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Agarwal A, Aggarwal A, Shamshery C, Gambhir S, Nazar AH, Rajput AK. Robotic computed tomography-guided celiac plexus neurolysis: our experience of technique and outcomes. Pain Manag 2022; 12:675-680. [PMID: 35713399 DOI: 10.2217/pmt-2021-0092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: We report the use of robot assistance for computed tomography-guided celiac plexus neurolysis for the first time. Materials & methods: Four patients of upper abdominal cancer with intractable pain despite opioids were positioned prone on the PET-computed tomography scanner, which measured the accurate coordinates for the entry, depth and angle of the target point. The robot positioned its arm over the patient in accordance with the set needle path. The physician manually inserted needle through it and injected 20 ml of 0.75% alcohol after dye confirmation. Results: Significant reduction in pain scores and oral morphine consumption were observed in patients during 3 months follow-up. Conclusion: The robot precisely orients and helps in accurate placement of the needle through the robotic arm.
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Affiliation(s)
- Anil Agarwal
- Department of Anesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, UP, 226014, India
| | - Aakanksha Aggarwal
- Department of Anesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, UP, 226014, India
| | - Chetna Shamshery
- Department of Anesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, UP, 226014, India
| | - Sanjay Gambhir
- Department of Nuclear Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, UP, 226014, India
| | - Aftab Hasan Nazar
- Department of Nuclear Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, UP, 226014, India
| | - Abhishek Kumar Rajput
- Department of Anesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, UP, 226014, India
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Li M, Wang Z, Chen Y, Wu Z, Huang X, Wu C, Tian B. EUS-CGN versus EUS-CPN in pancreatic cancer: A qualitative systematic review. Medicine (Baltimore) 2021; 100:e27103. [PMID: 34731101 PMCID: PMC8519191 DOI: 10.1097/md.0000000000027103] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/12/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Comparison between endosonographic ultrasonography (EUS)-guided celiac ganglia neurolysis (CGN) and EUS-guided celiac plexus neurolysis (CPN) in pain management for pancreatic cancer has engendered controversy. To analyze the effectiveness and safety of EUS-CGN and figure out whether EUS-CGN is better than EUS-CPN, a qualitative systematic review was conducted. METHODS Studies were searched from Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE up to April 2020. We only included studies with full-text and in English and assessed study quality with Newcastle-Ottawa Scale or Cochrane risk-of-bias tool. We recorded details of study design, participants, procedure performed, protocol of follow-up, pain response, quality of life, survival, and adverse events. The study was conducted under Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement 2009. RESULTS Five studies involving 319 patients were included. Short-term pain response rates ranged from 65.0% to 88.46% in EUS-CGN group and most studies reported its superiority over EUS-CPN. As for adverse events, the incidence of transient hypotension and gastrointestinal symptoms seemed comparable, while results of initial pain exacerbation varied among studies. Besides, EUS-CGN might provide a shorter survival. CONCLUSION EUS-CGN can be safely performed while it may shorten survival. In terms of short-term pain response, EUS-CGN is better than EUS-CPN while no conclusion of long-term pain control can be drawn.
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Gupta R, Madanat L, Jindal V, Gaikazian S. Celiac Plexus Block Complications: A Case Report and Review of the Literature. J Palliat Med 2021; 24:1409-1412. [PMID: 33395560 DOI: 10.1089/jpm.2020.0530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Celiac plexus block (CPB) has been widely used as a treatment option for chronic intractable abdominal pain resulting from intra-abdominal malignancies as well as benign conditions. Complications resulting from CPB have been long reported and include diarrhea, back pain, paraplegia, postural hypotension, pneumothorax, and local anesthesia toxicity. Diarrhea and postural hypotension are two most common complications with studies reporting incidences occurring in 44% to 60% and 10% to 52% of patients, respectively. Diarrhea is most often transient, resolving within 48 hours; however, literature reports cases in which diarrhea was chronic, debilitating, and in some instances life threatening. Persistent diarrhea proves difficult to treat. We report a case of a 76-year-old male with unresectable pancreatic adenocarcinoma who underwent computed tomography-guided CBP complicated by persistent diarrhea and fecal incontinence. After conventional antidiarrheal failed to improve the symptoms, octreotide proved to be beneficial and the patient reported significant improvement in symptoms.
