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

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.

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.

Regional Cancer Pain Syndromes

Cancer pain often presents in a body region. This review summarizes articles from 1999-2004 relevant to cancer pain syndromes in the head and neck, chest, back, abdomen, pelvis, and limbs. Although the evidence is limited, progress is being made in further development of the evidence base to support and guide current practice.

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.

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.

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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.

Current standards of surgery for pancreatic cancer

Background

Pancreatic cancer carries a dismal prognosis but there has been a vast increase in evidence on its management in the past decade.

Methods

An electronic and manual search was performed for articles on the surgical treatment of pancreatic cancer published in the past 10 years.

Results

Six major areas of advancement were identified. Groups at high risk of developing pancreatic cancer, notably those with chronic pancreatitis and hereditary pancreatitis, have been defined, raising the need for secondary screening. Methods of staging pancreatic cancer for resection have greatly improved but accuracy is still only 85–90 per cent. Pylorus-preserving partial pancreatoduodenectomy without extended lymphadenectomy is the simplest procedure; it does not compromise long-term survival. Adjuvant chemotherapy significantly improves long-term survival. Patients who are free from major co-morbidity have better palliation by surgery (with a double bypass) than by endoscopy. High-volume centres improve the results of surgery for all outcome measures including long-term survival.

Conclusion

The surgical management of pancreatic cancer has undergone a significant change in the past decade. It has moved away from no active treatment. The standard of care can now be defined as potentially curative resection in a specialist centre followed by adjuvant systemic chemotherapy.

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.

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.

Neurohistopathologic findings after a neurolytic celiac plexus block with alcohol in patients with pancreatic cancer pain

Pancreatic cancer has a very poor prognosis resulting in the death of 98% of patients. Pain may be severe and difficult to treat. Management of pain includes chemotherapy, radiotherapy, pharmacologic treatment, and neurolytic celiac plexus block. Recent reviews of the efficacy of neurolytic celiac plexus block however, have reached conflicting conclusions. In this paper, we present two patients with severe pancreatic cancer pain resistant to pharmacologic treatment. Analgesic effect following repeated neurolytic celiac plexus blocks with alcohol was limited in time. Post-mortem neurohistopathologic examination of the celiac plexus revealed an abnormal celiac architecture with a combination of abnormal neurons with vacuolization and normal looking neuronal structures (ganglionic structures and nerve fibers) embedded in fibrotic hyalinized tissue. Our results show that a neurolytic celiac plexus block with alcohol is capable of partially destroying the celiac plexus. These findings may explain the significant but short-lasting analgesic effect following neurolytic celiac plexus block with alcohol.

Surgical and medical therapy for pancreatic carcinoma

Progress on the treatment of pancreatic ductal adenocarcinoma has involved advances in medical and surgical care with important contributions from disciplines such as radiology and intensive care. In the last decade large randomized controlled trials have been undertaken that demonstrate the improved patient outcomes. There is an increased risk of pancreatic cancer in chronic pancreatitis, hereditary pancreatitis and a variety of familial cancer syndromes. The optimum outcome from pancreatic cancer needs management by multidisciplinary teams in regional specialist units. Endoscopic stenting, good pain relief and pancreatic enzyme supplementation are the basis of care in advanced pancreatic cancer. Chemotherapy prolongs survival in advanced pancreatic cancer with little to be gained using drugs other than 5FU. Resection, if possible, prolongs life and provides the best quality of life. Adjuvant chemoradiotherapy is of no benefit but chemotherapy may improve survival. Alongside the evolution in clinical management has been the elucidation of the molecular events that underlie pancreatic cancer and this knowledge has guided the introduction of targeted treatments for pancreatic cancer.

Update on pancreatic cancer

Pancreatic cancer is one of the commonest causes of cancer death worldwide. Patients with pancreatic cancer benefit from resectional surgery (improved quality of life) and adjuvant treatment (enhanced survival). This review covers advances in the understanding of the development of pancreatic cancer, state-of-the-art clinical management and, finally, novel treatment and screening techniques.

Supportive care for patients with pancreatic adenocarcinoma: symptom control and nutrition

Pancreatic cancer is most frequently a fatal disease with many associated morbidities. Clinicians skilled in its treatment are adept at management of symptoms caused by local and systemic effects of the malignancy. Patients should be assured that there are many treatments that can be used aggressively to maintain their comfort and independence for as long as possible. Patients should be encouraged to inform their health care providers of any discomfort or medical or psychological problems they are experiencing. At times, referrals to specialists can be beneficial for consideration of specific symptom-improving interventions. Timely referral to a palliative medicine service and hospice can have significant beneficial impact on the total care of the patient and on home caregiver.

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.

Advances in cancer pain management

Control of malignant pain and related symptoms is paramount to clinical success in caring for cancer patients. To achieve the best quality of life for patients and families, oncologists and palliative care clinicians must work together to understand problems related to psychologic, social, and spiritual pain. Pain is the primary problem targeted for control using the World Health Organization's (WHO) analgesic ladder. This article focuses on increased knowledge of analgesic action that may enable expansion of the WHO analgesic ladder to fulfill the broader objectives of palliative medicine. We discuss clinical experience with several classes of drugs that are currently used to treat cancer pain: 1) nonsteroidal anti-inflammatory drugs, with emphasis on cyclooxygenase-2 inhibitors; 2) opioid analgesics, with specific emphasis on methadone and its newly recognized value in cancer pain; 3) ketamine, an antagonist at N-methyl-d-aspartate receptors; and 4) bisphosphonates, used for pain resulting from bone metastases. New concepts that compare molecular actions of morphine at excitatory opioid receptors, and methadone at nonopioid receptor systems, are presented to underscore the importance of balancing central nervous system excitatory (anti-analgesic) versus inhibitory (analgesic) influences.

Palliative strategies for locally advanced unresectable and metastatic pancreatic cancer

Technical improvement in perioperative morbidity and mortality with improved long-term survival associated with pancreaticoduodenectomy for patients with pancreatic carcinoma has clearly established a role for this operation when performed with curative intent. Most patients with pancreatic adenocarcinoma will not be candidates for surgical resection of their disease. These patients will experience significant symptoms potentially requiring surgical and nonsurgical palliative interventions to treat unrelieved cancer-associated pain, obstructive jaundice, or the development of GOO. The primary goal for palliative interventions should be to relieve symptoms with minimal morbidity and to maintain or improve the quality of life for patients with an expected limited survival.

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.

Advances in cancer pain management

Control of malignant pain and related symptoms is paramount to clinical success in caring for cancer patients. To achieve the best quality of life for patients and families, oncologists and palliative care clinicians must work together to understand problems related to psychologic, social, and spiritual pain. Pain is the primary problem targeted for control using the World Health Organization's (WHO) analgesic ladder. This article focuses on increased knowledge of analgesic action that may enable expansion of the WHO analgesic ladder to fulfill the broader objectives of palliative medicine. We discuss clinical experience with several classes of drugs that are currently used to treat cancer pain: 1) nonsteroidal anti-inflammatory drugs (NSAIDs), with emphasis on cyclooxygenase-2 (COX-2) inhibitors; 2) opioid analgesics, with specific emphasis on methadone and its newly recognized value in cancer pain; 3) ketamine, an antagonist at N-methyl d-aspartate (NMDA) receptors; and 4) bisphosphonates, used for pain resulting from bone metastases. New concepts that compare molecular actions of morphine at excitatory opioid receptors, and methadone at non-opioid receptor systems, are presented to underscore the importance of balancing central nervous system excitatory (anti-analgesic) versus inhibitory (analgesic) influences.