Celiac Plexus Block in the Management of Chronic Abdominal Pain

Efficacy and Safety of Paragastric Neural Blockade in Controlling Pain, Nausea, and Vomiting After Sleeve Gastrectomy: A Randomized Controlled Trial

BACKGROUND

There are difficulties in controlling the symptoms of pain, nausea, and vomiting after laparoscopic sleeve gastrectomy (LSG). This study aimed to evaluate the efficacy and safety of PGNB on pain and nausea and vomiting in the early postoperative period in patients who underwent LSG.

METHODS

In this prospective, randomized, controlled, double-blind study, the patients were divided into two equally formed groups: patients who underwent PGNB after LSG and the control group. Postoperative pain symptoms were evaluated using the visual analog scale (VAS) scores, and nausea and vomiting symptoms were evaluated using the postoperative nausea and vomiting (PONV) scores.

RESULTS

The study was completed with 90 patients, 45 patients in each group. The VAS scores measured at postoperative hours 1, 6, and 12 were statistically significantly lower in the PGNB group. There was no significant difference between the two groups in terms of the 24th hour VAS scores. The mean PONV scores of the PGNB and control groups were 0.47 ± 0.89 and 1.67 ± 1.95, respectively, revealing a significantly higher value for the controls. The mean time to first mobilization in the postoperative period was significantly shorter in the PGNB group. Upon the evaluation of patient satisfaction, it was determined that the satisfaction score of the PGNB group was significantly higher.

CONCLUSIONS

PGNB is an effective and safe method for managing pain, nausea, and vomiting that occur in the early period after LSG.

Percutaneous Fluoroscopic-Guided Celiac Plexus Approach: Results in a Pig Cadaveric Model

Celiac plexus block (CPB) and neurolysis (CPN) are used for pain management in people suffering from abdominal tumours or chronic pancreatitis. The fluoroscopically guided approach common in human medicine has not been described in veterinary settings. The aim of this study was to describe a fluoroscopic approach to the celiac plexus (CP) in fresh pig cadavers. Twelve animals were included in the procedure. Cadavers were positioned in sternal position and, under fluoroscopic guidance, a Chiba needle was inserted parasagittal at 6 cm from the spinal midline at the level of the last thoracic vertebra. From the left side, the needle was directed medio-ventrally with a 45° angle towards the T15 vertebral body; once the vertebral body was contacted, the needle was advanced 1 cm ventrally towards the midline. Iodinated contrast was injected to confirm the location. Following this, 2 mL of dye (China ink) was injected. A laparotomy was performed, and dyed tissue was dissected and prepared for both histochemical and immunohistochemical techniques. In 10 out of 12 samples submitted for histological evaluation, nervous tissue belonging to CP was observed. Fluoroscopy guidance allows for feasible access to the CP in swine cadavers in this study. Further studies are warranted to determine the efficacy of this technique in swine and other veterinary species.

Topical Diclofenac to Manage Opioid-Refractory Pain in a Rare Pancreatic Fibrosarcoma

Pancreatic cancer is often diagnosed at an advanced stage and is frequently associated with severe pain. Traditional pain management in this condition may be improved with the use of topical diclofenac. A 39-year-old man with advanced pancreatic fibrosarcoma metastatic to the thoracic spine presented to the hospital with severe abdominal pain refractory to escalating doses of opioids. A celiac plexus block produced significant, yet inadequate, pain reduction. Satisfactory pain control and opioid de-escalation were ultimately achieved with the application of topical diclofenac gel to an area of bony metastasis. This case illustrates the potential for pain control using topical diclofenac in patients with pancreatic soft tissue tumors and vertebral metastases. Topical diclofenac may exert antitumoral effects and targeted application may improve absorption, leading to improved pain control. The use of topical diclofenac for pain management in metastatic pancreatic cancer presents an interesting tool that should be considered in similar cases.

Laparoscopic Median Arcuate Ligament Release: Surgical Technique and Clinical Outcomes

BACKGROUND

Median arcuate ligament syndrome (MALS) is characterized by a constellation of symptoms related to the compression of the celiac artery trunk. Laparoscopic release of the ligament has demonstrated its effectiveness in alleviating these symptoms while showing lower postoperative complication rates, reduced hospital stays, and improved clinical outcomes. This study describes a single institution's experience with this procedure and reports on the preoperative assessment, surgical technique, and clinical outcomes of patients with MALS.

METHODS

We performed a retrospective chart review of all patients who underwent a primary laparoscopic MAL release (MALR) at a single high-volume academic institution from June 2021 to July 2023. Patient demographics, preoperative assessment, postoperative complications, and resolution of preoperative symptoms data were collected.

