[Techniques of celiac plexus block and clinical results]

Coeliac plexus neurolesion techniques for pain due to upper abdominal cancer (pancreas cancer above all), have changed during the years. In this paper we report the results of coeliac plexus alcohol neurolysis for cancer of pancreas and of other abdominal organs achieved with the different techniques. It appears that precrural techniques provide very favorable results but they require the use of CT scan. Retrocrural techniques, while giving good results, can be performed under fluoroscopic control.

Has the analgesic efficacy of neurolytic celiac plexus block been demonstrated in pancreatic cancer pain?

Cancer of the pancreas is rising in incidence and will strike 27,000 Americans this year. There is no curative therapy for most patients, so palliation of symptoms should be the prime concern. Severe pain is very common, and often difficult to treat. Neurolytic celiac plexus block (NCPB) is claimed by some to be the most effective way to treat pancreatic cancer pain (PCP), yet only a minority of patients undergo this procedure. We have reviewed the literature on NCPB to determine if it has been adequately evaluated in the management of PCP. There have been 15 published series since 1964 on NCPB for PCP. A total of 480 patients with cancer of the pancreas were reported; at least a satisfactory response to NCPB was reported in 418 (87%). We found major deficiencies in these reports. None described the pre-NCPB analgesic history. Post-NCPB data were also limited. No information was given concerning post-NCPB analgesic dosages, and only 4 series stated that most patients did not require opiates. Information on whether NCPB was effective until death was lacking or incomplete in 12 series. Many claimed additional benefits of NCPB such as decreased nausea, decreased constipation, and increased appetite, but none provided any data to support these claims. We conclude that the data available on NCPB for PCP are insufficient to judge for efficacy, long-term morbidity, or cost effectiveness, and rigorous evaluation of the technique is required.

Nerve block in pancreatic pain

Pain from pancreatic cancer is, in most cases, both severe and debilitating. Large doses of morphine are sometimes not tolerated or accepted by the patient, and are often ineffective. It has been claimed that "coeliac plexus block is the simplest, most effective and least hazardous" means of palliation (49, 59); we think that this is true, and that coeliac plexus block should be considered more often than it is today, and at an earlier stage. Only in rare cases should pain from pancreatitis be treated with a nerve block.

Celiac plexus neurolysis with the modified transaortic approach

Celiac plexus block with alcohol was performed to relieve pain in 124 patients with abdominal malignancies. A transaortic technique was employed in which a single needle was advanced from a left posterior paramedian approach through the aorta to deposit anesthetic agent directly onto the celiac plexus. Ninety-one percent of patients experienced marked pain relief. No major hemorrhagic or neurologic complications were encountered. The transaortic method of celiac block is as effective as, easier to perform, and may be safer than the classic two-needle technique.

Teflon epidural catheter placement for intermittent celiac plexus blockade and celiac plexus neurolytic blockade

A 58-year-old with acute/chronic pancreatitis was treated with celiac plexus blockade. A percutaneous teflon catheter was placed for intermittent blockade and used for definitive neurolysis. There were no complications using this approach to celiac plexus blockade.

Pain treatment in cancer of the pancreas

Pancreatic cancer remains an important cause of suffering among oncologic patients. Due to the current poor response to specific therapies, a palliative approach represents the main treatment for this kind of tumour. The authors present the results of a prospective study performed on 41 patients treated according to the World Health Organization guidelines for cancer pain relief; 21 of them were treated by neurolytic coeliac blockade as well. Results, even if not comparable between the two groups, show that this neurolytic technique can play an important role in palliative treatment, on condition that it is part of a multimodal continuing care system.

