1
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Demuro M, Bratzu E, Lorrai S, Preti A. Quality of Life in Palliative Care: A Systematic Meta-Review of Reviews and Meta-Analyses. Clin Pract Epidemiol Ment Health 2024; 20:e17450179183857. [PMID: 39132583 PMCID: PMC11311734 DOI: 10.2174/0117450179183857240226094258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 10/15/2023] [Accepted: 11/20/2023] [Indexed: 08/13/2024]
Abstract
Background The area of palliative care is a setting in which the evaluation of the quality of life (QoL) is fundamental. However, the topic has been covered from many different points of view, and there is a lack of comprehensive synthesis of the evidence drawn from the available literature. Objective We carried out a meta-review of all available systematic reviews and meta-analyses that have dedicated part or most of the investigation to the assessment of QoL in palliative care to provide the most updated and comprehensive depiction of all available information about measurement and intervention aimed at improving QoL in palliative care. Methods A meta-review of all recent (5 years) available systematic reviews and meta-analyses on "palliative care" and "quality of life" was carried out. The quality of the extracted studies was assessed with the AMSTAR scale. Results The search extracted 24 systematic reviews, 14 systematic reviews followed by a meta-analysis on a subset of data, and 2 meta-analyses. In many studies, the investigation of QoL represented a secondary or even marginal outcome. In general, the results supported the efficacy of palliative care in terminal patients or patients with a permanent disability. However, the quality of the studies had a strong influence on the chance that some improvement in QoL was found in relation to palliative care. Studies of lower quality were more likely to report some efficacy of palliative care than studies with better quality. Conclusion The investigation of QoL in palliative care is understudied. In many studies, QoL is a secondary outcome, and there is some tendency to use a disparate range of tools to measure it, whose reliability and validity should still be established in some groups of patients.
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Affiliation(s)
- Mauro Demuro
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Elisa Bratzu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Stefano Lorrai
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Antonio Preti
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, Turin, Italy
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2
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Xu R, Zhang K, Ge N, Sun S. EUS-guided interventional therapies for pancreatic diseases. Front Med (Lausanne) 2024; 10:1329676. [PMID: 38259846 PMCID: PMC10801084 DOI: 10.3389/fmed.2023.1329676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 12/26/2023] [Indexed: 01/24/2024] Open
Abstract
Endoscopic ultrasound (EUS) is an integrated diagnostic technique merging endoscope and ultrasound to examine the digestive system. EUS has emerged as a primary diagnostic method for pancreatic diseases due to its distinctive benefits. Over the past four decades, EUS has undergone a transformation, shifting its role from primarily diagnostic to increasingly therapeutic. Additionally, in recent years, EUS has emerged as an increasingly prominent adjunctive or alternative approach to conventional surgical interventions. This review provides a comprehensive analysis of current technological approaches in the treatment of pancreatic diseases. The dynamic interplay with diverse therapeutic approaches has reinvigorated EUS and shaped its trajectory in the management of pancreatic diseases.
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Affiliation(s)
| | | | | | - Siyu Sun
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
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3
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Tavangar A, Samarasena JB. Endoscopic Ultrasound-Guided Pain Management. Gastrointest Endosc Clin N Am 2024; 34:179-187. [PMID: 37973228 DOI: 10.1016/j.giec.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
The diagnosis and management of pancreatic cancer has become a standard role for the endoscopic oncologist. Pancreatic cancer can produce disabling abdominal pain, and the medical management of this pain is often challenging. Endoscopic ultrasound-guided celiac plexus neurolysis and celiac ganglia neurolysis serve as an alternative or adjunct for pain control in these patients. There remains a great deal of practice variability with regard to techniques and approaches. This article summarizes the latest scientific evidence and highlights contemporary best practice advice for these procedures.
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Affiliation(s)
- Amirali Tavangar
- Division of Gastroenterology and Hepatology, Digestive Health Institute, University of California Irvine, Orange, CA, USA
| | - Jason B Samarasena
- Division of Gastroenterology and Hepatology, Digestive Health Institute, University of California Irvine, Orange, CA, USA.
