylactic antibiotics should be considered if acid suppressing agents are being taken.

A case of reversible paraparesis following celiac plexus block

BACKGROUND AND OBJECTIVES

Permanent and acute reversible paraplegia following celiac plexus block (CPB) have been reported. We report a case of prolonged reversible paraparesis after alcohol celiac plexus block.

CASE REPORT

A 72-year-old man with primary multicentric pancreatic tumor and multiple hepatic metastases underwent alcohol celiac plexus neurolysis for severe abdominal pain radiating to the back. The patient had complete pain relief after the block but developed paresthesia of the left leg, which then spread to the right leg. Subsequently, loss of flexion and extension of the muscles supplying the left hip, knee, and foot developed. Deep tendon reflexes were brisk on the left compared to the right, and both plantar reflexes gave flexor responses. Magnetic resonance imaging and myelography were normal. Motor-evoked potential recordings showed a spinal cord lesion with involvement of the pyramidal and spinothalamic tracts. Somatosensory-evoked potentials indicated a relative sparing of dorsal column pathways. Physiotherapy was started, the sensory changes gradually subsided, and the patient was discharged 30 days after the block with clinically insignificant neurological deficit.

CONCLUSIONS

Paraparesis following alcohol celiac plexus block may be reversible over an extended period of time.

Comparison of epidural butamben to celiac plexus neurolytic block for the treatment of the pain of pancreatic cancer

OBJECTIVE

To compare pain relief in metastatic pancreatic cancer patients between neurolytic celiac plexus block (NCPB) and epidural 5% butamben suspension (EBS), a material-based delivery system of a local anesthetic that produces a long-lasting differential nerve block.

DESIGN

Open-label patient-selected parallel groups.

SETTING

Urban tertiary care medical center.

PATIENTS

Twenty-four adult patients with metastatic pancreatic cancer experiencing pain uncontrolled by systemic opioids who were referred to a multidisciplinary pain clinic for interventional therapy.

INTERVENTIONS

Antecrural NCPB-block with ethanol and epidural 5% butamben suspension injections.

MEASURES

Subjective global pain relief assessments on a 0-100% scale were made weekly for 4 weeks and then monthly. Change in opioid use postintervention.

RESULTS

Eight patients had a single NCPB and three patients had two NCPB. Four of the former and two of the latter had successful pain relief defined to be a more than 75% reduction in pain when compared with pretreatment maintained for more than 4 weeks or until death (if less than 4 weeks). Thirteen patients received EBS in divided doses. Eleven patients received a cumulative EBS dose of 5 grams, one patient received a cumulative EBS dose of 2.5 grams, and one patient received a cumulative EBS dose of 8.75 grams. Nine of the eleven patients and each of the other two patients had successful pain relief. The overall incidence (85% EBS vs. 55% NCPB), the duration of successful pain relief, and the percent reduction in opioid use did not differ between the two groups. There were no serious complications.

CONCLUSION

EBS appears to be a safe and effective alternative to NCPB in the treatment of pancreatic cancer pain.

MRI-guided celiac plexus block

Celiac plexus block is used as a palliative procedure in cases of severe upper abdominal pain caused by pancreatitis or tumors of the pancreas. It can be guided by bony landmarks, fluoroscopy, ultrasound (US), or computed tomography (CT). To avoid severe complications, methods visualizing soft tissue, like CT and magnetic resonance (MR) imaging, are preferable. We describe celiac plexus blocks carried out in an open MR scanner, offering needle guidance with an optical tracking system and near real-time image acquisition. Eight patients with severe chronic abdominal pain were included. In these, 14 celiac blocks were carried out. Good or total pain relief was achieved in 8 of the 14 blocks (57%), a moderate effect in 5 blocks (36%), and no effect in 1 block (7%). The placement of the needle was easily guided with MR in all cases. The MR technique ensures good visualization of soft tissue, direct monitoring of needle movement and avoids exposure to ionizing radiation. Celiac plexus block can safely be carried out in an open MR scanner.