Regional anesthesia for hepatic arterial embolization

Hepatic arterial embolization (HAE) has been utilized for treatment of unresectable primary and metastatic hepatic malignancies. While palliation results from this procedure, one of the major drawbacks to its use is the immediate short-term side effects, especially the right upper quadrant and epigastric pain experienced by all patients. High doses of intravenous narcotics have been used for pain control. The data on 18 patients who received a celiac plexus block immediately prior to 31 HAE procedures were compared with those on 19 control patients who underwent 42 HAE procedures without celiac plexus block. All patients who received a celiac plexus block had relief of pain without requiring intravenous analgesic both during the procedure and for the first 8 hours after HAE. These patients also subsequently received substantially lower dosages of analgesics than the control subjects. Two patients had transient hypotension due to the celiac plexus block, but no other complications occurred. It is recommended that patients undergoing HAE first receive a celiac plexus block for pain control.

[Effects of celiac plexus block on splanchnic circulation--II: Changes in the systemic hemodynamics and the blood flow of the liver and kidney in dogs]

Effects of celiac plexus block (CPB) on systemic and splanchnic circulation, especially of liver and kidney, were investigated in twenty nine mongrel dogs. CPB was performed by an anterior approach through a catheter placed in a paraaortic compartment using 7 mg.kg-1 of 2% mepivacaine. Tissue blood flow measurement was performed by a hydrogen clearance method in eleven dogs, and vascular blood flow was measured in eighteen dogs by an electromagnetic flow meter. Swan-Ganz catheter was inserted to measure mean arterial pressure (ABP), heart rate (HR), central venous pressure (CVP), mean pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP) and cardiac output (CO). Then stroke volume (SV), systemic vascular resistance (SVR) and pulmonary vascular resistance (PVR) were calculated. Following CPB, ABP, HR, CVP and C.O. were significantly decreased at 7 to 9%. PAP decreased at 5%. PCWP, SV, SVR and PVR were unchanged. The hepatic arterial blood flow increased significantly, and portal venous blood flow decreased after CPB transiently, and then recovered to control value or to a higher level at 60min after CPB. The tissue blood flow of the liver tended to increase, but the change was not significant. In the kidney, both arterial and tissue blood flows increased significantly after CPB. The results suggest that following CPB, hepatic and renal tissue blood flows increased because of the increments of their arterial blood flows, unless a profound systemic hemodynamic depression occurred.

Percutaneous anterior approach to the coeliac plexus using ultrasound

A new approach is described to the neurolytic block of the coeliac plexus through the anterior abdominal wall using ultrasonic guidance. In nine patients, ultrasound was used for needle placement and examination of the spread of injection. Total pain relief was obtained in seven of the patients after 2 weeks and in five patients after 6 months. No serious complications were observed. The anterior approach is simple and useful in those patients with chronic pancreatic pain undergoing biopsy of the pancreas, and in those terminally ill or heavily sedated patients who have difficulty in tolerating the prone flexed position.

Management of pain in pancreatic cancer

Potentially useful modalities of pain control in pancreatic cancer include antitumor therapy, pharmacotherapy, celiac plexus block, splanchnic nerve block, intercostal nerve block, and psychological intervention. These modalities are often used concurrently in treating the multiple dimensions that affect pain. Although thorough assessments are lacking, preliminary data suggest that antitumor chemotherapy and radiotherapy and celiac plexus block are especially useful modalities of pain control in these patients. The optimal time in the disease course for intervention with celiac plexus block is not known. Further studies are needed to clarify the nature of pain syndromes involved and the role of the various therapeutic modalities.

[The effect of celiac plexus block on splanchnic circulation; changes in systemic hemodynamics and tissue blood flow of the liver and kidney in rabbits]

The effects of the celiac plexus block (CPB) on the hepatic and renal tissue blood flow (TBF) were investigated in 45 rabbits. Together with this, the effects of drugs (phenylephrine: PE, norepinephrine: NE, dopamine: DA, 6% hydroxyethyl starch: HES) used to increase mean blood pressure (MBP) up to control level were also investigated. TBF was measured by the hydrogen clearance method. Following CPB, MBP and heart rate decreased significantly. TBF of the liver and kidney both decreased significantly for 14.3% and 25.9% respectively. A correlation was observed between the decreases of MBP and renal TBF. An increase in hepatic TBF beyond the control level was observed in DA group, and in both hepatic and renal TBF in the HES group after adjustment of MBP. In other groups, both hepatic and renal TBF tended to decrease. It was concluded that hepatic and renal TBF decreased because of hemodynamic suppression following CPB. The results also suggest that both TBFs would have increased if systemic hemodynamic change was not so great.

