[Echo-guided percutaneous celiac plexus block with alcohol with an anterior approach]

The authors report the use of ultrasound as a guide to the execution of celiac plexus alcoholization with the anterior approach. Five patients with severe pain resistant to pharmacologic treatment with NSAID, cortisone and morphine have been treated. Once found out the celiac trunk and the best direction, using ultrasound, the needle is advanced slowly beyond the anterior lateral wall of the aorta, in order to recognize the tip with the same ultrasound response of the retroperitoneal tissue. After calculating the distance between the celiac trunk and the needle tip, this is withdrawn in order to be set in the alcoholization point of injection. No complication directly related to the technique has been observed in the five patients. Pain relief was optimal in four out of five patients and was kept until the exitus.

[The anterior sonographic-guided celiac plexus blockade. Review and personal observations]

The coeliac plexus block is an approved method for the relief of upper abdominal pain due to cancer of the upper intra-abdominal viscera or to chronic pancreatitis. While there are many reports concerning the posterior approach to the coeliac plexus block, little attention has been given the anterior approach. There are two ways of implementing the anterior approach to the coeliac plexus: CT-guided and the ultrasound guided approach. METHODS. The ultrasonic-guided anterior approach to the coeliac plexus block is used with the patient in the supine position. The aorta and discharge of the truncus coeliacus or the a. lienalis respectively, are ultrasonographically presented at two levels. After setting local cutaneous and subcutaneous anaesthesia, a 15-cm-long 25 G-needle is introduced into the epigastrium. The point of the needle is--ultrasonographically guided--inserted into the pre-aortic area near the discharge of the truncus coeliacus. The position of the needle point is ultrasonographically controlled on two levels. For the enforcement of a diagnostic coeliac plexus block after careful aspiration on two levels, 10 ml of bupivacaine 0.5% is injected. The spread of the solution is evaluated by ultrasound. If the needle position is correct; a few minutes later the patient has a feeling of warmth in the upper abdominal region. For the enforcement of a neurolytic coeliac plexus block 10 ml ethanol 96% and 10 ml prilocaine 1% can be administered. The two solutions are applied as small volumes in permanent succession. Thus the burning pain, which is often observed after the injection of alcohol, is avoided. RESULTS. In the literature there are only a few reports, about the results and side-effects after use of the anterior approach in the coeliac plexus block. The results of these investigations and our own show total pain relief or at least good pain reduction by at best 85%. The reduction in pain achieved continues in as many as 60% of the treated patients. There is the possibility to stop or at least reduce the analgesic premedication. These results are comparable with those after using the posterior approach to the coeliac plexus block. When carrying out the anterior approach in the coeliac plexus block, most of the patients showed increased intestinal motility. Therefore, about 60% of all patients had transitory diarrhoea. In 12-25% of the patients orthostatic hypotension was observed. This side-effect is avoided by an appropriate infusion before enforcement of the block. In a frequency of 4-100% the occurrence of burning pain was reported during injection of the alcohol. No serious side-effects were observed. CONCLUSIONS. The results concerning total pain relief or at least pain reduction are comparable to the posterior approach for the block. Nevertheless, there are some advantages to the ultrasound-guided anterior approach. There is less risk using this technique. No methodological complications have been observed so far. There is no risk of neurological complications such as paraplegia. Because the patients remain in the supine position, the anterior approach to the coeliac plexus block is suitable for terminally ill patients, who are not able to tolerate the prone position and need careful supervision and good ventilation. Also, no contrast medium is necessary. Only a small volume of local anaesthetics or alcohol is required. We prefer the anterior approach of the coeliac plexus block as a fast, safe and cost-effective method, which should receive increasing attention during the next few years.

Celiac plexus block: efficacy and safety of the anterior approach

OBJECTIVE

A celiac plexus block performed via an anterior approach offers several potential advantages over a posterior approach, including shorter procedure time, less discomfort to the patient, and less risk of neurologic complications. We evaluated the use of an anterior approach to determine its efficacy and safety.