RESULTS

A total of 30 patients underwent laparoscopic MALR, with 76.7% being female and a mean age of 33.4±16.3 years. The most common presenting symptom was postprandial epigastric pain (100%), followed by abdominal pain and nausea (83.3%), among others. The preoperative evaluation for all patients included a duplex mesenteric doppler and CT angiogram during inspiration and expiration and 3D reconstruction. Successful laparoscopic decompression of the celiac artery was achieved in 96.6% of cases, with only one conversion to an open procedure. There was only one reported early (<30 d postoperatively) complication with no subsequent late complications or mortality. None of the patients required reintervention or reoperation. Only 1 patient required postoperative celiac plexus/splanchnic block injection to alleviate pain.

CONCLUSIONS

MALS can be effectively and safely managed using a laparoscopic approach when performed by an experienced minimally invasive surgeon. Further studies with longer follow-ups are needed to confirm the long-term effectiveness of this technique.

Adrenal Abscesses: A Systematic Review of the Literature

Objective: To summarize the existing knowledge about adrenal gland abscesses, including etiology, clinical presentation, common laboratory and imaging findings, management and overall morbidity and mortality. Design: Systematic literature review. Methods: We performed a search in the PubMed database using search terms: 'abscess and adrenal glands', 'adrenalitis', 'infection and adrenal gland', 'adrenal abscess', 'adrenal infection' and 'infectious adrenalitis'. Articles from 2017 to 2022 were included. We found total of 116 articles, and after applying exclusion criteria, data from 73 articles was included in the final statistical analysis. Results: Of 84 patients included in this review, 68 were male (81%), with a mean age of 55 years (range: 29 to 85 years). Weight loss was the most frequent symptom reported in 58.3% patients, followed by fever in 49%. Mean duration of symptoms was 4.5 months. The most common laboratory findings were low cortisol (51.9%), elevated ACTH (43.2%), hyponatremia (88.2%) and anemia (83.3%). Adrenal cultures were positive in 86.4% cases, with Histoplasma capsulatum (37.3%) being the leading causative agent. Blood cultures were positive in 30% of patients. The majority of the adrenal infections occurred through secondary dissemination from other infectious foci and abscesses were more commonly bilateral (70%). A total of 46.4% of patients developed long-term adrenal insufficiency requiring treatment. Abscess drainage was performed in 7 patients (8.3%) and adrenalectomy was performed in 18 (21.4%) patients. The survival rate was 92.9%. Multivariate analysis showed that the only independent risk factor for mortality was thrombocytopenia (p = 0.048). Conclusion: Our review shows that adrenal abscesses are usually caused by fungal pathogens, and among these, Histoplasma capsulatum is the most common. The adrenal glands are usually involved in a bilateral fashion and become infected through dissemination from other primary sources of infection. Long-term adrenal insufficiency develops in 46% of patients, which is more common than what is observed in non-infectious etiology of adrenal gland disorders. Mortality is about 7%, and the presence of thrombocytopenia is associated with worse prognosis. Further prospective studies are needed to better characterize optimal testing and treatment duration in patients with this relatively rare but challenging disorder.

Multimodal locoregional procedures for cancer pain management: a literature review

Pain is the most common and fearsome symptom in cancer patients, particularly in the advanced stage of disease. In cancer pain management, the first option is represented by analgesic drugs, whereas surgery is rarely used. Prior to considering surgical intervention, less invasive locoregional procedures are available from the wide pain management arsenal. In this review article, comprehensive information about the most commonly used locoregional options available for treating cancer pain focusing on interventional radiology (neurolysis, augmentation techniques, and embolization) and interventional radiotherapy were provided, also highlighting the potential ways to increase the effectiveness of treatments.

Multidisciplinary management of chronic refractory pain in autosomal dominant polycystic kidney disease

BACKGROUND

Chronic pain is often difficult to manage in autosomal dominant polycystic kidney disease (ADPKD) patients and sometimes even leads to nephrectomy. We analyzed the long-term efficacy of our innovative multidisciplinary protocol to treat chronic refractory pain that aims to preserve kidney function by applying among other sequential nerve blocks.

METHODS

Patients were eligible if pain was present ≥3 months with a score of ≥50 on a visual analog scale (VAS) of 100, was negatively affecting quality of life and if there had been insufficient response to previous therapies, including opioid treatment. Treatment options were, in order, analgesics, cyst aspiration and fenestration, nerve blocks and nephrectomy.