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4
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Rizzo GEM, Carrozza L, Rancatore G, Binda C, Fabbri C, Anderloni A, Tarantino I. The Role of Endoscopy in the Palliation of Pancreatico-Biliary Cancers: Biliary Drainage, Management of Gastrointestinal Obstruction, and Role in Relief of Oncologic Pain. Cancers (Basel) 2023; 15:5367. [PMID: 38001627 PMCID: PMC10670525 DOI: 10.3390/cancers15225367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/20/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
Therapeutic endoscopy permits many and various treatments for cancer palliation in patients with bilio-pancreatic cancers, enabling different options, supporting patients during their route to oncologic treatments, and trying to improve their quality of life. Therefore, both endoscopic and endoscopic ultrasound (EUS)-guided techniques are performed in this scenario. We performed a literature review focusing on the role of endoscopy in the palliation of those advanced pancreatic and biliary cancers developing malignant biliary obstruction (MBO), gastric outlet obstruction (GOO), and pain unresponsive to medical therapies. Therefore, we explored and focused on the clinical outcomes of endoscopic procedures in this scenario. In fact, the endoscopic treatment is based on achieving biliary drainage in the case of MBO through endoscopic retrograde cholangiopancreatography (ERCP) or EUS-guided biliary drainage (EUS-BD), while GOO is endoscopically treated through the deployment of an enteral stent or the creation of EUS-guided gastro-entero-anastomosis (EUS-GEA). Furthermore, untreatable chronic abdominal pain is a major issue in patients unresponsive to high doses of painkillers, so EUS-guided celiac plexus neurolysis (CPN) or celiac ganglia neurolysis (CGN) helps to reduce dosage and have better pain control. Therefore, therapeutic endoscopy in the palliative setting is an effective and safe approach for managing most of the clinical manifestations of advanced biliopancreatic tumors.
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Affiliation(s)
- Giacomo Emanuele Maria Rizzo
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
- Ph.D. Program, Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, 90133 Palermo, Italy
| | - Lucio Carrozza
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
| | - Gabriele Rancatore
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, 48100 Forlì-Cesena, Italy; (C.B.); (C.F.)
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, 48100 Forlì-Cesena, Italy; (C.B.); (C.F.)
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy;
| | - Ilaria Tarantino
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
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5
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Okita M, Otani K, Matsui S. Efficacy of Endoscopic Ultrasound-guided Celiac Plexus Neurolysis for Abdominal Pain in Patients With Unresectable Pancreatic Cancer: Network Meta-analysis of Randomized Controlled Trials. J Clin Gastroenterol 2023; 57:1054-1062. [PMID: 36227001 DOI: 10.1097/mcg.0000000000001773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 05/10/2022] [Indexed: 12/10/2022]
Abstract
GOALS We conducted a systematic review and network meta-analysis to investigate the effect of endoscopic ultrasound-guided celiac plexus neurolysis added to medical management (EUS-CPN+MM) compared with MM, percutaneous CPN (P-CPN)+MM, or intraoperative CPN (I-CPN)+MM for abdominal pain associated with unresectable pancreatic cancer. BACKGROUND Many approaches to CPN have been proposed since 1919. EUS-CPN, which is less invasive and safer than traditional procedures, has been preferred recently, but the superiority of EUS-CPN+MM has not been fully investigated. STUDY We performed searches of PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) on March 16, 2021. We conducted the network meta-analysis using a frequentist weighted least-squares approach. We used a random-effects model to synthesize the primary outcome, defined as the mean difference between treatment groups in standardized pain intensity scores at 4 and 12 weeks. RESULTS We selected 10 RCTs involving 662 individuals. At 4 weeks, the estimated mean difference between the EUS-CPN+MM and MM groups was -1.30 (95% CI: -2.19 to -0.41) in favor of EUS-CPN+MM, and that between the EUS-CPN+MM and P-CPN+MM groups was -0.88 (95% CI: -1.82 to 0.06). At 12 weeks, the estimated mean difference between the EUS-CPN+MM and MM groups was -2.58 (95% CI: -3.68 to -1.48), and that between the EUS-CPN+MM and P-CPN+MM groups was -2.44 (95% CI: -4.03 to -0.84), both in favor of EUS-CPN+MM. CONCLUSIONS The combination of EUS-CPN+MM was effective at 4 and 12 weeks, although the risk of bias in synthesized studies was generally high, necessitating careful interpretation.
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Affiliation(s)
- Muneyori Okita
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Japan
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6
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Motoyama Y, Sato H, Nomura Y, Obata N, Mizobuchi S. Percutaneous retrocrural versus ultrasound-guided coeliac plexus neurolysis for refractory pancreatic cancer pain. BMJ Support Palliat Care 2023; 13:e81-e83. [PMID: 32527787 DOI: 10.1136/bmjspcare-2020-002246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 05/05/2020] [Indexed: 11/04/2022]
Abstract
We report a successful case of fluoroscopic percutaneous retrocrural coeliac plexus neurolysis (PRCPN) for pancreatic cancer pain refractory to endoscopic ultrasound-guided coeliac plexus neurolysis (EUS-CPN). A 55-year-old man with upper abdominal pain due to end-stage pancreatic cancer underwent EUS-CPN. Although CT revealed distribution of the contrast medium with neurolytic agent around the left and cephalic sides of the coeliac artery, the pain did not improve and became even more severe. PRCPN was performed, resulting in the drastic improvement of pain immediately. PRCPN should be considered when EUS-CPN is not effective.