MATERIALS AND METHODS

The procedure was performed in 17 consecutive patients referred for treatment of chronic abdominal pain thought clinically to be of celiac ganglion origin. A subjective evaluation of the degree of pain relief was obtained by retrospectively reviewing the notes of physicians and nurses. The degree of pain relief was graded from 1+ (no change) to 4+ (complete relief). An objective evaluation was also obtained by comparing average daily in-hospital analgesic usage before and after the procedure.

RESULTS

Ethanol injection was performed successfully in 13 of 14 patients with pancreatic carcinoma and in two of three patients with other causes of pain. Eleven (79%) of the 14 patients with pancreatic carcinoma had some (2+ or greater) relief of pain, and eight of these patients had considerable or complete (3+ or 4+) relief of pain. Of the 10 patients with pancreatic carcinoma for whom complete data on the use of pain medication were available, the mean daily analgesic usage declined from 17% to 100% (mean, 58%) relative to preprocedure doses. Complications, all relatively mild, were encountered in only three of 17 patients, and no patient had neurologic symptoms or long-term sequelae.

CONCLUSION

The anterior approach to a celiac plexus block is a safe and effective means of pain control in patients with pancreatic carcinoma. It offers several potential advantages to the posterior approach, and should be considered for all patients with pain caused by pancreatic carcinoma that is refractory to pain medication.

Celiac (solar) plexus syndrome. A frequently overlooked source of abdominal pain

Of the nonorganic abdominal disorders the celiac/solar plexus syndrome represents a frequently seen entity characterized by the typical association of epigastric pain and "lambda-type" tenderness. It is a special type of abdominal neurosis in which the pain arises in the periaortic nervous plexuses. Its clinical importance is in the differential diagnosis, since it is often misinterpreted as a painful condition of abdominal or retroperitoneal origin.

Coeliac plexus block with bupivacaine reduces intestinal dysfunction in neurosurgical ICU patients

Coeliac plexus block, an established method of treatment for pain associated with pancreatitis and cancer, was used in neurosurgical patients with gastrointestinal dysfunction. The study was performed in 16 patients whose gastric reflux volume exceeded 600 ml per day for 3 consecutive days. Patients were allocated to a block group (n = 8) or a control group (n = 8). Coeliac plexus block was accomplished with a modified Moore technique using 50 ml bupivacaine 0.25%. In the block group, gastric reflux volumes for 3 days preceding coeliac plexus block and 3 consecutive days following coeliac plexus block were analysed. In the control group, gastric reflux volumes were observed over a period of 6 days. Mean (SEM) gastric reflux volume decreased significantly following coeliac plexus block from 770 (50) ml to 60 (30) ml (p < 0.01). In the control group, gastric reflux remained unchanged over the corresponding periods (730 (60) ml c.f. 670 (50) ml). The response of gastric reflux volume to coeliac plexus block suggests that the mechanism is related to inhibition of sympathetic activity in patients whose sympathetic drive is increased due to the underlying neurological disease, and possibly due to sedation withdrawal symptoms.

Celiac plexus block versus analgesics in pancreatic cancer pain

Twenty pancreatic cancer patients were studied to assess the effectiveness and duration of celiac plexus block compared to traditional treatment with analgesics by considering the previous and subsequent consumption of narcotics until their death. After 1 week of therapy with NSAID-narcotic sequence according to the WHO method, 10 patients were continued on this treatment, while the other 10 patients underwent celiac plexus block. Subsequently analgesics were administered as in the patients not treated by the block. A visual analogue score and opioid consumption were used to calculate the effective analgesic dose at weekly intervals until death. Celiac plexus block made pain control possible with a reduction in opioid consumption for a mean survival period of about 51 days. Administration of only analgesics resulted in an equal reduction in VAS pain score until death, but with more unpleasant side effects than when using celiac plexus block.