RESULTS

A total of 101 patients were assessed in our clinic (mean age 50 ± 11 years, 65.3% females). Eight patients were treated with medication, 6 by cyst aspiration or fenestration, 63 by nerve blocks and 6 received surgery as the first treatment option. Overall, 76.9% experienced a positive effect on pain complaints shortly after treatment. The VAS score was reduced from 60/100 to 20/100 (P < 0.001) and patients decreased their number of nonopioid and opioid analgesics significantly (P < 0.001, P = 0.01, respectively). A substantial number of the patients (n = 51) needed additional treatment. At the end of follow-up in only 13 patients (12.9%) was surgical intervention necessary: 11 nephrectomies (of which 10 were in patients already on kidney function replacement treatment), 1 liver transplantation and 1 partial hepatectomy. After a median follow-up of 4.5 years (interquartile range 2.5-5.3), 69.0% of the patients still had fewer pain complaints.

CONCLUSIONS

These data indicate that our multidisciplinary treatment protocol appears effective in reducing pain in the majority of patients with chronic refractory pain, while postponing or even avoiding in most patients surgical interventions such as nephrectomy in most patients.

Role of erector spinae plane block in controlling functional abdominal pain: Case reports

RATIONALE

Functional abdominal pain is an intractable medical condition that often reduces quality of life. Celiac plexus block is a representative intervention for managing intractable abdominal pain. However, celiac plexus block can be technically difficult to perform and carries the risk of potential complications. During erector spinae plane block (ESPB), the injectate can enter the paravertebral space and reach the sympathetic chain. If local anesthetics spread to the sympathetic chain that supplies fibers to the splanchnic nerve, abdominal pain theoretically could be reduced.

PATIENT CONCERNS

Three patients suffered from abdominal pain of unknown cause, and no medical abnormalities were found in various examinations.

DIAGNOSIS

As a result of collaboration with related medical departments, the abdominal symptoms of the patients were suspected to be functional abdominal pain.

INTERVENTIONS

We successfully controlled symptoms by performing ESPB at the lower thoracic level in 3 patients with functional abdominal pain.

OUTCOMES

After the procedure, the patients' abdominal pain improved significantly over several months.

LESSONS

We suggest that lower thoracic ESPB could be an option for management of functional abdominal pain.

Chronic Pancreatitis: Epidemiology, Diagnosis, and Management Updates

Chronic pancreatitis is a clinical entity that results from the progressive inflammation and irreversible fibrosis of the pancreas resulting from the cumulative injury sustained by the pancreas over time. It is an illness with variable presentations that can severely impact quality of life, while its long-term complications such as exocrine pancreatic insufficiency (EPI), diabetes mellitus, and risk of pancreatic cancer can become life threatening. The diagnosis of chronic pancreatitis can be challenging as despite the recent advancements in imaging technology, the radiographic findings do not become prominent until late stages of disease. Thus, the physicians' clinical acumen in obtaining thorough history taking focusing on risk factors, clinical symptoms, in addition to high-quality imaging, often guide to the accurate diagnosis of chronic pancreatitis. Endoscopy also plays a pivotal role in the diagnosis and management of chronic pancreatitis. Endoscopic ultrasound (EUS) is believed to be the most sensitive modality for diagnosing chronic pancreatitis. Despite efforts, however, natural history studies have demonstrated that 61% of individuals with chronic pancreatitis will require at least one endoscopic intervention, while 31% will require a surgical procedure as part of their management strategy. Recent advancements in genomic studies have furthered our understanding of the genetic polymorphisms that are associated with the pathogenesis of chronic pancreatitis. Genetic testing offers the potential to reveal treatable pancreatitis-related disorders, and can inform decision making with regard to radical therapies for persistent or severe disease such as total pancreatectomy with islet autotransplantation (TPIAT). The management of patients suffering from chronic pancreatitis often requires a multi-disciplinary approach, addressing pertinent symptoms as well as the sequelae of chronic inflammation and fibrosis. Abdominal pain is the prevailing symptom and most common complication of chronic pancreatitis, and impairs quality of life. Although heavily dependent on a wide range of analgesia, endoscopic treatment such as endoscopic retrograde cholangiopancreatography (ERCP) and surgical intervention can offer long-lasting relief of symptoms. For EPI, treatment with pancreatic enzyme supplements offers marginal-to-moderate relief. The most feared complication of chronic pancreatitis-the development of pancreatic cancer-has no known prevention measure to date.

Minimally Invasive Surgery for Median Arcuate Ligament Syndrome and Celiac Artery Stenosis

Median arcuate ligament syndrome (MALS) is a pathology commonly reported in educational literature, although in reality it is scarcely seen. Herein, we present the case of a 48-year-old female patient who presented with nausea, vomiting, and unintentional weight loss. After thorough work up of her symptoms through a variety of different modalities, MALS was confirmed and she underwent surgical release via a minimally invasive approach. The authors of this article feel that this case is important to present due to paucity of reported cases in the literature. In addition, this patient was exceptionally unique to report as we selected to perform a slight adaptation of a minimally invasive approach, while there are multiple different treatment techniques and management plans that have previously been described in a variety of different literatures and require further discussion.