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Affiliation(s)
- Ruby Gupta
- Department of Hematology and Medical Oncology, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Luai Madanat
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Vishal Jindal
- Department of Hematology and Medical Oncology, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Susanna Gaikazian
- Department of Hematology and Medical Oncology, William Beaumont Hospital, Royal Oak, Michigan, USA
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Filippiadis DK, Tselikas L, Tsitskari M, Kelekis A, de Baere T, Ryan AG. Percutaneous Neurolysis for Pain Management in Oncological Patients. Cardiovasc Intervent Radiol 2019; 42:791-799. [DOI: 10.1007/s00270-019-02185-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 02/13/2019] [Indexed: 12/29/2022]
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Liu C, Wang L, He X, Xu Y, Lu D, Li P, Lv R, Feng Y, Liu M, Li C. 1.0T MR-guided percutaneous coaxial cutting needle biopsy in pancreatic lesion diagnosis. J Magn Reson Imaging 2018; 48:382-388. [PMID: 29319916 DOI: 10.1002/jmri.25952] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 12/21/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Pancreatic carcinoma is a common cause of cancer deaths worldwide. Biopsy is often required for the initial diagnosis of pancreatic masses. Biopsy can be performed endoscopically or percutaneously with computed tomography (CT) and ultrasound (US) guidance. MRI offers many inherent advantages over CT and US. PURPOSE/HYPOTHESIS To prospectively evaluate the feasibility, accuracy, and safety of MRI-guided percutaneous coaxial cutting needle biopsy of pancreatic lesions using an open 1.0T high-field MR scanner. STUDY TYPE Prospective. POPULATION Thirty-one patients with 31 pancreatic lesions underwent MR-guided percutaneous coaxial cutting needle biopsy. FIELD STRENGTH/SEQUENCE 1.0T T2 WI-TSE PDW-aTSE T1 WI-TFE. ASSESSMENT Final diagnosis was confirmed by surgery and clinical follow-up for at least 12 months. The accuracy, sensitivity, and specificity were calculated. Complications were recorded. STATISTICAL TESTS There was no statistical analysis in this study. RESULTS The procedure was technically successful and final biopsy samples were adequate for histopathological examination in all patients. Biopsy pathology revealed malignant pancreatic tumor in 25 patients (25/31, 80.6%), and benign pancreatic lesions were present in six patients (6/31, 19.4%). The final diagnosis was pancreatic malignancy in 27 patients and benign disease in four patients, which was confirmed by surgery and clinical follow-up. Two biopsy results were false-negative. The diagnostic accuracy in biopsies was 93.5% (29 of 31). The sensitivity to detect a malignant disease was 92.6% (25 of 27), and the specificity was 100%. All patients tolerated the procedure well; minor peripancreatic hemorrhage was found in two patients after the procedure, and none had major complications either during or after the procedure. DATA CONCLUSION MRI-guided percutaneous biopsy of pancreatic lesions using an open 1.0T high-field scanner has high diagnostic accuracy, which is feasible and safe for use in clinical practice. LEVEL OF EVIDENCE 2 Technical Efficacy: Stage 2 J. MAGN. RESON. IMAGING 2018;48:382-388.
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Affiliation(s)
- Chao Liu
- Department of Minimally Invasive Tumor, Tai'an Central Hospital, Tai'an, Shandong, P.R. China
| | - Ligang Wang
- Department of Interventional Therapy, Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, P.R. China
| | - Xiangmeng He
- Department of Interventional MRI, Shandong Medical Imaging Research Institute affiliated to Shandong University, Jinan, Shandong, P.R. China
| | - Yujun Xu
- Department of Interventional MRI, Shandong Medical Imaging Research Institute affiliated to Shandong University, Jinan, Shandong, P.R. China
| | - Dong Lu
- Department of Interventional Radiology, Affiliated Anhui Provincial Hospital of Anhui Medical University, Hefei, Anhui, P.R. China
| | - Peipei Li
- Department of Oncology, Liaocheng Tumor Hospital, Liaocheng, Shandong, P.R. China
| | - Rongbin Lv
- Department of Nuclear Medicine, Tai'an Central Hospital, Tai'an, Shandong, P.R. China
| | - Yong Feng
- Department of Minimally Invasive Tumor, Tai'an Central Hospital, Tai'an, Shandong, P.R. China
| | - Ming Liu
- Department of Interventional MRI, Shandong Medical Imaging Research Institute affiliated to Shandong University, Jinan, Shandong, P.R. China
| | - Chengli Li
- Department of Interventional MRI, Shandong Medical Imaging Research Institute affiliated to Shandong University, Jinan, Shandong, P.R. China
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Marker DR, U Thainual P, Ungi T, Flammang AJ, Fichtinger G, Iordachita II, Carrino JA, Fritz J. 1.5 T augmented reality navigated interventional MRI: paravertebral sympathetic plexus injections. Diagn Interv Radiol 2018; 23:227-232. [PMID: 28420598 DOI: 10.5152/dir.2017.16323] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE The high contrast resolution and absent ionizing radiation of interventional magnetic resonance imaging (MRI) can be advantageous for paravertebral sympathetic nerve plexus injections. We assessed the feasibility and technical performance of MRI-guided paravertebral sympathetic injections utilizing augmented reality navigation and 1.5 T MRI scanner. METHODS A total of 23 bilateral injections of the thoracic (8/23, 35%), lumbar (8/23, 35%), and hypogastric (7/23, 30%) paravertebral sympathetic plexus were prospectively planned in twelve human cadavers using a 1.5 Tesla (T) MRI scanner and augmented reality navigation system. MRI-conditional needles were used. Gadolinium-DTPA-enhanced saline was injected. Outcome variables included the number of control magnetic resonance images, target error of the needle tip, punctures of critical nontarget structures, distribution of the injected fluid, and procedure length. RESULTS Augmented-reality navigated MRI guidance at 1.5 T provided detailed anatomical visualization for successful targeting of the paravertebral space, needle placement, and perineural paravertebral injections in 46 of 46 targets (100%). A mean of 2 images (range, 1-5 images) were required to control needle placement. Changes of the needle trajectory occurred in 9 of 46 targets (20%) and changes of needle advancement occurred in 6 of 46 targets (13%), which were statistically not related to spinal regions (P = 0.728 and P = 0.86, respectively) and cadaver sizes (P = 0.893 and P = 0.859, respectively). The mean error of the needle tip was 3.9±1.7 mm. There were no punctures of critical nontarget structures. The mean procedure length was 33±12 min. CONCLUSION 1.5 T augmented reality-navigated interventional MRI can provide accurate imaging guidance for perineural injections of the thoracic, lumbar, and hypogastric sympathetic plexus.