[Treatment of pain in advanced-stage intra-abdominal neoplasms]

Different types of pain are present in far advanced intra-abdominal cancer, sometimes in the same site too. An accurate semeiological analysis of pain is important because different types of pain often differently respond to the available therapeutical tools. In this paper the results and the complications of the most important methods of pain management in far advanced intra-abdominal cancer are examined. Analysis of the data reveals that the association of more methods, pharmacological and non, should be a rule rather than the exception.

Audit of neural blockade for palliative care patients in an acute unit

During the period from September 1990 to March 1992, 155 nerve blocks were performed for 125 patients as part of the clinical management of pain due to malignant disease. The efficacy, in terms of pain score reduction, and spontaneously reported side effects secondary to these procedures were prospectively audited. Neural blockade was undertaken in accordance with strict clinical criteria, and medication was optimized with the aim of achieving maximum analgesia with minimum side effects at all times. Pain was assessed before the block, 24 hours after the block and at follow-up (two to six weeks) using visual analogue scores or verbal rating scales. All patients were audited. The total (all patients, all blocks) median (lower-upper quartile) pain score dropped from 8 (6-10) cm before the block to 2 (0-4) cm at 24 hours after the block (p < 0.05) and to 1 (0-4) cm at follow-up (p < 0.005). A concomitant reduction in analgesic requirements was observed. The incidence of serious side effects was low (two patients in this series). The results indicate the usefulness of these techniques for patients in the palliative care setting.

Pancreatic pain: is there a medical alternative to surgery?

The non-surgical management of chronic pancreatic pain is reviewed. In accordance with the suggested multifactorial origin of pancreatic pain, different treatment principles are practised. Besides conventional analgesic drugs, oral pancreatic enzymes seem efficient in a subgroup of patients with chronic pancreatitis. Endoscopic treatment aiming at reduction of the pancreatic duct-tissue pressure is promising, but it is still in its infancy. Coeliac nerve blockage is recommended in patients with pancreatic cancer and pain, whereas external radiotherapy plays a role in a diminishing number of these patients. Treatment of chronic pancreatic pain is an example of a complex clinical problem in which a multidisciplinary approach is mandatory.

Reversible paraplegia following coeliac plexus block

Permanent paraplegia following coeliac plexus block has been reported on several occasions. We report a case of reversible paraplegia following coeliac plexus block.

[Alcohol block of the celiac plexus in severe visceral pain]

The authors present their own experience with percutaneous alcohol block of the coeliac plexus. Between April 1988 and December 1991 they used it in 22 patients. Except one patient the others suffered from severe pain of abdominal organs associated with carcinoma of the pancreas. The first four operations were made using angiography, the remainder under CT control. During evaluation of results two weeks after the intervention complete regression of pain was recorded in six patients. A partial effect was achieved in 11 patients, and the intervention failed in five patients. The intervention was repeated in four patients. The authors emphasize that the procedure is relatively simple and safe, and if successful, makes it possible to reduce or even eliminate opiates. It improves the quality of the remaining life of the patient.

Arteriovenous differences of blood alcohol concentrations after celiac plexus block

After a celiac plexus block with ethyl alcohol, patients sometimes complain of symptoms of alcohol intoxication. We studied the consecutive changes of arterial and venous blood alcohol concentrations in 11 patients and investigated whether an arteriovenous difference exists. We performed a celiac plexus block with 10 ml absolute ethyl alcohol. The sampling sites were radial artery and internal jugular vein. Blood samples were collected at 0, 5, 10, 15, 30, 60, 120, 240 and 480 minutes after the block. The maximum level was reached 15 minutes after injection in both arterial and venous blood, 29.9 +/- 19.4 and 27.7 +/- 21.8 mg/dl (means +/- SD), respectively. Arteriovenous differences were observed 5 and 10 minutes after ethyl alcohol injection (p less than 0.01). There was a significant negative correlation between the ratio of arteriovenous differences to venous sampling and the time elapsed after the block (r = 0.41, p less than 0.01).