Paraplegia after coeliac plexus block

A case is described in which paraplegia followed a coeliac plexus block performed using 90% alcohol under X ray screening. The likely cause was an ischaemic injury to the cord secondary to damage to the artery of Adamkiewicz. This rare complication seems difficult to avoid.

Pain therapy for pancreatic carcinoma with neurolytic celiac plexus block

The past year's experience of the Pain and Regional Anesthesia Service at Hartford Hospital with neurolytic celiac plexus blockade for pancreatic cancer has been reviewed. The series includes eight patients with intractable pain from pancreatic cancer as well as two patients with pain from other abdominal malignancies. Nearly all patients noted good to excellent analgesia for up to 11 months. The only complication noted was one episode of mild, transient hypotension. Neurolytic celiac plexus blockade is a safe and effective means to relieve the terminal pain associated with not only pancreatic cancer but also other abdominal malignancies.

Coeliac plexus block and cephalic spread of injectate

Extensive cephalic spread of solution occurred in three out of seven cases studied during coeliac plexus blockade. Spread on to cardiac nerves and plexus may be a factor in hypotension following this procedure. Incremental dosage and careful screening is recommended.

Crossover study on effects of duct obliteration, celiac denervation, and autotransplantation on glucose- and meal-stimulated insulin, glucagon, and pancreatic polypeptide levels

In segmental-pancreas transplantation the body and tail of the pancreas are used. In an experimental study in dogs, the effects of sequentially conducted removal of the right pancreatic lobe (pancreatic head), duct obliteration, celiac denervation, and autotransplantation were studied according to a crossover design. Two groups of dogs were studied. In both groups the right lobe of the pancreas was removed at primary operation, and the duct of the transected left lobe (body and tail) was injected with fibrin sealant. The left lobe was completely freed from surrounding tissue (celiac denervation) in group 1 (n = 9), and the innervation of the left lobe was left intact in group 2 (n = 8). At 12 wk, two dogs in group 1 and four dogs in group 2 underwent successful autotransplantation of the left lobe. Pancreatic hormone secretion was stimulated by intravenous glucose injection and test-meal administration before primary operation and at 11 and 18 wk thereafter. The combination of removal of the right lobe and duct obliteration led to a decrease in glucose tolerance at both stimulation tests and a decrease in peripheral insulin release after intravenous glucose injection. At test-meal administration, no change in insulin and glucagon levels was demonstrated. If celiac denervation was added, similar results were obtained based on the understanding that the peripheral insulin release after the test meal was significantly elevated. Meal-stimulated pancreatic polypeptide response was abolished in both groups. Removal of the right lobe leads to parasympathic denervation of the left lobe, and celiac denervation mainly interferes with alpha-adrenergic innervation.(ABSTRACT TRUNCATED AT 250 WORDS)

Steroid celiac plexus block for chronic pancreatitis: results in 16 cases

Sixteen cases in which celiac plexus block with depot steroid was used to treat chronic pancreatitis pain were reviewed. Only 4 of 16 patients reported pain relief with the procedure. Of the 12 patients who did not obtain relief, narcotic dependence was present in 11 of 12. No patients in the "relief" group were narcotic dependent. Prior pancreatic surgery was present in 9 of the 12 patients without relief and in 1 of 4 patients with relief. It is postulated that refractory chronic pancreatitis pain may be an extreme form of what has been termed "abnormal illness behavior." Furthermore, these results underscore the poor results experienced using neural blockade for the relief of chronic pain when narcotic dependence is present.