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Affiliation(s)
- David R Marker
- Russel H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Cornman-Homonoff J, Holzwanger DJ, Lee KS, Madoff DC, Li D. Celiac Plexus Block and Neurolysis in the Management of Chronic Upper Abdominal Pain. Semin Intervent Radiol 2017; 34:376-386. [PMID: 29249862 DOI: 10.1055/s-0037-1608861] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Chronic upper abdominal pain occurs as a complication of various malignant and benign diseases including pancreatic cancer and chronic pancreatitis, and when present may contribute to lower quality of life and higher mortality. Though various pain management strategies are available as part of a multimodal approach, they are often incompletely effective and accompanied by side effects. Pain originating in upper abdominal viscera is transmitted through the celiac plexus, which is an autonomic plexus located in the retroperitoneum at the root of the celiac trunk. Direct intervention at the level of the plexus, referred to as celiac plexus block or neurolysis depending on the injectate, is a minimally invasive therapeutic strategy which has been demonstrated to decrease pain, improve function, and reduce opiate dependence. Various percutaneous techniques have been reported, but, with appropriate preprocedural planning, use of image guidance (usually computed tomography), and postprocedural care, the frequency and severity of complications is low and the success rate high regardless of approach. The main benefit of the intervention may be in reduced opiate dependence and opiate-associated side effects, which in turn improves quality of life. Celiac plexus block and neurolysis are safe and effective treatments for chronic upper abdominal pain and should be considered early in patients experiencing such symptoms.
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Affiliation(s)
- Joshua Cornman-Homonoff
- Department of Radiology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Daniel J Holzwanger
- Department of Radiology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Kyungmouk S Lee
- Department of Radiology, Division of Interventional Radiology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - David C Madoff
- Department of Radiology, Division of Interventional Radiology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - David Li
- Department of Radiology, Division of Interventional Radiology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
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Edelstein MR, Gabriel RT, Elbich JD, Wolfe LG, Sydnor MK. Pain Outcomes in Patients Undergoing CT-Guided Celiac Plexus Neurolysis for Intractable Abdominal Visceral Pain. Am J Hosp Palliat Care 2016; 34:111-114. [PMID: 26345319 DOI: 10.1177/1049909115604670] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The purpose of this study was to assess outcomes in patients who have undergone celiac plexus neurolysis (CPN) as treatment for refractory abdominal visceral pain at a tertiary care medical center. This study involved retrospective analysis of all patients who had undergone computed tomography (CT)-guided CPN over a 7-year period, as identified in the medical record. Cases were categorized into 1 of 3 groups-group 1: patients getting at least moderate improvement in pain but with improvements subsiding within 2 days; group 2: patients with some sustained pain relief but still requiring heavy doses of narcotics; group 3: patients with major or complete sustained reduction in pain where the narcotic dose was able to be reduced. One hundred thirty-eight cases were identified, 51 of which had no or insufficient follow-up, leaving 87 cases for analysis. Of the 87 cases, 31 (36%) were categorized as group 1, 21 (24%) as group 2, and 35 (40%) as group 3. There were no statistical differences in outcomes based on patient age, gender, time since diagnosis, or type of cancer. Documented postoperative complications were diarrhea (11 cases) and 1 case each of obtundation, hypotension, and presyncopal event. We conclude that patients undergoing CT-guided CPN for abdominal visceral pain achieve moderate or major short-term pain relief in a majority of cases. The procedure is safe with minimal complications.