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Affiliation(s)
- Yasushi Motoyama
- Anesthesiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hitoaki Sato
- Anesthesiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuki Nomura
- Anesthesiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Norihiko Obata
- Anesthesiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Satoshi Mizobuchi
- Anesthesiology, Kobe University Graduate School of Medicine, Kobe, Japan
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7
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On W, Ahmed W, Everett S, Huggett M, Paranandi B. Utility of interventional endoscopic ultrasound in pancreatic cancer. Front Oncol 2023; 13:1252824. [PMID: 37781196 PMCID: PMC10540845 DOI: 10.3389/fonc.2023.1252824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/30/2023] [Indexed: 10/03/2023] Open
Abstract
Endoscopic ultrasound (EUS) has an important role in the management algorithm of patients with pancreatic ductal adenocarcinoma (PDAC), typically for its diagnostic utilities. The past two decades have seen a rapid expansion of the therapeutic capabilities of EUS. Interventional EUS is now one of the more exciting developments within the field of endoscopy. The local effects of PDAC tend to be in anatomical areas which are difficult to target and endoscopy has cemented itself as a key role in managing the clinical sequelae of PDAC. Interventional EUS is increasingly utilized in situations whereby conventional endoscopy is either impossible to perform or unsuccessful. It also adds a different dimension to the host of oncological and surgical treatments for patients with PDAC. In this review, we aim to summarize the various ways in which interventional EUS could benefit patients with PDAC and aim to provide a balanced commentary on the current evidence of interventional EUS in the literature.
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Affiliation(s)
- Wei On
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
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8
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Wyse JM, Sahai AV. EUS-guided celiac plexus neurolysis for pancreas cancer - Finally established or still under review? Best Pract Res Clin Gastroenterol 2022; 60-61:101809. [PMID: 36577532 DOI: 10.1016/j.bpg.2022.101809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 11/10/2022] [Indexed: 11/23/2022]
Abstract
Patients with pancreas cancer must deal frequently with intractable and refractory pain. Endoscopic ultrasound guided-celiac plexus neurolysis (EUS-CPN) has been the most studied and used therapeutic technique aimed to destroy the pain fibres that allow the pancreas to communicate with the central nervous system. A neurolytic agent, most commonly ethanol, is optimally spread around the celiac axis in order to reduce pain and mitigate narcotic requirements. This can be performed early to prevent the spiral of pain and medication use, or more historically as salvage therapy. Different techniques to best administer the ethanol for effective EUS-CPN are still being debated. New EUS-guided injection techniques with radiofrequency, radioactive, and/or chemotherapeutic agents need more study.
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Affiliation(s)
- Jonathan M Wyse
- Division of Gastroenterology, Jewish General Hospital, McGill University, Montreal, Canada.
| | - Anand V Sahai
- Division of Gastroenterology, Center Hospitalier de l'Université de Montréal, Montreal, Canada
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9
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Abstract
Pancreatobiliary malignancies have poor prognosis, and many patients are inoperable at the time of diagnosis. When surgical resection is impossible, systemic chemotherapy or radiotherapy is traditionally conducted with trial of immunotherapy or gene therapy lately. With the rapid development of endoscopic instruments and accessories in recent years, not only endoscopic early detection, characterization, and staging but also endoscopic palliative management of the pancreatobiliary malignancies is expanding the horizons. Endoscopic management is often preferred due to similar efficacy to surgical management with less morbidity. Here, we review the methodology and treatment outcome of various endoscopic management strategies in pancreatobiliary malignancies including endoscopic complication management, local palliative therapy, endoscopy-assisted therapy, and pain control utilizing endoscopic retrograde cholangiopancreatography or endoscopic ultrasound.
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10
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Kerdsirichairat T, Shin EJ. Endoscopic ultrasound guided interventions in the management of pancreatic cancer. World J Gastrointest Endosc 2022; 14:191-204. [PMID: 35634485 PMCID: PMC9048490 DOI: 10.4253/wjge.v14.i4.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/09/2021] [Accepted: 03/27/2022] [Indexed: 02/06/2023] Open
Abstract
There has been a growing interest in developing endoscopic ultrasound (EUS)-guided interventions for pancreatic cancer, some of which have become standard of care. There are two main factors that drive these advancements to facilitate treatment of patients with pancreatic cancer, ranging from direct locoregional therapy to palliation of symptoms related to inoperable pancreatic cancer. Firstly, an upper EUS has the capability to access the entire pancreas–lesions in the pancreatic head and uncinate process can be accessed from the duodenum, and lesions in the pancreatic body and tail can be accessed from the stomach. Secondly, there has been a robust development of devices that allow through-the-needle interventions, such as placement of fiducial markers, brachytherapy, intratumoral injection, gastroenterostomy creation, and ablation. While these techniques are rapidly emerging, data from a multicenter randomized controlled trial for some procedures are awaited prior to their adoption in clinical settings.