Continuous coeliac plexus blockade plus intermittent wound infiltration with bupivacaine following upper abdominal surgery: a double-blind randomised study

In this double-blind trial, we observed the effect of intermittent wound infiltration with local anaesthetic plus continuous coeliac plexus blockade on postoperative pain relief, pulmonary function, the neuroendocrine and acute phase protein response following upper abdominal surgery. In Group A (n = 10) patients received bupivacaine intermittently into the wound and continuously into the coeliac plexus following an initial bolus. A total of 862.5 mg of bupivacaine was used over 12 h with no observed toxicity. Group B (n = 10) received equal volumes of saline. Although pain relief was poor in both groups, the bupivacaine group used less morphine postoperatively and had lower pain scores than the saline group 4 h after operation (P less than 0.05). Pulmonary function was significantly reduced in both groups with no statistical difference between the two. Significant reductions in serum glucose and cortisol were achieved (P less than 0.05), suggesting that afferent neural blockade was partially effective in attenuating the neuroendocrine response. However, the postoperative rise in interleukin-6 was not affected by this technique. It is concluded that total afferent neural blockade cannot be achieved with peripheral wound and coeliac plexus administration of relatively large doses of local anaesthetic during upper abdominal surgery.

Sonographically guided coeliac plexus block

A sonographically guided anterior approach to block the coeliac plexus with local anaesthetic was attempted on supine patients before hepatobiliary interventional procedures. A satisfactory block was achieved in 8/9 patients and the minor complication of transient hypotension was encountered in two which were managed conservatively. Comparison with controls showed the coeliac block patients to require significantly less intravenous sedation and analgesia to control pain during these procedures.

[Urinoma: a complication of celiac plexus infiltration]

A case is described in which a major complication resulted from this technique. We have found no previous record of urinoma due to infiltration of a caustic agent.

Three posterior percutaneous celiac plexus block techniques. A prospective, randomized study in 61 patients with pancreatic cancer pain

Variations and refinements of the classic retrocrural technique of neurolytic celiac plexus block (NCPB) for pancreatic cancer pain (PCP) have been proposed over the last 30 yr to improve success rates, avoid complications and enhance diagnostic accuracy. The aim of this prospective, randomized study was to assess the efficacy and morbidity of three posterior percutaneous NCPB techniques in 61 patients with PCP. The 61 patients were randomly allocated to three NCPB treatment groups: group 1 (20 patients, transaortic plexus block); group 2 (20 patients, classic retrocrural block); and group 3 (21 patients, bilateral chemical splanchnicectomy). The quality and quantity of pain were analyzed before and after NCPB. No statistically significant differences (P greater than 0.05) were found among the three techniques in terms of either immediate or up-to-death results. Operative mortality was nil with the three techniques and morbidity negligible. NCPB abolished celiac PCP in 70-80% of patients immediately after the block and in 60-75% until death. Because celiac pain was only a component of PCP in all patients, especially in those with a longer time course until death: 1) abolition of such pain did not ensure high percentages of complete pain relief (immediate pain relief in 40-52%; pain relief until death in 10-24%); 2) NCPB was effective in controlling PCP in a higher percentage of cases if performed early after pain onset, when the pain was still only or mainly of celiac type and responded well to nonsteroidal antiinflammatory drug therapy; and 3) the probability of patients remaining completely pain-free diminished with increased survival time.(ABSTRACT TRUNCATED AT 250 WORDS)

Ultrasonic guidance of lumbar sympathetic and celiac plexus block: a new technique

BACKGROUND AND OBJECTIVES

Lumbar sympathetic and celiac plexus block are widely used to treat chronic pain of diverse etiologies. To avoid complications and confirm the correct position of the needle, fluoroscopy and computed tomography have been used to follow the procedure visually. Our objective was to examine whether ultrasonography could be used instead of these techniques.