Celiac plexus block in cancer pain management

The neurolytic celiac plexus block (NCPB) has been recommended for pain relief in patients with upper abdominal cancer by the WHO Cancer Pain Relief Program. In this article, we review the indications, techniques, and adverse effects of NCPB based on the previous findings in the literature and our own experience of 142 NCPBs during the past 11 years. No well-validated indication criteria for the NCPB have been available from invasive trials or non-invasive pain evaluations. Thus, the procedure has been employed using comprehensive pain assessment. Several modified approaches have been described for NCPB with differences in the target space where the alcohol is injected (precrural and retrocrural) and the insertion route of the needle (posterolateral and transdiscal). We have used the retrocrural transdiscal approach because of its simplicity and safety. The efficacy of the resultant pain relief does not differ among these techniques. Therefore, whether a distinction exists between blocks of the celiac plexus and those of the splanchnic nerves is controversial. The term "peri-aortic nerve block" may better describe the feature of this neurolytic intervention. The noteworthy adverse effects of alcoholic neurolysis include regional pain, hypotension, diarrhea, hypoxemia, and acute alcoholic intoxication. Most of them are transient and controllable. The diarrhea may counteract the morphine-induced constipation. NCPB relieves visceral pain in upper abdominal cancer with no serious adverse effects. We recommend this procedure to improve the quality of life of the patients suffering from abdominal cancer pain.

Development of a laparoscopic approach to neurolytic celiac plexus block in a porcine model

BACKGROUND

Neurolytic celiac plexus block (NCPB) is an effective method of palliative pain control in cases of inoperable pancreatic cancer. This study was undertaken to evaluate the feasibility of a laparoscopic approach to NCPB in an experimental animal model.

METHODS

The laparoscopic technique for NCPB was developed in an acute study of six domestic swine followed by a chronic study of nine domestic swine that were monitored 3-21 days after surgery for adverse neurologic, gastrointestinal, or other sequelae. Using a four-port laparoscopic technique, the esophageal hiatus was dissected to expose the aorta at the level of the diaphragmatic crura. Under combined endoscopic and laparoscopic ultrasound (LUS) guidance, 5 ml of sclerosant dye (95% ethanol mixed with India ink) was injected into either side of the para-aortic soft tissue via a percutaneously placed 18-gauge spinal needle. After the animals were killed, the aorta and periaortic tissue were harvested from each animal for gross and histologic analysis.

RESULTS

Under LUS guidance, sclerosant was injected successfully into the para-aortic soft tissue in all animals. There were no intraoperative complications in the acute animal group. Placement of sclerosant injection was successful in all nine chronic cases. Two pigs in the chronic study group died in the immediate postoperative period secondary to pneumothorax. No adverse neurologic, gastrointestinal, or other sequelae were observed in the remaining seven animals at 3-21 days postoperatively. After the animals were killed, we found no injuries to the aorta or esophagus, and histologic analysis demonstrated good placement of dye-labeled sclerosant with no compromise of aortic structural integrity.

CONCLUSION

A laparoscopic approach to the aortic hiatus and NCPB is feasible. Further studies are warranted to evaluate this approach in patients who undergo staging laparoscopy for pancreatic cancer and are found to have unresectable disease.

Spinal cord stimulation: a possible therapeutic alternative for chronic mesenteric ischaemia

A 78-year-old male patient had chronic, unrelieved abdominal pain due to mesenteric ischaemia. Unsuccessful pharmacological approaches included oral morphine plus coadjuvants as well as a sympathetic celiac plexus block which gave pain relief that lasted for 72 h. In order to obtain long-lasting relief, a trial epidural stimulating electrode was implanted after obtaining informed consent and Ethical Committee approval. Complete analgesia was achieved during a trial period of 2 weeks. Thereafter, a spinal cord stimulator was implanted. At the time of writing, 11 months after implantation, the degree of analgesia is complete. We believe that spinal cord stimulation may represent an alternative approach in controlling pain due to mesenteric ischaemia.

Neural blockade for abdominopelvic pain of oncologic origin

Neural blockade, like other accepted treatments for persistent pain, is not a panacea. Careful assessment is required to elicit the need for complementary interventions, including pharmacological management and psychobehavioral and rehabilitative approaches, combined with attention to the palliation of other symptoms. Celiac and superior hypogastric plexus blocks are well-accepted, effective, and minimally hazardous means for providing palliation of visceral abdominopelvic pain. Although they require radiological imaging, they are relatively undemanding of the experienced anesthesiologist pain specialist and do not deplete patients' limited resources and energy. Because of their uniquely favorable risk:benefit ratio, these procedures should be considered early in the course of treating patients with abdominopelvic pain that is expected to persist.

The role of endoscopic ultrasonography in diagnosis, staging, and management of pancreatic disease states

The role of endoscopic ultrasound in evaluation of pancreatic diseases is evolving. This article reviews the advantages and limitations of endoscopic ultrasound when compared with other available imaging technologies in the evaluation of chronic pancreatitis, pancreatic cancer, neuroendocrine tumors, and cystic lesions of the pancreas. New therapeutic procedures using endoscopic ultrasound in the treatment of pancreatic disease are discussed, in addition to potential future applications.