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Affiliation(s)
| | - Eun Ji Shin
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD 21287, United States
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11
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Pérez-Aguado G, de la Mata DMA, Valenciano CML, Sainz IFU. Endoscopic ultrasonography-guided celiac plexus neurolysis in patients with unresectable pancreatic cancer: An update. World J Gastrointest Endosc 2021; 13:460-472. [PMID: 34733407 PMCID: PMC8546561 DOI: 10.4253/wjge.v13.i10.460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/27/2021] [Accepted: 09/08/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer produces disabling abdominal pain, and the pain medical management for pancreatic cancer is often challenging because it mainly relies on the use of narcotics (major opioids). However, opioids often provide suboptimal pain relief, and the use of opioids can lead to patient tolerance and several side effects that considerably reduce the quality of life of pancreatic cancer patients. Endosonography-guided celiac plexus neurolysis (EUS-CPN) is an alternative for pain control in patients with nonsurgical pancreatic cancer; EUS-CPN consists of the injection of alcohol and a local anesthetic into the area of the celiac plexus to achieve chemical ablation of the nerve tissue. EUS-CPN via the transgastric approach is a safer and more accessible technique than the percutaneous approach. We have reviewed most of the studies that evaluate the efficacy of EUS-CPN and that have compared the different approaches that have been performed by endosonographers. The efficacy of EUS-CPN varies from 50% to 94% in the different studies, and EUS-CPN has a pain relief duration of 4–8 wk. Several factors are involved in its efficacy, such as the onset of pain, previous use of chemotherapy, presence of metastatic disease, EUS-CPN technique, type of needle or neurolytic agent used, etc. According to this review, injection into the ganglia may be the best technique, and a good visualization of the ganglia is the best predictor for a good EUS-CPN response, although more studies are needed. However, any of the 4 different techniques could be used to perform EUS-CPN effectively with no differences in terms of complications between the techniques, but more studies are needed. The effect of EUS-CPN on pain improvement, patient survival and patient quality of life should be evaluated in well-designed randomized clinical trials. Further research also needs to be performed to clarify the best time frame in performing a EUS-CPN.
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Affiliation(s)
- Guillermo Pérez-Aguado
- Department of Gastroenterology, Complejo Hospitalario Insular Materno Infantil de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas 35016, Spain
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12
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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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13
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Hickman K, Godfrey E, Ajithkumar T. Endoscopic ultrasound-guided neurolysis in advanced pancreatic cancer: current status. BMJ Support Palliat Care 2021; 12:22-28. [PMID: 34635545 DOI: 10.1136/bmjspcare-2021-002905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 07/11/2021] [Indexed: 11/04/2022]
Abstract
Pancreatic cancer has a very poor prognosis with patients often presenting with locally advanced, inoperable or metastatic disease. A significant proportion of patients have visceral pain due to perineural infiltration or coeliac plexus involvement by the tumour. This pain is difficult to control and may become refractory to conventional pain management. Therefore, coeliac plexus neurolysis (CPN) has been proposed to ablate the neuronal transmission pathway of pain permanently. CPN is recommended for those who have uncontrolled pain, are experiencing unacceptable opioid adverse effects or are receiving escalating doses of analgesics. It is not known whether CPN performed at diagnosis as the first-line treatment ('early') would impact short-term and long-term pain control and quality of life. NICE has recommended (2018) a randomised trial comparing early endoscopic ultrasound-guided coeliac plexus neurolysis (EUS-CPN) with on-demand EUS-CPN in pancreatic cancer. In this context, we will review the current evidence on its clinical benefits.
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Affiliation(s)
- Katy Hickman
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Edmund Godfrey
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Thankamma Ajithkumar
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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14
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Kwon HJ, Jang K, Leem JG, Shin JW, Kim DH, Choi SS. Factors associated with successful response to neurolytic celiac plexus block in patients with upper abdominal cancer-related pain: a retrospective study. Korean J Pain 2021; 34:479-486. [PMID: 34593666 PMCID: PMC8494952 DOI: 10.3344/kjp.2021.34.4.479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/05/2021] [Accepted: 07/13/2021] [Indexed: 12/04/2022] Open
Abstract
Background Prior studies have reported that 40%-90% of the patients with celiac plexus-mediated visceral pain benefit from the neurolytic celiac plexus block (NCPB), but the predictive factors of response to NCPB have not been evaluated extensively. This study aimed to identify the factors associated with the immediate analgesic effectiveness of NCPB in patients with intractable upper abdominal cancer-related pain. Methods A retrospective review was performed of 513 patients who underwent NCPB for upper abdominal cancer-related pain. Response to the procedure was defined as (1) a decrease of ≥ 50% or ≥ 4 points on the numerical rating scale (NRS) in pain intensity from the baseline without an increase in opioid requirement, or (2) a decrease of ≥ 30% or ≥ 2 points on the NRS from the baseline with simultaneously reduced opioid consumption after NCPB. Logistic regression analysis was performed to determine the factors associated with successful responses to NCPB. Results Among the 513 patients included in the analysis, 255 (49.8%) and 258 (50.2%) patients were in the non-responder and responder group after NCPB, respectively. Multivariable logistic regression analysis showed that diabetes (odds ratio [OR] = 0.644, P = 0.035), history of upper abdominal surgery (OR = 0.691, P = 0.040), and celiac metastasis (OR = 1.496, P = 0.039) were the independent factors associated with response to NCPB. Conclusions Celiac plexus metastases, absence of diabetes, and absence of prior upper abdominal surgery may be independently associated with better response to NCPB for upper abdominal cancer-related pain.