Interventional Therapies for Pain in Cancer Patients: a Narrative Review

PURPOSE OF REVIEW

Pain is a prevalent symptom in the lives of patients with cancer. In light of the ongoing opioid epidemic and increasing awareness of the potential for opioid abuse and addiction, clinicians are progressively turning to interventional therapies. This article reviews the interventional techniques available to mitigate the debilitating effects that untreated or poorly treated pain have in this population.

RECENT FINDINGS

A range of interventional therapies and technical approaches are available for the treatment of cancer-related pain. Many of the techniques described may offer effective analgesia with less systemic toxicity and dependency than first- and second-line oral and parenteral agents. Neuromodulatory techniques including dorsal root ganglion stimulation and peripheral nerve stimulation are increasingly finding roles in the management of oncologic pain. The goal of this pragmatic narrative review is to discuss interventional approaches to cancer-related pain and the potential of such therapies to improve the quality of life of cancer patients.

Clinical Response to Celiac Plexus Block Confirms the Neurogenic Etiology of Median Arcuate Ligament Syndrome

PURPOSE

To evaluate the response of median arcuate ligament syndrome (MALS) symptoms, including postprandial pain, nausea, and vomiting, to celiac plexus block (CPB) and correlate the response with arterial anatomy.

MATERIALS AND METHODS

In a single-institution, retrospective cohort of clinically diagnosed MALS patients, 96 patients (female, 75; male, 21; mean age, 27 years) underwent 103 computed tomography‒guided percutaneous CPB procedures. Imaging, procedural, and clinical reports were reviewed. Primary outcomes evaluated were technical success, change in self-reported pain score, and change in nausea and vomiting.

RESULTS

Computed tomography imaging before the procedure was available for 81 of 96 patients and demonstrated findings of celiac artery compression in 22 of 81 (27%) patients. Technical success was achieved in 102 of 103 cases. No major adverse events and 1 moderate adverse event were reported. The postprandial pain score decreased in 86 (84%) patients, and the mean score decreased from 6.3 to 0.9 points (P < .001). The prevalence of postprandial nausea decreased from 37.9% to 11.6% (P < .001) and that of vomiting decreased from 15.5% to 4.9% (P = .019). No differences were noted in pain relief after CPB between patients with and without celiac artery compression (P = .745).

CONCLUSIONS

In patients with a clinical diagnosis of MALS, a large majority reported pain relief and decreased gastrointestinal symptoms after CPB. Pain relief did not correlate with the presence of celiac arterial abnormalities. This supports neuropathy as the primary etiology of MALS and suggests that the absence of celiac stenosis should not be used as an exclusion criterion.

Pain Management in Chronic Pancreatitis: Summary of Clinical Practice, Current Challenges and Potential Contribution of the M-ANNHEIM Classification

Abdominal pain, diarrhea with weight loss, and endocrine insufficiency represent the dominant symptoms of chronic pancreatitis (CP). High intensity of pain and constant pain have been shown to reduce quality of life in CP and may result in disability and increased health resource utilization. Various basic challenges and unanswered questions still exist regarding the treatment of pain in CP. Recently, limited evidence has been gained that early surgery for painful disease might be associated with better treatment results. Thus, timing of pancreatic surgery in painful disease represents a major issue that needs to be clarified in future studies. In this context, surveillance of patients is necessary in clinical practice. It appears that a generally accepted classification of the disease represents a major requirement for inter-institutional comparison of data with future progress in clinical research. Among recently proposed classification systems, the M-ANNHEIM classification system of CP with its recently presented M-ANNHEIM Surgery Score might be a useful tool to picture the course of the disease and to monitor treatment results. Future research is required to clarify the possible role of this system in the management of pain in CP. In the present article, we provide an overview of current status, challenges, and unanswered questions in the treatment of pain in CP, and we demonstrate the potential benefits of the M-ANNHEIM classification system in the management of painful CP.

Efficacy of Intercostal Nerve Block for Pain Control After Percutaneous Nephrolithotomy: A Systematic Review and Meta-Analysis

Background: We aimed to assess the efficacy of intercostal nerve block (ICNB) for pain relief after percutaneous nephrolithotomy (PCNL).

Methods: An electronic search of the databases of PubMed, Science Direct, BioMed Central, CENTRAL, Embase, and Google Scholar was conducted. All types of studies conducted on adult patients undergoing PCNL, comparing ICNB with control or any other anesthetic method, and reporting postoperative pain outcomes were included.