[Moderating action of celiac block in experimental pancreatitis in the dog]

BACKGROUND

Pancreatic ischemia seems to be responsible of transition from edematous to hemorrhagic forms in acute pancreatitis. (AP) Sympathetic system vasoconstriction, through celiac plexus play an important role in the pathogenesis of acute pancreatitis.

OBJECTIVE

Determinate the effects of anesthetic celiac blockade in an experimental model of AP.

METHODS

Distal pancreatectomy and intraductal injection of autologous bile in 28 mongrel dogs. Blockade of celiac plexus with bupivacaine in the experimental group B. Anatomopathologic examination after 72 hours.

RESULTS

Experimental group B developed milder forms of AP, while the control group A developed severe forms.

CONCLUSIONS

Results suggest that celiac plexus blockade with bupivacaine may prevent the development of necrohemorrhagic forms of PA in a canine model.

Efficacy of neurolytic celiac plexus block in varying locations of pancreatic cancer: influence on pain relief

BACKGROUND

Neurolytic celiac plexus block (NCPB) is an effective way of treating severe pain in some patients with pancreatic malignancy. However, there are no studies to date that evaluate the effectiveness of NCPB related to the site of primary pancreas cancer. The aim of the study was to assess the effectiveness of NCPB in pancreatic cancer pain, depending on the location of the pancreatic tumor.

METHODS

The prospective study was conducted in 50 consecutive patients diagnosed with pancreatic cancer. The patients were categorized into two different groups depending on tumor localization: group 1: patients with the cancer of the head of the pancreas and group 2: patients with the cancer of the body and tail of the pancreas. The qualitative and quantitative pain analyses were performed before and after NCPB. The patients underwent prognostic celiac plexus block with bupivacaine, followed by neurolysis during fluoroscopic control within the next 24 h.

RESULTS

After NCPB, 37 patients (74%) had effective pain relief during the first 3 months or until death. Of the 37 patients who had effective pain relief, 33 (92%) were from group 1 and 4 (29%) were from group 2. In the remaining 13 patients (3 patients from group 1 and 10 patients from group 2), pain relief after NCPB was not satisfactory. Those patients were scheduled for repeated retrocrural neurolysis during computed tomography control. Computed tomography showed massive growth of the tumor around the celiac axis with metastases. After repeated neurolysis, pain relief clinically still was not satisfactory, necessitating additional opioid treatment.

CONCLUSION

In this study, unilateral transcrural celiac plexus neurolysis has been shown to provide effective pain relief in 74% of patients with pancreatic cancer pain. Neurolysis was more effective in cases with tumor involving the head of the pancreas. In the cases with advanced tumor proliferation, regardless of the technique used, the analgesic effects of NCPB were not satisfactory.

Benign pancreatic duct strictures: medical and endoscopic therapy

Pancreatic duct strictures usually reflect underlying pancreatic disease and are likely caused by one or more of the following: acute or chronic pancreatitis, benign or malignant pancreatic neoplasm, pseudocyst and trauma. The characteristics of pancreatic strictures are identified, and medical and endoscopic therapy options are reviewed.

Paraplegia following intraoperative celiac plexus injection

The technique for percutaneous and open neurolytic celiac plexus injection, using ethanol or phenol, for relief of intractable pancreatic cancer pain has been well described. Prospective randomized studies, demonstrating safety and efficacy with few complications, have led to widespread acceptance and use of this palliative procedure. The complications of neurolytic celiac plexus injection are rare, and are usually minor. However, transient or permanent paraplegia has been reported previously in 10 cases. The case described herein represents the third reported case of permanent paraplegia following open intraoperative neurolytic celiac plexus injection using 50% ethanol. The literature surveying the indications for this procedure, routes of administration, known complications, and their pathophysiology are reviewed.

Palliation of pain in chronic pancreatitis. Use of neural blocks and neurotomy

Effective management of the pain of chronic pancreatitis may require a multidisciplinary approach involving gastroenterologists, anesthesiologists, psychologists or counselors for chemical addiction (alcohol, narcotics), and surgeons. Viable approaches use pharmacologic analgesics with selected psychotropic medications, celiac plexus blocks, and possibly thoracoscopic splanchnic nerve transections. If these management techniques that preserve pancreatic parenchyma and function, fail, resective surgical therapy may be indicated. For most of these patients, all attempts at nonresective therapy should be exhausted before operative intervention.