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Affiliation(s)
- Hyun-Jung Kwon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyunghwan Jang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Gil Leem
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Woo Shin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Doo-Hwan Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong-Soo Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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15
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Abstract
PURPOSE OF REVIEW To update on recent advances in interventional endoscopic ultrasound (INVEUS) techniques. RECENT FINDINGS The introduction of linear echoendoscopes with larger instrument channels and the combined development of new tools and devices have enabled various new applications of minimally invasive endoscopic ultrasound (EUS)-guided transluminal interventions of the pancreas, biliary system and peri-gastrointestinal structures. In this review, EUS-guided interventions are discussed and evaluated: drainage of peripancreatic fluid collections, access and drainage of bile ducts, gallbladder and pancreatic duct, treatment of gastrointestinal haemorrhage, coeliac plexus block and coeliac plexus neurolysis, fiducial placement, solid and cystic tumour ablation, drug delivery and brachytherapy, gastroenterostomy, angiotherapy and other EUS-guided applications. The EUS-guided interventions are classified based on the available evidence as established or experimental, standardized or nonstandardized procedures in common or rare diseases with well or little known complications and their established or nonestablished treatment. SUMMARY Some EUS-guided interventions have sparse published evidence with only single-centre studies, case series or individual case reports, others like drainage of peripancreatic fluid collections have become widely accepted practice. INVEUS has been accepted as an alternative to several surgical approaches, EUS-guided techniques result in faster recovery times, shorter hospital stay and lower costs.
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Affiliation(s)
- Christoph F Dietrich
- Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Beau Site, Salem und Permanence, Switzerland
| | - Barbara Braden
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Christian Jenssen
- Department of Internal Medicine, Krankenhaus Maerkisch-Oderland, D-15344 Strausberg and Brandenburg Institute of Clinical Ultrasound at Medical University Brandenburg, Germany
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Aman MM, Mahmoud A, Deer T, Sayed D, Hagedorn JM, Brogan SE, Singh V, Gulati A, Strand N, Weisbein J, Goree JH, Xing F, Valimahomed A, Pak DJ, El Helou A, Ghosh P, Shah K, Patel V, Escobar A, Schmidt K, Shah J, Varshney V, Rosenberg W, Narang S. The American Society of Pain and Neuroscience (ASPN) Best Practices and Guidelines for the Interventional Management of Cancer-Associated Pain. J Pain Res 2021; 14:2139-2164. [PMID: 34295184 PMCID: PMC8292624 DOI: 10.2147/jpr.s315585] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/18/2021] [Indexed: 12/17/2022] Open
Abstract
Moderate to severe pain occurs in many cancer patients during their clinical course and may stem from the primary pathology, metastasis, or as treatment side effects. Uncontrolled pain using conservative medical therapy can often lead to patient distress, loss of productivity, shorter life expectancy, longer hospital stays, and increase in healthcare utilization. Various publications shed light on strategies for conservative medical management for cancer pain and a few international publications have reviewed limited interventional data. Our multi-institutional working group was assembled to review and highlight the body of evidence that exists for opioid utilization for cancer pain, adjunct medication such as ketamine and methadone and interventional therapies. We discuss neurolysis via injections, neuromodulation including targeted drug delivery and spinal cord stimulation, vertebral tumor ablation and augmentation, radiotherapy and surgical techniques. In the United States, there is a significant variance in the interventional treatment of cancer pain based on fellowship training. As a first of its kind, this best practices and interventional guideline will offer evidenced-based recommendations for reducing pain and suffering associated with malignancy.