Results: Six studies were included. Studies compared ICNB with peritubal (PT) infiltration and with control. Pooled analysis of ICNB vs. PT infiltration indicated no difference between the two groups for pain scores at 6–8 h (MD −0.44; 95% CI −3.41, 2.53; I² = 99%; p = 0.77), 12 h (MD −0.98; 95% CI −4.90, 2.94; I² = 99%; p = 0.62) and 24 h (MD 0.16; 95% CI −0.90, 1.21; I² = 88%; p = 0.77). Time for first analgesic demand was also not significantly different between the two groups. Meta-analysis of ICNB vs. control indicated statistical significant difference in pain scores between the two groups at 8 h (MD −1.55; 95% CI −2.60, −0.50; I² = 47%; p = 0.04), 12 h (SMD −2.49; 95% CI −4.84, −0.13; I² = 96%; p = 0.04) and 24 h (SMD −1.22; 95% CI −2.12, −0.32; I² = 88%; p = 0.008). The total analgesic requirement in morphine equivalents was not significantly different between the two groups.

Conclusions: ICNB may be effective in reducing postoperative pain after PCNL. However, its efficacy may not be greater than PT infiltration. Current evidence is from a limited number of studies. Further, high-quality randomized controlled trials are needed to provide robust evidence.

Celiac Plexus Block Complications: A Case Report and Review of the Literature

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.

Addition of corticosteroids to local anaesthetics for chronic non-cancer pain injections: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Despite common use, the benefit of adding steroids to local anaesthetics (SLA) for chronic non-cancer pain (CNCP) injections is uncertain. We performed a systematic review and meta-analysis of English-language RCTs to assess the benefit and safety of adding steroids to local anaesthetics (LA) for CNCP.

METHODS

We searched MEDLINE, EMBASE, and CENTRAL databases from inception to May 2019. Trial selection and data extraction were performed in duplicate. Outcomes were guided by the Initiative in Methods, Measurements, and Pain Assessment in Clinical Trials (IMMPACT) statement with pain improvement as the primary outcome and pooled using random effects model and reported as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CIs).

RESULTS

Among 5097 abstracts, 73 trials were eligible. Although SLA increased the rate of success (42 trials, 3592 patients; RR=1.14; 95% CI, 1.03-1.25; number needed to treat [NNT], 13), the effect size decreased by nearly 50% (NNT, 22) with the removal of two intrathecal injection studies. The differences in pain scores with SLA were not clinically meaningful (54 trials, 4416 patients, MD=0.44 units; 95% CI, 0.24-0.65). No differences were observed in other outcomes or adverse events. No subgroup effects were detected based on clinical categories. Meta-regression showed no significant association with steroid dose or length of follow-up and pain relief.

CONCLUSIONS

Addition of cortico steroids to local anaesthetic has only small benefits and a potential for harm. Injection of local anaesthetic alone could be therapeutic, beyond being diagnostic. A shared decision based on patient preferences should be considered. If used, one must avoid high doses and series of steroid injections.

CLINICAL TRIAL REGISTRATION

PROSPERO #: CRD42015020614.

A Comprehensive Review of the Celiac Plexus Block for the Management of Chronic Abdominal Pain

PURPOSE OF REVIEW

Chronic abdominal pain (CAP) is a significant health problem that can dramatically affect quality of life and survival. Pancreatic cancer is recognized as one of the most painful malignancies with 70-80% suffering from substantial pain, often unresponsive to typical medical management. Celiac plexus neurolysis and celiac plexus block (CPB) can be performed to mitigate pain through direct destruction or blockade of visceral afferent nerves. The objective of this manuscript is to provide a comprehensive review of the CPB as it pertains to CAP with a focus on the associated anatomy, indications, techniques, neurolysis/blocking agents, and complications observed in patients who undergo CPB for the treatment of CAP.

RECENT FINDINGS

The CAP is difficult to manage due to lack of precision in diagnosis and limited evidence from available treatments. CAP can arise from both benign and malignant causes. Treatment options include pharmacologic, interventional, and biopsychosocial treatments. Opioid therapy is typically utilized for the treatment of CAP; however, opioid therapy is associated with multiple complications. CPB has successfully been used to treat a variety of conditions resulting in CAP. The majority of the literature specifically related to CPB is surrounding chronic pain associated with pancreatic cancer. The literature shows emerging evidence in managing CAP with CPB, specifically in pancreatic cancer. This review provides multiple aspects of CAP and CPB, including anatomy, medical necessity, indications, technical considerations, available evidence, and finally complications related to the management.

CT guided neurolytic blockade of the coeliac plexus in patients with advanced and intractably painful pancreatic cancer

Background and aims:

Pain caused by infiltrating pancreatic cancer is complex in nature and may therefore be difficult to treat. In addition to conventional analgesics, neurolytic blockade of the coeliac plexus is often recommended. However, different techniques are advocated, and procedures vary, and the results may therefore be difficult to compare. Therefore strong evidence for the effect of this treatment is still lacking, and more studies are encouraged. Our aim was to describe our technique and procedures using a Computer Tomograph (CT) guided procedure with a dorsal approach and present the results.