A prospective randomized comparison of endoscopic ultrasound- and computed tomography-guided celiac plexus block for managing chronic pancreatitis pain

OBJECTIVE

Computed tomography (CT)-guided celiac plexus neurolysis has been used for controlling the chronic abdominal pain associated with intra-abdominal malignancy and chronic pancreatitis. Endoscopic ultrasound (EUS)-guided celiac plexus neurolysis has been reported to have some success in controlling pain from pancreatic cancer. The aim of this study is to assess the efficacy of EUS-guided celiac plexus block versus CT-guided celiac plexus block for controlling the chronic abdominal pain associated with chronic pancreatitis.

METHODS

Patients enrolled were randomly assigned to EUS-guided or CT-guided celiac plexus block. Pain scores were determined pre- and postceliac block for both techniques. Follow-up was obtained by a nurse at 1 day post-block, then weekly thereafter for 24 wk. Patients also rated overall experience with these procedures. The EUS celiac block was performed with a 22-gauge sterile needle inserted into the celiac region with guidance of real-time linear array endosonography followed by injection of 10 ml of bupivacaine (0.75%) and 3 ml (40 mg) of triamcinolone on both sides of the celiac area.

RESULTS

Twenty-two consecutive patients (10 men, 12 women), were ultimately enrolled in this study between 7/1/95 and 12/30/95; four patients were excluded for protocol violations. We performed EUS-guided celiac block in 10 patients and CT-guided celiac block in eight. A significant improvement in pain scores with reduction in pain medication usage occurred in 50% (five of 10) of patients having the EUS block. The mean postprocedure follow-up was 15 weeks (range: 8-24 wk). Persistent benefit was experienced by 40% of patients at 8 wk and by 30% at 24 wk. In the patients with CT block, however, only 25% (two of eight) had relief. The mean follow-up was 4 wk (range: 2-6 wk). Only 12% (one of eight) had some relief at 12 wk of follow-up. There were no complications. EUS-guided celiac block was the preferred technique among patients who experienced both techniques. A cost comparison between both celiac block techniques shows EUS to be less costly than CT.

CONCLUSIONS

EUS-guided celiac block provided more persistent pain relief than CT-guided block and was the preferred technique among the subjects studied. EUS-guided celiac block appears to be a safe, effective, and less costly method for controlling the abdominal pain that can accompany chronic pancreatitis in some patients.

Pain relief and functional recovery after endoscopic interventions for chronic pancreatitis

BACKGROUND

Pain and functional deterioration in chronic pancreatitis is multifactorial. Early surgery in non-alcoholic patients with mild to moderate chronic pancreatitis can relieve pain and prevent progression of pancreatic insufficiency for some time, but the good results are only short term. Endoscopic intervention can relieve pain and recover pancreatic function without surgery.

METHODS AND RESULTS

To achieve the burned out state of chronic pancreatitis, occlusion of the pancreatic duct was first attempted by our team with Ethibloc at ERCP. Temporary obstruction of the pancreatic duct did not result in a long-lasting symptom and relapse-free situation because of early recovery of pancreatic function. On the contrary, endoscopic simple and double papillotomy, pancreatic drainage with citrate lavage, biliary endoprosthesis with multiple stents and endoscopic decompression of pseudocysts with or without jejunal feeding resulted in pain-free patients for a considerable time and in several cases significant functional recovery occurred. In cases where pain remained, percutaneous celiac plexus block with long-lasting steroids can be applied and only if all of these treatments fail should surgery be recommended.

CONCLUSION

Endoscopic intervention can successfully substitute for surgery for chronic pancreatitis in individual cases.

Young woman's digestive arterial occlusion--a case report and literature review

The authors report the observation of a 31-year-old woman who presented with total occlusion of digestive arteries and was successfully treated pharmacologically. A review of the literature shows that digestive arteries thrombosis is a rare condition in young women. Only 15 cases have been previously reported. Prognosis was poor with a mortality rate of 71%; 93% used oral contraception and more than 50% were smokers. All these cases were curiously similar. The authors accentuate the role of iloprost in the recovery of the patient. Digestive artery occlusion should be taken into consideration in the differential diagnosis of abdominal pain, especially in young women who smoke and take estrogen-containing birth control pills.

Chronic diarrhea--induced by celiac plexus block?

A 59-year-old man had severe chronic diarrhea after a celiac plexus block. The block was performed because of unbearable abdominal pain caused by a benign cyst in the lesser sac. The patient also had diabetes mellitus and was treated with metformin. Thorough investigation and various therapeutic trials failed to detect the cause for the diarrhea or to improve it. Based on the temporal relationship we wonder whether the diarrhea was induced by the celiac block procedure. The relevant literature is reviewed.