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Affiliation(s)
- Mark R Edelstein
- 1 Department of Radiology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Ryan T Gabriel
- 1 Department of Radiology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Jeffrey D Elbich
- 1 Department of Radiology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Luke G Wolfe
- 2 Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Malcolm K Sydnor
- 1 Department of Radiology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
- 2 Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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Marker DR, U-Thainual P, Ungi T, Flammang AJ, Fichtinger G, Iordachita II, Carrino JA, Fritz J. MR-guided perineural injection of the ganglion impar: technical considerations and feasibility. Skeletal Radiol 2016; 45:591-7. [PMID: 26791162 DOI: 10.1007/s00256-016-2333-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 01/03/2016] [Accepted: 01/07/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Perineural ganglion impar injections are used in the management of pelvic pain syndromes; however, there is no consensus regarding the optimal image guidance. Magnetic resonance imaging (MRI) provides high soft tissue contrast and the potential to directly visualize and target the ganglion. The purpose of this study was to assess the feasibility of MR-guided percutaneous perineural ganglion impar injections. MATERIALS AND METHODS Six MR-guided ganglion impar injections were performed in six human cadavers. Procedures were performed with a clinical 1.5-Tesla MRI system through a far lateral transgluteus approach. Ganglion impar visibility, distance from the sacrococcygeal joint, number of intermittent MRI control steps required to place the needle, target error between the intended and final needle tip location, inadvertent punctures of non-targeted vulnerable structures, injectant distribution, and procedure time were determined. RESULTS The ganglion impar was seen on MRI in 4/6 (66 %) of cases and located 0.8 mm cephalad to 16.3 mm caudad (average 1.2 mm caudad) to the midpoint of the sacrococcygeal joint. Needle placement required an average of three MRI control steps (range, 2-6). The average target error was 2.2 ± 2.1 mm. In 6/6 cases (100 %), there was appropriate periganglionic distribution and filling of the presacrococcygeal space. No punctures of non-targeted structures occurred. The median procedure time was 20 min (range, 12-29 min). CONCLUSION Interventional MRI can visualize and directly target the ganglion impar for accurate needle placement and successful periganglionic injection with the additional benefit of no ionizing radiation exposure to patient and staff. Our results support clinical evaluation.
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Affiliation(s)
- David R Marker
- Russell H. Morgan Department of Radiology and Radiological Science, Musculoskeletal Radiology, Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 3140A, Baltimore, MD, 21287, USA
| | - Paweena U-Thainual
- Department of Mechanical and Materials Engineering, Queen's University, 99 University Avenue, Kingston, ON, Canada
| | - Tamas Ungi
- School of Computing, Queen's University, 557 Goodwin Hall, Queen's University, Kingston, ON, Canada
| | - Aaron J Flammang
- Siemens Corporate Research, Center for Applied Medical Imaging, Baltimore, MD, USA
| | - Gabor Fichtinger
- School of Computing, Queen's University, 557 Goodwin Hall, Queen's University, Kingston, ON, Canada
| | - Iulian I Iordachita
- Department of Mechanical Engineering and Laboratory for Computational Sensing and Robotics, Johns Hopkins University, 3400 N. Charles St., Hackerman 112, Baltimore, MD, 21218, USA
| | - John A Carrino
- Russell H. Morgan Department of Radiology and Radiological Science, Musculoskeletal Radiology, Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 3140A, Baltimore, MD, 21287, USA
| | - Jan Fritz
- Russell H. Morgan Department of Radiology and Radiological Science, Musculoskeletal Radiology, Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 3140A, Baltimore, MD, 21287, USA.
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Liu S, Fu W, Liu Z, Liu M, Ren R, Zhai H, Li C. MRI-guided celiac plexus neurolysis for pancreatic cancer pain: Efficacy and safety. J Magn Reson Imaging 2016; 44:923-8. [PMID: 27019192 DOI: 10.1002/jmri.25246] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/03/2016] [Accepted: 03/04/2016] [Indexed: 01/29/2023] Open
Abstract
PURPOSE To prospectively determine the efficacy and safety of magnetic resonance imaging (MRI)-guided celiac plexus neurolysis (CPN) for pancreatic cancer pain. MATERIALS AND METHODS In all, 39 patients with pancreatic cancer underwent 0.23T MRI-guided CPN with ethanol via the posterior approach. The pain relief, the opioid intake, and pain interference with appetite, sleep, and communication in patients were assessed after CPN during a 4-month follow-up period. The complications were also evaluated during or after CPN. RESULTS CPN procedures were successfully completed for all patients. Minor complications included diarrhea (9 of 39; 23.1%), orthostatic hypotension (14 of 39; 35.9%), and local backache (20 of 39; 51.3%). No major complication occurred. Pain relief was observed in 36 (92.3%), in 15 (40.5%), and in 11 (35.5%) patients at 1-, 2-, and 3-month visits, respectively. The median duration of pain relief was 2.9 months (95% confidence interval [CI], 2.4-3.4). The opioid intake significantly decreased at the 1-, 2-, and 3-month visits (P < 0.001, < 0.001, = 0.001 respectively), and there was significant improvement in sleep at the 1-, 2-, and 3-month visits (P < 0.001, < 0.001, = 0.001 respectively), and appetite and communication were significantly improved at the 1- and 2-month visits (all P < 0.001); all compared with baseline. CONCLUSION MRI-guided CPN appears to be an effective and minimally invasive procedure for palliative pain management of pancreatic cancer. J. MAGN. RESON. IMAGING 2016;44:923-928.