Methods:

The procedures were performed in collaboration between a radiologist and an anaesthesiologist. All patients had advanced pancreatic cancer. The patients were placed in prone position on pillows, awake and monitored. Optimal placement of injection needles was guided by CT, and the radiologist injected a small dose of contrast as a control. When optimal needle position, the anaesthesiologist took over and completed the procedure. At first 40 mg methylprednisolone was injected to prevent inflammation. Thereafter a mixture of 99% ethanol diluted to 50% by ropivacaine 7.5 mg/mL to a total amount of 20–30 mL per needle was slowly injected. Repeated aspiration was performed during injection to avoid intravasal injection. Pain treatment and pain score was recorded and compared before and after the treatment.

Results:

Eleven procedures in 10 patients were performed. Age 49–75, mean 59 years. Median rest life time was 36 days (11–140). Significant reduction of analgesics was observed 1 week after the procedure, and most patients also reported reduction of pain. No serious side effects were observed.

Conclusions:

CT guided neurolytic celiac plexus blockade is a safe and effective treatment for intractable pain caused by advanced pancreatic cancer. Not all patients experience a significant effect, but the side effects are minor, and the procedure should therefore be offered patients experiencing intractable cancer related pain.

Ganglion blocks as a treatment of pain: current perspectives

The inputs from sympathetic ganglia have been known to be involved in the pathophysiology of various painful conditions such as complex regional pain syndrome, cancer pain of different origin, and coccygodynia. Sympathetic ganglia blocks are used to relieve patients who suffer from these conditions for over a century. Many numbers of local anesthetics such as bupivacaine or neurolytic agents such as alcohol can be chosen for a successful block. The agent is selected according to its duration of effect and the purpose of the injection. Most commonly used sympathetic blocks are stellate ganglion block, lumbar sympathetic block, celiac plexus block, superior hypogastric block, and ganglion Impar block. In this review, indications, methods, effectiveness, and complications of these blocks are discussed based on the data from the current literature.

Guidelines for the understanding and management of pain in chronic pancreatitis

Abdominal pain is the foremost complication of chronic pancreatitis (CP). Pain can be related to recurrent or chronic inflammation, local complications or neurogenic mechanisms with corresponding changes in the nervous systems. Both pain intensity and the frequency of pain attacks have been shown to reduce quality of life in patients with CP. Assessment of pain follows the guidelines for other types of chronic pain, where the multidimensional nature of symptom presentation is taken into consideration. Quantitative sensory testing may be used to characterize pain, but is currently used in a research setting in advanced laboratories. For pain relief, current guidelines recommend a simple stepwise escalation of analgesic drugs with increasing potency until pain relief is obtained. Abstinence from alcohol and smoking should be strongly advised. Pancreatic enzyme therapy and antioxidants may be helpful as initial treatment. Endoscopic treatment can be used in patients with evidence of ductal obstruction and may be combined with extracorporeal shock wave lithothripsy. The best candidates are those with distal obstruction of the main pancreatic duct and in early stage of disease. Behavioral interventions should be part of the multidisciplinary approach to chronic pain management particularly when psychological impact is experienced. Surgery should be considered early and after a maximum of five endoscopic interventions. The type of surgery depends on morphological changes of the pancreas. Long-term effects are variable, but high success rates have been reported in open studies and when compared with endoscopic treatment. Finally, neurolytical interventions and neuromodulation can be considered in difficult patients.

Novel treatment protocol for ameliorating refractory, chronic pain in patients with autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) patients can suffer from chronic pain that can be refractory to conventional treatment, resulting in a wish for nephrectomy. This study aimed to evaluate the effect of a multidisciplinary treatment protocol with sequential nerve blocks on pain relief in ADPKD patients with refractory chronic pain. As a first step a diagnostic, temporary celiac plexus block with local anesthetics was performed. If substantial pain relief was obtained, the assumption was that pain was relayed via the celiac plexus and major splanchnic nerves. When pain recurred, patients were then scheduled for a major splanchnic nerve block with radiofrequency ablation. In cases with no pain relief, it was assumed that pain was relayed via the aortico-renal plexus, and catheter-based renal denervation was performed. Sixty patients were referred, of which 44 were eligible. In 36 patients the diagnostic celiac plexus block resulted in substantial pain relief with a change in the median visual analogue scale (VAS) score pre-post intervention of 50/100. Of these patients, 23 received a major splanchnic nerve block because pain recurred, with a change in median VAS pre-post block of 53/100. In 8 patients without pain relief after the diagnostic block, renal denervation was performed in 5, with a borderline significant change in the median VAS pre-post intervention of 20/100. After a median follow-up of 12 months, 81.8% of the patients experienced a sustained improvement in pain intensity, indicating that our treatment protocol is effective in obtaining pain relief in ADPKD patients with refractory chronic pain.