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Affiliation(s)
- Mansoor M Aman
- Department of Anesthesiology, Division of Pain Medicine, Advocate Aurora Health, Oshkosh, WI, USA
| | - Ammar Mahmoud
- Department of Anesthesiology, Division of Pain Medicine, Northern Light Health Eastern Maine Medical Center, Bangor, ME, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Dawood Sayed
- Department of Anesthesiology, Pain and Perioperative Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shane E Brogan
- Department of Anesthesiology, Division of Pain Medicine, University of Utah, Salt Lake City, UT, USA
| | - Vinita Singh
- Department of Anesthesiology, Division of Pain Medicine, Emory University, Atlanta, GA, USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Natalie Strand
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Jacqueline Weisbein
- Department of Anesthesiology, Chronic Pain Division, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Johnathan H Goree
- Interventional Pain Medicine, Napa Valley Orthopedic Medical Group, Napa, CA, USA
| | - Fangfang Xing
- Swedish Pain Services, Swedish Health Services, Seattle, WA, USA
| | - Ali Valimahomed
- Gramercy Pain Center, Holmdel, NJ, & Advanced Orthopedics Sports Medicine Institute, Freehold, NJ, USA
| | - Daniel J Pak
- Department of Anesthesiology, Division of Pain Medicine, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA
| | - Antonios El Helou
- Department of Neurosciences, Division of Neurosurgery, The Moncton Hospital, Moncton, NB. Assistant Professor, Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | | | - Krishna Shah
- Assistant Professor of Anesthesiology, Baylor St. Luke’s Medical Center, Baylor College of Medicine, Houston, TX, USA
| | - Vishal Patel
- Department of Anesthesiology, Division of Pain Medicine, Advocate Aurora Health, Oshkosh, WI, USA
| | - Alexander Escobar
- Department of Anesthesiology and Pain Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Keith Schmidt
- AMITA Neurosciences Institute, Comprehensive Pain Management Program, St. Alexius Medical Center, Hoffman Estates, IL, USA
| | - Jay Shah
- SamWell Institute for Pain Management, Colonia, NJ, USA
| | - Vishal Varshney
- Department of Anesthesia, Providence Healthcare, Vancouver, BC, Canada & Department of Anesthesiology, Pharmacology, Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - William Rosenberg
- Center for the Relief of Pain, Midwest Neurosurgery Associates, Kansas City, Missouri, USA
| | - Sanjeet Narang
- Department of Anesthesiology, Pain and Perioperative Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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17
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Wada S, Arai Y, Sone M, Sugawara S, Itou C. The value of angio-CT system on splanchnic nerve neurolysis. Diagn Interv Radiol 2021; 27:408-412. [PMID: 33769290 DOI: 10.5152/dir.2021.20224] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to evaluate the effectiveness and safety of splanchnic nerve neurolysis (SNN) with angio-CT, a hybrid system combining computed tomography (CT) with X-ray fluoroscopy. METHODS Thirty-three SNN procedures with angio-CT performed in 30 patients with severe epigastric cancer pain (11 males and 19 females; median age, 57 years; age range, 19-79 years) between January 2010 and July 2017 were retrospectively evaluated. The primary endpoints were the technical success and adverse event rates. The secondary endpoints included the clinical success rate, defined as a reduction in the numerical rating scale for pain score or a decrease in the consumption of analgesics on day 1 and at 1-2 weeks after the procedure; procedure time; the number of needle punctures; amount of ethanol required; and the distribution of contrast medium in the retrocrural space. These endpoints were compared with previous studies that did not employ the angio-CT system. RESULTS The technical success rate was 96.97%. There were two procedure-related adverse events (one retroperitoneal hemorrhage, one pneumothorax). The clinical success rates on day 1 and at 1-2 weeks after the procedure were 84.38% and 87.5%, respectively. The median procedure time was 60 minutes. The median number of needles used was 2. The median amount of ethanol used was 20 mL. CONCLUSION SNN under angio-CT is safe and effective, with excellent technical and clinical success rates and acceptable adverse event rates. These results are comparable with previous studies that did not involve angio-CT. However, the use of angio-CT allows for easier needle positioning and an earlier response to complications compared with conventional methods.