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Affiliation(s)
- Shangang Liu
- Department of Medical Oncology, Fourth People's Hospital of Zibo City, The affiliated Hospital of Shandong Cancer Hospital and Institute, Zibo, China
| | - Weiwei Fu
- Department of Medical Oncology, Fourth People's Hospital of Zibo City, The affiliated Hospital of Shandong Cancer Hospital and Institute, Zibo, China
| | - Zengjun Liu
- Department of Medical Oncology, Shandong Cancer Hospital and Institute, Jinan, China
| | - Ming Liu
- Department of Interventional MRI, Shandong Medical Imaging Research Institute, Shandong University, Jinan, China
| | - Ruimei Ren
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, China
| | - Huaxu Zhai
- Department of Medical Oncology, Fourth People's Hospital of Zibo City, The affiliated Hospital of Shandong Cancer Hospital and Institute, Zibo, China
| | - Chengli Li
- Department of Interventional MRI, Shandong Medical Imaging Research Institute, Shandong University, Jinan, China.
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Abstract
BACKGROUND Pain originating from the organs of the upper abdomen, especially in patients suffering from inoperable carcinoma of the pancreas or advanced inflammatory conditions, is difficult to treat in a significant number of patients. STANDARD RADIOLOGICAL PROCEDURES Computed tomography (CT) guided neurolysis is the most commonly used technique for neurolysis of the celiac plexus. Ethanol is used to destroy the nociceptive fibers passing through the plexus and provides an effective means of diminishing pain arising from the upper abdomen. METHODS Using either an anterior or posterior approach, a 22 G Chiba needle is advanced to the antecrural space and neurolysis is achieved by injecting a volume of 20-50 ml of ethanol together with a local anesthetic and contrast medium. PERFORMANCE In up to 80% of patients suffering from tumors of the upper abdomen, CT-guided celiac plexus neurolysis diminishes pain or allows a reduction of analgesic medication; however, in some patients the effect may only be temporary necessitating a second intervention. In inflammatory conditions, celiac neurolysis is often less effective in reducing abdominal pain. PRACTICAL RECOMMENDATIONS The CT-guided procedure for neurolysis of the celiac plexus is safe and effective in diminishing pain especially in patients suffering from tumors of the upper abdomen. The procedure can be repeated if the effect is only temporary.
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Pereira GAM, Lopes PTC, Dos Santos AMPV, Pozzobon A, Duarte RD, Cima ADS, Massignan Â. Celiac plexus block: an anatomical study and simulation using computed tomography. Radiol Bras 2015; 47:283-7. [PMID: 25741102 PMCID: PMC4341398 DOI: 10.1590/0100-3984.2013.1881] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 03/10/2014] [Indexed: 01/09/2023] Open
Abstract
Objective To analyze anatomical variations associated with celiac plexus complex by means of
computed tomography simulation, assessing the risk for organ injury as the
transcrural technique is utilized. Materials and Methods One hundred eight transaxial computed tomography images of abdomen were analyzed.
The aortic-vertebral, celiac trunk (CeT)-vertebral, CeT-aortic and
celiac-aortic-vertebral topographical relationships were recorded. Two needle
insertion pathways were drawn on each of the images, at right and left, 9 cm and
4.5 cm away from the midline. Transfixed vital organs and gender-related
associations were recorded. Results Aortic-vertebral - 45.37% at left and 54.62% in the middle; CeT-vertebral - T12,
36.11%; T12-L1, 32.4%; L1, 27.77%; T11-T12, 2.77%; CeT-aortic - 53.7% at left and
46.3% in the middle; celiac-aortic-vertebral - L-l, 22.22%; M-m, 23.15%; L-m,
31.48%; M-l, 23.15%. Neither correspondence on the right side nor significant
gender-related associations were observed. Conclusion Considering the wide range of abdominal anatomical variations and the
characteristics of needle insertion pathways, celiac plexus block should not be
standardized. Imaging should be performed prior to the procedure in order to
reduce the risks for injuries or for negative outcomes to patients. Gender-related
anatomical variations involved in celiac plexus block should be more deeply
investigated, since few studies have addressed the subject.