Effectiveness of Percutaneous Celiac Plexus Ablation in the Treatment of Severe Cancer Pain in Upper Abdomen and Evaluation of Health Economics

Objective:

To compare the effectiveness, adverse effects, and cost-effectiveness of percutaneous neurolytic celiac plexus block (NCPB) versus traditional medication strategies for the treatment of patients with advanced cancer having severe upper abdominal cancer pain.

Methods:

This retrospective study included 81 patients with advanced upper abdominal cancer admitted to The Sixth People’s Hospital Affiliated to Shanghai Jiaotong University between January 2013 and July 2014. The patients were divided into percutaneous NCPB (treatment) and medication for pain (control) groups. The outcomes were measured in terms of Numeric Rating Scale (NRS) score and Karnofsky Performance Status (KPS) score before treatment and on the 3rd, 7th, 14th, and 28th days posttreatment. The effectiveness and cost-effectiveness of the therapy were assessed using analysis of the health economics.

Results:

The improvements in NRS score (1.42 ± 1.09 vs 4.03 ± 0.96, P < .01) and KPS score (65.55 ± 9.09 vs 63.03 ± 8.961, P < .01) in the treatment group were significantly superior compared to the control group on the 7th day of treatment, followed by no significant difference between the 2 groups on the 14th and the 28th day of treatment. Health economics evaluation revealed that the medicine-specific costs and total health care costs were significantly reduced in the treatment group compared to the control group ( P < .05), but no significant differences between the 2 groups ( P > .05) were seen in the costs of hospitalization, examinations, and treatment.

Conclusion:

The percutaneous NCPB method shows promising results and better cost-effectiveness for treating patients with advanced cancer having severe upper abdominal pain.

A case report: Clinical application of celiac plexus block in bile duct interventional procedures

Although percutaneous transhepatic biliary drainage (PTBD) and tract dilatation (TD) are very painful procedures, almost all of those procedures have been conducted under local anesthesia and opioid injection due to the lack of manpower and time. Celiac plexus block (CPB) is an interventional technique used for diagnostic and therapeutic purposes in the treatment of abdominovisceral pain. CPB decreases the side effects of opioid medications and enhances analgesia from medications. We present the case of a patient who underwent PTBD and TD under CPB in order to reduce procedure-related abdominal pain.CPB can be a useful alternative technique for pain management during and after biliary interventional procedures, although CPB-induced complications must always be kept in mind.

Median Arcuate Ligament Syndrome Is Not a Vascular Disease

BACKGROUND

Median arcuate ligament syndrome (MALS) is a rare disorder characterized by postprandial abdominal pain, weight loss, and celiac stenosis. Diagnosis can be challenging, leading to a delay in treatment. We report on our continued experience using a laparoscopic approach for this uncommon diagnosis.

METHODS

This is an Institutional Review Board-approved, prospectively collected retrospective analysis of patients treated with laparoscopic MAL release at our institution. Data collected included patient demographics, preoperative symptoms, operative approach, and postoperative outcomes. Patients were then contacted to complete a postoperative survey designed to assess the improvement of symptoms and overall patient satisfaction.

RESULTS

A total of 39 patients (33 women and 6 men) underwent laparoscopic MAL release from March 2007 to July 2014. Mean age was 40.6 years (range, 17-77 years). Thirty of 39 patients had a postoperative celiac axis ultrasound. Twenty-three had a patent celiac axis on postoperative duplex. Of the remaining 7, 5 with residual celiac axis stenosis and 1 with occlusion, reported complete resolution of their symptoms. One remaining patient with occlusion remained symptomatic. Thirty-three of 39 (84.6%) reported symptom relief after surgery. Nine of 33 (27.3%) responders had cardiovascular risk factors versus 4 of 6 (67%) nonresponders. Five patients with atypical presentations underwent preoperative diagnostic celiac plexus block using local anesthetic, with 4 reporting symptom reliefs after block. These 4 patients also reported postoperative symptom relief. One patient of 39 received a postoperative celiac stent placement and remained symptomatic. There were 4 conversions to open surgery (10.3%) and no deaths.

CONCLUSIONS

Laparoscopic MAL release continues to be a safe and effective means of managing MALS. Our data suggest that the symptoms associated with MALS are not related to vascular compromise, and atherosclerotic risk factors may predict poorer outcomes. Symptomatic relief is seen in the vast majority of patients undergoing this procedure. However, patient selection remains critically important in obtaining optimal results.