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Affiliation(s)
- Shinji Wada
- Department of Radiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Yasuaki Arai
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
| | - Miyuki Sone
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
| | - Shunsuke Sugawara
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
| | - Chihiro Itou
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
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18
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Koulouris AI, Alexandre L, Hart AR, Clark A. Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) technique and analgesic efficacy in patients with pancreatic cancer: A systematic review and meta-analysis. Pancreatology 2021; 21:434-442. [PMID: 33461931 DOI: 10.1016/j.pan.2020.12.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/19/2020] [Accepted: 12/21/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic Ultrasound-guided Celiac Plexus Neurolysis (EUS-CPN) for the treatment of abdominal pain in pancreatic cancer can be administered in three different ways, depending on the site of needle insertion: central injection (CI), bilateral injection (BI) and celiac ganglia neurolysis (CGN). This meta-analysis aimed to (1) estimate the overall efficacy of the EUS-CPN; (2) compare the efficacy of each of the three techniques; and (3) investigate demographic and disease characteristics as potential predictors of treatment response. METHODS We searched MEDLINE and EMBASE for studies that reported the proportion of treatment responders to EUS-CPN overall, and according to the technique used. We performed a random effects meta-analysis of proportions, and meta-regression was used to estimate the association between technique and clinical characteristics on treatment response. The safety profile was reviewed through narrative synthesis. RESULTS Overall response rate to EUS-CPN was 68% (95% CI 61%-74%) at week two and 53% (95% CI 45%-62%) at week four. There was no evidence of a significant difference in the response rates between the three techniques. Demographics and disease characteristics were not associated with treatment response. Serious complications have been reported for BI and CGN but not for CI. Moderate to high risk of bias was observed. DISCUSSION EUS-CPN is a useful adjunct to opioids in the management of pain. There is no evidence of a difference in the efficacy among the three techniques, however, CI is the only one for which serious complications have not been reported. Future research should focus on the appropriate timing of EUS-CPN (early versus on demand) and randomised comparison to establish the comparative efficacy of each technique.
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Affiliation(s)
- A I Koulouris
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk NR4 7TJ, United Kingdom; Norfolk and Norwich University Hospital. Norwich, Colney Lane, NR4 7UY, United Kingdom.
| | - Leo Alexandre
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk NR4 7TJ, United Kingdom; Norfolk and Norwich University Hospital. Norwich, Colney Lane, NR4 7UY, United Kingdom
| | - A R Hart
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk NR4 7TJ, United Kingdom; Norfolk and Norwich University Hospital. Norwich, Colney Lane, NR4 7UY, United Kingdom
| | - A Clark
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk NR4 7TJ, United Kingdom
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19
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Wong KC, Tang SYR, Ng KCK, Chong CNC. Endoscopic ultrasound guided coeliac plexus neurolysis (
EUS‐CPN
). SURGICAL PRACTICE 2021. [DOI: 10.1111/1744-1633.12480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Kam Cheung Wong
- Department of Surgery Prince of Wales Hospital, The Chinese University of Hong Kong Hong Kong China
| | - Shing Yan Raymond Tang
- Department of Medicine and Therapeutics Prince of Wales Hospital, The Chinese University of Hong Kong Hong Kong China
| | - Kwok Chai Kelvin Ng
- Department of Surgery Prince of Wales Hospital, The Chinese University of Hong Kong Hong Kong China
| | - Ching Ning Charing Chong
- Department of Surgery Prince of Wales Hospital, The Chinese University of Hong Kong Hong Kong China
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20
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Han CQ, Tang XL, Zhang Q, Nie C, Liu J, Ding Z. Predictors of pain response after endoscopic ultrasound-guided celiac plexus neurolysis for abdominal pain caused by pancreatic malignancy. World J Gastroenterol 2021; 27:69-79. [PMID: 33505151 PMCID: PMC7789068 DOI: 10.3748/wjg.v27.i1.69] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 08/15/2020] [Accepted: 11/12/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) has gained popularity as a minimally invasive approach and is currently widely used to treat pancreatic cancer-associated pain. However, response to treatment is variable.
AIM To identify the efficacy of EUS-CPN and explore determinants of pain response in EUS-CPN for pancreatic cancer-associated pain.
METHODS A retrospective study of 58 patients with abdominal pain due to inoperable pancreatic cancer who underwent EUS-CPN were included. The efficacy for palliation of pain was evaluated based on the visual analog scale pain score at 1 wk and 4 wk after EUS-CPN. Univariable and multivariable logistic regression analyses were performed to explore predictors of pain response.
RESULTS A good pain response was obtained in 74.1% and 67.2% of patients at 1 wk and 4 wk, respectively. Tumors located in the body/tail of the pancreas and patients receiving bilateral treatment were weakly associated with a good outcome. Multivariate analysis revealed patients with invisible ganglia and metastatic disease were significant factors for a negative response to EUS-CPN at 1 wk and 4 wk, respectively, particularly for invasion of the celiac plexus (odds ratio (OR) = 13.20, P = 0.003 for 1 wk and OR = 15.11, P = 0.001 for 4 wk). No severe adverse events were reported.
CONCLUSION EUS-CPN is a safe and effective form of treatment for intractable pancreatic cancer-associated pain. Invisible ganglia, distant metastasis, and invasion of the celiac plexus were predictors of less effective response in EUS-CPN for pancreatic cancer-related pain. For these patients, efficacy warrants attention.