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Affiliation(s)
| | | | | | - Adriane Pozzobon
- PhD, Human Anatomy Professor, Centro Universitário Univates, Lajeado, RS, Brazil
| | | | - Alexandre da Silveira Cima
- MDs, Undergraduates, Specialization Program, Radiology and Imaging Diagnosis, Fundação Serdil/Saint Pastous, Porto Alegre, RS, Brazil
| | - Ângela Massignan
- MDs, Undergraduates, Specialization Program, Radiology and Imaging Diagnosis, Fundação Serdil/Saint Pastous, Porto Alegre, RS, Brazil
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MR Imaging-guided Lumbosacral Spinal Injection Procedures. Tech Orthop 2013. [DOI: 10.1097/bto.0b013e3182867817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Akural E, Ojala RO, Järvimäki V, Kariniemi J, Tervonen OA, Blanco Sequeiros R. MR-guided Neurolytic Celiac Plexus Ablation: An Evaluation of Effect and Injection Spread Pattern in Cancer Patients with Celiac Tumor Infiltration. Cardiovasc Intervent Radiol 2012; 36:472-8. [DOI: 10.1007/s00270-012-0417-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 04/22/2012] [Indexed: 10/28/2022]
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Kambadakone A, Thabet A, Gervais DA, Mueller PR, Arellano RS. CT-guided celiac plexus neurolysis: a review of anatomy, indications, technique, and tips for successful treatment. Radiographics 2012; 31:1599-621. [PMID: 21997984 DOI: 10.1148/rg.316115526] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The celiac plexus is the largest visceral plexus and is located deep in the retroperitoneum, over the anterolateral surface of the aorta and around the origin of the celiac trunk. It serves as a relay center for nociceptive impulses that originate from the upper abdominal viscera, from the stomach to the proximal transverse colon. Celiac plexus neurolysis, with agents such as ethanol, is an effective means of diminishing pain that arises from these structures. Percutaneous imaging-guided celiac plexus neurolysis has been established as an invaluable therapeutic option in the management of intractable abdominal pain in patients with upper abdominal malignancy. The use of multidetector computed tomography (CT) for imaging guidance has superseded other modalities and allows direct visualization of the spread of the neurolytic agent in the antecrural space. Accurate depiction of the retroperitoneal anatomy and the position of the needle tip helps avoid crucial anatomic structures such as the pancreas, aorta, celiac artery, and superior mesenteric artery. Proper patient education, meticulous preprocedure planning, use of optimal multidetector CT techniques, adjunctive CT maneuvers, and postprocedure care are integral to successful celiac plexus neurolysis. Celiac plexus neurolysis does not completely abolish pain; rather, it diminishes pain, helping to reduce opioid requirements and their related side effects and improving survival in patients with upper abdominal malignancy.
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Affiliation(s)
- Avinash Kambadakone
- Division of Abdominal Imaging and Intervention, Massachusetts General Hospital, 55 Fruit St, White 270, Boston, MA 02114, USA
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Abstract
Magnetic resonance (MR)-guided spine injections describe techniques for selective spine injection procedures, in which MR imaging is used to visualize spinal targets and needle placement, monitor the injected drugs, and detect spread to potentially confounding nearby structures. The introduction of clinical high-field wide-bore MR imaging systems has increased the practicability and availability of MR-guided spine injections. The use of 1.5-T field strength, modern coils, and parallel imaging technology increases the MR signal, which can be utilized for faster temporal image acquisition, higher image resolution, better image contrast, or combinations thereof. Magnetic resonance imaging guidance provides excellent osseous and soft-tissue detail of spinal structures and is well suited to avoid radiation exposure. In this article, we discuss the technical background of interventional MR imaging, review the literature, and illustrate interventional MR imaging techniques of commonly performed spinal injection procedures, including sacroiliac joint injections, lumbar facet joint injections, selective spinal nerve root infiltration, and percutaneous drug delivery to the lumbar sympathetic nerves.
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Affiliation(s)
- Jan Fritz
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Bhatnagar S, Khanna S, Roshni S, Goyal GN, Mishra S, Rana SPS, Thulkar S. Early ultrasound-guided neurolysis for pain management in gastrointestinal and pelvic malignancies: an observational study in a tertiary care center of urban India. Pain Pract 2011; 12:23-32. [PMID: 21615855 DOI: 10.1111/j.1533-2500.2011.00467.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Patients with advanced gastrointestinal and pelvic malignancies commonly present with pain of varying severity. In a majority of these patients, pain can be effectively managed using an integrated systemic pharmacological approach with oral morphine being the cornerstone of treatment. However, with escalating doses, intolerable side effects of oral morphine may lead to patient dissatisfaction. When oral pharmacotherapy fails to adequately address the issue of pain or leads to insufferable side effects, neurolytic blocks of the sympathetic axis are usually used for pain alleviation. As these blocks may reduce oral analgesic requirement, a reevaluation of their timing is merited. This article presents our hospital-based in-patient palliative care unit experience with early ultrasonography-guided neurolysis of celiac plexus, superior hypogastric plexus and ganglion impar. Of the 44 patients we studied, 20 underwent celiac plexus neurolysis, 18 superior hypogastric plexus neurolysis, and 6 ganglion impar neurolysis. Their pain was being managed with oral morphine before neurolysis, but only 11.4% patients required oral morphine for satisfactory pain control, 2 months after neurolysis. The mean Visual Analog Scale score before block placement was 5.64 ± 0.69 and fell to 2.25 ± 1.33 at 2 months post neurolysis (P < 0.001). We suggest that bedside ultrasonography-guided sympathetic axis neurolysis may be employed early in patients with incurable abdominal or pelvic cancer. Its use as a first-line intervention for achieving pain control with minimal complications warrants further consideration and investigation.
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Affiliation(s)
- Sushma Bhatnagar
- Department of Anesthesiology, IRCH, All India Institute of Medical Sciences, New Delhi, India.