Pulse Transit Time as a Predictor of the Efficacy of a Celiac Plexus Block in Patients With Chronic Intractable Abdominal Pain

OBJECTIVE

There is no well-defined predictor of satisfactory pain relief after celiac plexus block (CPB) at the early stage of treatment. This study evaluated whether measurement of the electrocardiographic R-wave and the arrival time of the pulses at the toe pulse transit time (E-T PTT) can be an early predictor of pain response and success of CPB in patients with chronic intractable visceral pain.

METHODS

Twelve patients aged between 20 and 80 years who underwent CPB for treatment of chronic intractable cancer-related abdominal pain were included. A successful CPB was determined as a >50% decrease on the numerical rating scale measured 24 hours after the procedure. The E-T PTT at baseline and at 5, 10, 20, and 30 minutes after the injection of local anesthetic was measured as the time between the R-wave on the electrocardiogram and the peak point of the corresponding plethysmogram wave from the ipsilateral great toe. The change in the E-T PTT that was predictive of a successful CPB was analyzed using receiver operating characteristic curve analysis.

RESULTS

A CPB was successful in 9 of 12 cases; the dE-T PTT5/E-T PTT0 of the success group was 6.84%±5.04% versus 0.72%±0.78% in the failure group (P=0.021). The mean E-T PTTx differed significantly between timepoints (F=9.313, P=0.014) and between the success and failure groups (P<0.01). The best value of dE-T PTT5/E-T PTT0 indicating a successful CPB, estimated by receiver operating characteristic curve analysis, was 2.30% (sensitivity 88.9%, specificity 100%). The area under the curve was 96% (95% confidence interval, 85.7%-100%).

CONCLUSIONS

Prolongation of E-T PTT at 5 minutes after CPB correlates closely with a significant analgesic effect.

Alternative Method of Retrocrural Approach during Celiac Plexus Block Using a Bent Tip Needle

Background

This study sought to determine safe ranges of oblique angle, skin entry point and needle length by reviewing computed tomography (CT) scans and to evaluate the usefulness of a bent tip needle during celiac plexus block (CPB).

Methods

CT scans of 60 CPB patients were reviewed. Image of the uppermost margin of L2 vertebral body was used to measure the minimal and maximal oblique angles and the distances from the midline to skin puncture point. The imaginary needle trajectory distance was calculated by three-dimensional measurement. When the procedure was performed by using a 10° bent tip needle under a 20° oblique X-ray fluoroscopic view, the distance (GF/G'F) from the midline to the actual puncture site was measured.

Results

The imaginary safe oblique angle range was 26.4-34.2° and 27.7-36.0° on the right and left, respectively. The distance from the midline to skin puncture point was 6.1-7.6 cm on the right and 6.3-7.6 cm on the left. The needle trajectory distance at minimal angle was 9.6-11.6 cm on the right and 9.5-11.5 cm on the left. The distance of GF/G'F was 5.1-6.5 cm and 5.0-6.4 cm on the right and left, respectively. All imaginary parameters were correlated with BMI except for GF/G'F. All complications were mild and transient.

Conclusions

We identified safe values of angles and distances using a straight needle. Furthermore, using a bent tip needle under a 20° oblique fluoroscopic view, we could safely perform CPB with smaller parameter values.

Correlation of clinical stage and performance status with quality of life in patients seen in a pancreas multidisciplinary clinic

INTRODUCTION

The objectives of this study were to evaluate quality of life (QoL) in patients presenting to the Johns Hopkins Pancreas Multidisciplinary Clinic (PMDC), and to examine associations between disease status, performance status, and QoL in order to identify patient subgroups that are most at risk for reduced QoL.

PATIENTS AND METHODS

Data from 77 patients were evaluated. At initial presentation, disease and performance status were assessed, as well as QoL, which was obtained with the European Organisation for Research and Treatment of Cancer QLQ-PAN26 questionnaire. Statistical analyses examined associations between QoL, disease status, and performance status.

RESULTS

Digestive symptoms (P < .003) significantly differed by pancreatic disease status (resectable, resected, locally advanced, and metastatic). Patients with a worse performance status, defined as Eastern Cooperative Oncology Group ≥ 1, were more likely to report symptomatic pancreatic pain (P = .001), digestive symptoms (P = .017), cachexia (P = .004), and ascites (P < .001) compared with patients with a performance status of 0. The majority (92%) of patients reported a significant fear of future health problems, regardless of disease status or performance status.

CONCLUSION

Although several measures of QoL have been observed in all patients, certain measures appear to correlate specifically with worse disease status. Therefore, routine assessment of QoL is suggested in order to guide treatment decisions. Further investigation on optimizing the use of QoL measures and patient-reported outcomes to better tailor management is warranted.