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Affiliation(s)
- Chao-Qun Han
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Xue-Lian Tang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Qin Zhang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Chi Nie
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Jun Liu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Zhen Ding
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
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21
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Yasuda I, Hanaoka T, Takahashi K, Araki Y, Doi S, Iwashita T, Iwata K, Mukai T. Recent topics on endoscopic ultrasonography-guided celiac plexus neurolysis. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii200033] [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: 11/22/2022] Open
Affiliation(s)
- Ichiro Yasuda
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Tatsuyuki Hanaoka
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Kosuke Takahashi
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Yasuhiro Araki
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Shinpei Doi
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University, Gifu, Japan
| | - Keisuke Iwata
- Department of Gastroenterology, Gifu Prefectural Medical Center, Gifu, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
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Gurakar M, Faghih M, Singh VK. Endoscopic intervention in pancreatitis: perspectives from a gastroenterologist. Abdom Radiol (NY) 2020; 45:1308-1315. [PMID: 31768596 DOI: 10.1007/s00261-019-02314-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The last decade has seen a dramatic paradigm shift for the treatment of pancreatitis and its related complications away from surgery to minimally invasive endoscopic approaches. In this review, we provide an overview of the indications, techniques and outcomes of endoscopic interventions in the management of acute and chronic pancreatitis. Emphasis is placed on drainage of pancreatic pseudocysts and treatment of pain in chronic pancreatitis.
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Affiliation(s)
- Merve Gurakar
- Division of Gastroenterology, Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mahya Faghih
- Division of Gastroenterology, Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Vikesh K Singh
- Division of Gastroenterology, Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
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23
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Wyse JM, Sahai AV. Endoscopic Ultrasound-Guided Management of Pain in Chronic Pancreatitis and Pancreatic Cancer: an Update. ACTA ACUST UNITED AC 2018; 16:417-427. [DOI: 10.1007/s11938-018-0193-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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24
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Pain in pancreatic ductal adenocarcinoma: A multidisciplinary, International guideline for optimized management. Pancreatology 2018; 18:446-457. [PMID: 29706482 DOI: 10.1016/j.pan.2018.04.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 04/18/2018] [Accepted: 04/20/2018] [Indexed: 02/07/2023]
Abstract
Abdominal pain is an important symptom in most patients with pancreatic ductal adenocarcinoma (PDAC). Adequate control of pain is often unsatisfactory due to limited treatment options and significant variation in local practice, emphasizing the need for a multidisciplinary approach. This review contends that improvement in the management of PDAC pain will result from a synthesis of best practice and evidence around the world in a multidisciplinary way. To improve clinical utility and evaluation, the evidence was rated according to the GRADE guidelines by a group of international experts. An algorithm is presented, which brings together all currently available treatment options. Pain is best treated early on with analgesics with most patients requiring opioids, but neurolytic procedures are often required later in the disease course. Celiac plexus neurolysis offers medium term relief in a substantial number of patients, but other procedures such as splanchnicectomy are also available. Palliative chemotherapy also provides pain relief as a collateral benefit. It is stressed that the assessment of pain must take into account the broader context of other physical and psychological symptoms. Adjunctive treatments for pain, depression and anxiety as well as radiotherapy, endoscopic therapy and neuromodulation may be required in selected patients. There are few comparative studies to help define which combination and order of these treatment options should be applied. New pain therapies are emerging and could for example target neural transmitters. However, until better methods are available, management of pain should be individualized in a multidisciplinary setting to ensure optimal care.
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Alleviating Pancreatic Cancer-Associated Pain Using Endoscopic Ultrasound-Guided Neurolysis. Cancers (Basel) 2018; 10:cancers10020050. [PMID: 29462851 PMCID: PMC5836082 DOI: 10.3390/cancers10020050] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 02/09/2018] [Accepted: 02/12/2018] [Indexed: 12/17/2022] Open
Abstract
The most common symptom in patients with advanced pancreatic cancer is abdominal pain. This has traditionally been treated with nonsteroidal anti-inflammatory drugs and opioid analgesics. However, these treatments result in inadequate pain control or drug-related adverse effects in some patients. An alternative pain-relief modality is celiac plexus neurolysis, in which the celiac plexus is chemically ablated. This procedure was performed percutaneously or intraoperatively until 1996, when endoscopic ultrasound (EUS)-guided celiac plexus neurolysis was first described. In this transgastric anterior approach, a neurolytic agent is injected around the celiac trunk under EUS guidance. The procedure gained popularity as a minimally invasive approach and is currently widely used to treat pancreatic cancer-associated pain. We focus on two relatively new techniques of EUS-guided neurolysis: EUS-guided celiac ganglia neurolysis and EUS-guided broad plexus neurolysis, which have been developed to improve efficacy. Although the techniques are safe and effective in general, some serious adverse events including ischemic and infectious complications have been reported as the procedure has gained widespread popularity. We summarize reported clinical outcomes of EUS-guided neurolysis in pancreatic cancer (from the PubMed and Embase databases) with a goal of providing information useful in developing strategies for pancreatic cancer-associated pain alleviation.
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