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Raphael J, Hester J, Ahmedzai S, Barrie J, Farqhuar-Smith P, Williams J, Urch C, Bennett MI, Robb K, Simpson B, Pittler M, Wider B, Ewer-Smith C, DeCourcy J, Young A, Liossi C, McCullough R, Rajapakse D, Johnson M, Duarte R, Sparkes E. Cancer pain: part 2: physical, interventional and complimentary therapies; management in the community; acute, treatment-related and complex cancer pain: a perspective from the British Pain Society endorsed by the UK Association of Palliative Medicine and the Royal College of General Practitioners. PAIN MEDICINE 2010; 11:872-96. [PMID: 20456069 DOI: 10.1111/j.1526-4637.2010.00841.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE This discussion document about the management of cancer pain is written from the pain specialists' perspective in order to provoke thought and interest in a multimodal approach to the management of cancer pain, not just towards the end of life, but pain at diagnosis, as a consequence of cancer therapies, and in cancer survivors. It relates the science of pain to the clinical setting and explains the role of psychological, physical, interventional and complementary therapies in cancer pain. METHODS This document has been produced by a consensus group of relevant healthcare professionals in the United Kingdom and patients' representatives making reference to the current body of evidence relating to cancer pain. In the second of two parts, physical, invasive and complementary cancer pain therapies; treatment in the community; acute, treatment-related and complex cancer pain are considered. CONCLUSIONS It is recognized that the World Health Organization (WHO) analgesic ladder, whilst providing relief of cancer pain towards the end of life for many sufferers world-wide, may have limitations in the context of longer survival and increasing disease complexity. To complement this, it is suggested that a more comprehensive model of managing cancer pain is needed that is mechanism-based and multimodal, using combination therapies including interventions where appropriate, tailored to the needs of an individual, with the aim to optimize pain relief with minimization of adverse effects.
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Affiliation(s)
- Jon Raphael
- Faculty of Health, Birmingham City University, Birmingham, UK.
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Bhatnagar S, Gupta D, Mishra S, Thulkar S, Chauhan H. Bedside Ultrasound-Guided Celiac Plexus Neurolysis with Bilateral Paramedian Needle Entry Technique can be an Effective Pain Control Technique in Advanced Upper Abdominal Cancer Pain. J Palliat Med 2008; 11:1195-9. [DOI: 10.1089/jpm.2008.0082] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sushma Bhatnagar
- Department of Anesthesiology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gupta
- Department of Anesthesiology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Seema Mishra
- Department of Anesthesiology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Thulkar
- Department of Radiology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Himanshu Chauhan
- Department of Anesthesiology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
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Celiac Plexus Blockade in Children Using a Three-Dimensional Fluoroscopic Reconstruction Technique. Reg Anesth Pain Med 2007. [DOI: 10.1097/00115550-200711000-00010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Zhang XM, Zhao QH, Zeng NL, Cai CP, Xie XG, Li CJ, Liu J, Zhou JY. The Celiac Ganglia: Anatomic Study Using MRI in Cadavers. AJR Am J Roentgenol 2006; 186:1520-3. [PMID: 16714639 DOI: 10.2214/ajr.04.1765] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Our objective was to facilitate the in vivo identification of the celiac ganglia on MRI by using MRI to identify the celiac ganglia in cadavers. CONCLUSION MRI can show the celiac ganglia accurately in cadavers when the ganglia are large and labeled with gadolinium. The findings in cadavers can be a reference for identifying the celiac ganglia in vivo.
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Affiliation(s)
- Xiao Ming Zhang
- Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Wenhua Road 63, Nanchong, Sichuan 637000, PR China
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24
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Akinci D, Akhan O. Celiac ganglia block. Eur J Radiol 2005; 55:355-61. [PMID: 16129244 DOI: 10.1016/j.ejrad.2005.03.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2005] [Revised: 03/07/2005] [Accepted: 03/10/2005] [Indexed: 11/16/2022]
Abstract
Pain occurs frequently in patients with advanced cancers. Tumors originating from upper abdominal viscera such as pancreas, stomach, duodenum, proximal small bowel, liver and biliary tract and from compressing enlarged lymph nodes can cause severe abdominal pain, which do not respond satisfactorily to medical treatment or radiotherapy. Percutaneous celiac ganglia block (CGB) can be performed with high success and low complication rates under imaging guidance to obtain pain relief in patients with upper abdominal malignancies. A significant relationship between pain relief and degree of tumoral celiac ganglia invasion according to CT features was described in the literature. Performing the procedure in the early grades of celiac ganglia invasion on CT can increase the effectiveness of the CGB, which is contrary to World Health Organization criteria stating that CGB must be performed in patients with advanced stage cancer. CGB may also be effectively performed in patients with chronic pancreatitis for pain palliation.