METHODS

Forty-eight neurolytic sympathectomies were performed using ultrasonographic guidance. The results were evaluated clinically and by color-doppler technique as applicable.

RESULTS

This new technique was shown to provide excellent results in ensuring the safe passage of the needle and documenting the correct spread of neurolytic agent (phenol-glycerol). The correct position of the needle was achieved on the first attempt in all cases.

CONCLUSIONS

The benefits of this technique are that it is inexpensive, there is no radiation, and the anatomy involved can be thoroughly examined before and after the procedure. Phenolglycerol may be the best choice as the neurolytic agent because it provides excellent contrast.

Paraplegia following coeliac plexus block

A case is described in which a coeliac plexus block with alcohol 48%, performed under X ray control, resulted in paraplegia. Ischaemia of the spinal cord, due to damage to the arterial blood supply, was thought to be the cause.

[Percutaneous alcoholization of the celiac plexus under echographic guidance: an alternative to splanchnicectomy? Study of 21 cases]

Celiac plexus block is usually performed under fluoroscopic or tomodensitometric guidance. We report on a new procedure using sonographic guidance. The patient lies in supine position. We use a real-time sonograph (Kontron Sigma 1 AC) with a 3.5 MHz probe. On a transverse plane, the celiac axis is localized emerging from aorta. After local anesthesia, the tip of the spinal needle (177 mm, 22 G) is placed close to aorta (about 5 mm) on both sides. 10 to 15 ml of 1 per cent lidocaine then 10 to 15 ml of absolute alcohol are injected on each side. 21 patients (10 males, 11 females, mean age: 61) underwent the procedure. They presented with cancer of the pancreas in 14 cases, metastatic nodes in 3 cases, cholangiocarcinoma in 2 cases and chronic calcifying pancreatitis (CCP) in 2 cases. No pain relief occurred in 3 patients (14 per cent). On of those presented with CCP but the endoscopic cystic diversion of a small cyst was successful to eradicate pain. Partial pain relief occurred in 5 cases (24 per cent). Total pain relief was obtained in 13 cases (62 per cent). No complication related to the treatment was observed. Sonography is a simple and safe method of guidance to perform alcohol block of the celiac plexus. The anterior approach may prevent neurologic complications related to other methods of guidance.

Improving palliation in pancreatic cancer: intraoperative celiac plexus block for pain relief

Most patients with pancreatic carcinoma are not curable. Surgical palliation of obstructive jaundice and gastric outlet obstruction leaves many patients with severe pain from pancreatic carcinoma. Anesthesiologists have drawn increasing attention to the successful use of postoperative percutaneous celiac plexus block for the treatment of pancreatic pain. Ironically, little attention has been paid to celiac plexus block during laparotomy. We reviewed the cases of 12 patients with pancreatic carcinoma and severe abdominal pain who were treated surgically. All patients had operative celiac plexus block with absolute alcohol at the time of exploratory laparotomy for biliary bypass, gastroenterostomy, or tumor biopsy. Complete postoperative pain relief was obtained in 10 of the 12 patients; two had only partial relief. No operative complications were related to celiac plexus block; one patient died postoperatively of pneumonia. Average postoperative hospital stay was 13 days and average postoperative survival was 3 1/2 months. Most patients had excellent pain relief for at least 2 months or until death. Because most patients treated surgically for pancreatic carcinoma are receiving only palliation with biliary bypass or gastroenterostomy, surgeons should pay increased attention to pain relief. Operative celiac plexus block is easy, safe, and highly effective in relieving the agonizing pain of pancreatic carcinoma.

Diarrhoea--an unrecognised hazard of coeliac plexus block

Coeliac plexus block is a safe procedure with relatively few side-effects. We report two cases of persistent severe diarrhoea following coeliac plexus block and explore the possible reasons for this previously unrecognised side-effect. We postulate that somatostatin analogue may be useful as treatment for diarrhoea following neurolytic coeliac plexus block that is unresponsive to conventional anti-diarrhoeal agents.