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Affiliation(s)
- Devrim Akinci
- Department of Radiology, Hacettepe University School of Medicine, Sihhiye, 06100 Ankara, Turkey
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Abstract
AIDS is an advanced disease with systemic and infectious complications that can be fatal. When a patient with AIDS presents with right upper quadrant or midepigastric pain, cholestasis, and symptoms of cholangitis, AIDS cholangiopathy should be suspected and appropriate diagnostic and therapeutic interventions should be initiated. Opportunistic infections such as Cryptosporidium and cytomegalovirus are the most common cause of AIDS cholangiopathy. Four distinct cholangiographic abnormalities have been demonstrated by endoscopic retrograde cholangiopancreatography, the most common being papillary stenosis with sclerosing cholangitis. Antimicrobial therapy is often ineffective. Highly active antiretroviral therapy may enhance immune function and offers the best medical therapy to clear the opportunistic infections. Ursodeoxycholic acid has a limited benefit in patients with sclerosing cholangitis and cholestasis. Endoscopic sphincterotomy has been shown to relieve pain and biliary obstruction in patients with papillary stenosis. Balloon dilation of strictures and stent placement decompress the biliary system and may be helpful. Cholecystectomy is recommended to treat acalculous cholecystitis, and celiac plexus block may be offered to patients with terminal disease and intractable abdominal pain.
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Affiliation(s)
- Tony E. Yusuf
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
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Bhutani MS, Pasricha PJ. Neurolytic Approaches for the Treatment of Pain in Patients with Chronic Pancreatitis. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2003; 6:375-379. [PMID: 12954144 DOI: 10.1007/s11938-003-0040-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
In large part, treatment options for patients with painful chronic pancreatitis remain empirical because of our limited understanding of the pathobiology of pancreatic pain. The procedures of neural block/ablation exemplify these limitations, which include the lack of a clear biologic rationale for various approaches, as well as unequivocal data on long-term outcomes and efficacy. Although the techniques themselves appear to be well established, controlled trials of various medical, endoscopic, radiologic, and surgical options to define the best treatment are clearly needed. In addition, the lack of uniform improvement with any technique underscores the need for applying a multidisciplinary approach to these patients, as should be the case for any chronic pain disorder.
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Affiliation(s)
- Manoop S. Bhutani
- Division of Gastroenterology and Hepatology, University of Texas Medical Branch, 4.106 McCullough Building, 301 University Boulevard, Galveston, TX 77555-0764, USA.
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el-Kamar FG, Grossbard ML, Kozuch PS. Metastatic pancreatic cancer: emerging strategies in chemotherapy and palliative care. Oncologist 2003; 8:18-34. [PMID: 12604729 DOI: 10.1634/theoncologist.8-1-18] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
This update is devoted to discussion of optimal supportive and palliative care of patients with pancreatic cancer. Approximately 33,000 new cases of pancreatic cancer are predicted for the U.S. in 2002. Because diagnosis and intervention occur late in the course of this disease, the vast majority of patients already have metastatic disease at the time of diagnosis. These tumors are relatively resistant to systemic chemotherapy, making pancreatic cancer the fourth leading cause of cancer-related death in the U.S. and the Western world. For these reasons, efforts at identifying and treating disease-related symptomatology are priorities. This update overviews symptom management, supportive care strategies, and both standard and emerging palliative chemotherapy options. The incorporation of molecularly targeted therapies into treatment of metastatic pancreatic cancer is reviewed as well. These strategies are of relevance to internists, gastroenterologists, oncologists, and other specialists who care for patients with pancreatic cancer.
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Affiliation(s)
- Francois G el-Kamar
- Division of Hematology and Oncology, St. Luke's-Roosevelt Hospital Center, New York, New York 10019, USA
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Titton RL, Lucey BC, Gervais DA, Boland GW, Mueller PR. Celiac plexus block: a palliative tool underused by radiologists. AJR Am J Roentgenol 2002; 179:633-6. [PMID: 12185033 DOI: 10.2214/ajr.179.3.1790633] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Ross L Titton
- Department of Radiology, Division of Abdominal Imaging and Intervention, Massachusetts General Hospital, White 270, 55 Fruit St., Boston, MA 02114, USA
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Sze DY, Mackey SC. MR guidance of sympathetic nerve blockade: measurement of vasomotor response initial experience in seven patients. Radiology 2002; 223:574-80. [PMID: 11997570 DOI: 10.1148/radiol.2231010751] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The authors performed sympathetic nerve blockades in seven patients with peripheral ischemia and possible autonomic dysfunction. Magnetic resonance (MR) imaging was used to guide needle placement, to monitor distribution of injected agents, and to measure increases in blood flow, which were as much as 10-fold. MR imaging can provide both procedural imaging guidance and measurement of efficacy for sympathetic nerve blocks.
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Affiliation(s)
- Daniel Y Sze
- Division of Cardiovascular and Interventional Radiology, Department of Radiology, Stanford University Medical Center, 300 Pasteur Dr, Stanford, CA 94305, USA.
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31
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Ellison NM, Chevlen E, Still CD, Dubagunta S. Supportive care for patients with pancreatic adenocarcinoma: symptom control and nutrition. Hematol Oncol Clin North Am 2002; 16:105-21. [PMID: 12063822 DOI: 10.1016/s0889-8588(01)00006-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Neil M Ellison
- Palliative Medicine Program, Department of Medical Oncology, Geisinger Medical Center, 100 North Academy Avenue, Danville, PA 17822-0140, USA.
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