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Nagar SD, Nagar SJ, Jordan V, Dawson J. Sympathetic nerve blocks for persistent pain in adults with inoperable abdominopelvic cancer. Cochrane Database Syst Rev 2024; 6:CD015229. [PMID: 38842054 PMCID: PMC11154857 DOI: 10.1002/14651858.cd015229.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
BACKGROUND Persistent visceral pain is an unpleasant sensation coming from one or more organs within the body. Visceral pain is a common symptom in those with advanced cancer. Interventional procedures, such as neurolytic sympathetic nerve blocks, have been suggested as additional treatments that may play a part in optimising pain management for individuals with this condition. OBJECTIVES To evaluate the benefits and harms of neurolytic sympathetic nerve blocks for persistent visceral pain in adults with inoperable abdominopelvic cancer compared to standard care or placebo and comparing single blocks to combination blocks. SEARCH METHODS We searched the following databases without language restrictions on 19 October 2022 and ran a top-up search on 31 October 2023: CENTRAL; MEDLINE via Ovid; Embase via Ovid; LILACS. We searched trial registers without language restrictions on 2 November 2022: ClinicalTrials.gov; WHO International Clinical Trials Registry Platform (ICTRP). We searched grey literature, checked reference lists of reviews and retrieved articles for additional studies, and performed citation searches on key articles. We also contacted experts in the field for unpublished and ongoing trials. Our trial protocol was preregistered in the Cochrane Database of Systematic Reviews on 21 October 2022. SELECTION CRITERIA We searched for randomised controlled trials (RCTs) comparing any sympathetic nerve block targeting sites commonly used to treat abdominal pelvic pain from inoperable malignancies in adults to standard care or placebo. DATA COLLECTION AND ANALYSIS We independently selected trials based on predefined inclusion criteria, resolving any differences via adjudication with a third review author. We used a random-effects model as some heterogeneity was expected between the studies due to differences in the interventions being assessed and malignancy types included in the study population. We chose three primary outcomes and four secondary outcomes of interest. We sought consumer input to refine our review outcomes and assessed extracted data using Cochrane's risk of bias 2 tool (RoB 2). We assessed the certainty of evidence using the GRADE system. MAIN RESULTS We included 17 studies with 1025 participants in this review. Fifteen studies with a total of 951 participants contributed to the quantitative analysis. Single block versus standard care Primary outcomes No included studies reported our primary outcome, 'Proportion of participants reporting no worse than mild pain after treatment at 14 days'. The evidence is very uncertain about the effect of sympathetic nerve blocks on reducing pain to no worse than mild pain at 14 days when compared to standard care due to insufficient data (very low-certainty evidence). Sympathetic nerve blocks may provide small to 'little to no' improvement in quality of life (QOL) scores at 14 days after treatment when compared to standard care, but the evidence is very uncertain (standardised mean difference (SMD) -0.73, 95% confidence interval (CI) -1.70 to 0.25; I² = 87%; 4 studies, 150 participants; very low-certainty evidence). The evidence is very uncertain about the risk of serious adverse events as defined in our review as only one study contributed data to this outcome. Sympathetic nerve blocks may have an 'increased risk' to 'no additional risk' of harm compared with standard care (very low-certainty evidence). Secondary outcomes Sympathetic nerve blocks showed a small to 'little to no' effect on participant-reported pain scores at 14 days using a 0 to 10 visual analogue scale (VAS) for pain compared with standard care, but the evidence is very uncertain (mean difference (MD) -0.44, 95% CI -0.98 to 0.11; I² = 56%; 5 studies, 214 participants; very low-certainty evidence). There may be a 'moderate to large' to 'little to no' reduction in daily consumption of opioids postprocedure at 14 days with sympathetic nerve blocks compared with standard care, but the evidence is very uncertain (change in daily consumption of opioids at 14 days as oral milligrams morphine equivalent (MME): MD -41.63 mg, 95% CI -78.54 mg to -4.72 mg; I² = 90%; 4 studies, 130 participants; very low-certainty evidence). The evidence is very uncertain about the effect of sympathetic nerve blocks on participant satisfaction with procedure at 0 to 7 days and time to need for retreatment or treatment effect failure (or both) due to insufficient data. Combination block versus single block Primary outcomes There is no evidence about the effect of combination sympathetic nerve blocks compared with single sympathetic nerve blocks on the proportion of participants reporting no worse than mild pain after treatment at 14 days because no studies reported this outcome. There may be a small to 'little to no' effect on QOL score at 14 days after treatment, but the evidence is very uncertain (very low-certainty evidence). The evidence is very uncertain about the risk of serious adverse events with combination sympathetic nerve blocks compared with single sympathetic nerve blocks due to limited reporting in the included studies (very low-certainty evidence). Secondary outcomes The evidence is very uncertain about the effect of combination sympathetic nerve blocks compared with single sympathetic nerve blocks on participant-reported pain score and change in daily consumption of opioids postprocedure, at 14 days. There may be a small to 'little to no' effect, but the evidence is very uncertain (very low-certainty evidence). There is no evidence about the effect on participant satisfaction with procedure at 0 to 7 days and time to need for retreatment or treatment effect failure (or both) due to these outcomes not being measured by the studies. Risk of bias The risk of bias was predominately high for most outcomes in most studies due to significant concerns regarding adequate blinding. Very few studies were deemed as low risk across all domains for any outcome. AUTHORS' CONCLUSIONS There is limited evidence to support or refute the use of sympathetic nerve blocks for persistent abdominopelvic pain due to inoperable malignancy. We are very uncertain about the effect of combination sympathetic nerve blocks compared with single sympathetic nerve blocks. The certainty of the evidence is very low and these findings should be interpreted with caution.
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Affiliation(s)
- Sachin D Nagar
- Department of Hospital Palliative Care, North Shore Hospital, Te Whatu Ora - Waitemata, Auckland, New Zealand
| | - Sarah J Nagar
- Neurogenetics, Center for Brain Research, University of Auckland, Auckland, New Zealand
| | - Vanessa Jordan
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Jennifer Dawson
- Department of Hospital Palliative Care, Middlemore Hospital, Te Whatu Ora - Counties Manukau, Auckland, New Zealand
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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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Yanaizumi R, Nagamine Y, Harada S, Kuramochi T, Ota S, Abe Y, Nakagawa M, Kamijima K, Hayashi M, Tazawa T, Ogawa K, Goto T. Long-Term Analgesic Efficacy of Neurolytic Splanchnic Nerve Block via the Transintervertebral Disc Approach to Retrocrural Space: A Multicenter Retrospective Study. Pain Ther 2023; 12:825-840. [PMID: 37052814 PMCID: PMC10199966 DOI: 10.1007/s40122-023-00506-0] [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: 11/09/2022] [Accepted: 03/21/2023] [Indexed: 04/14/2023] Open
Abstract
INTRODUCTION The celiac plexus block is effective for treating intractable cancer pain and has been the focus of many studies. At our affiliated institution, fluoroscopy-guided splanchnic nerve block with a single needle via the transintervertebral disc approach was the first choice of treatment. The short-term efficacy of this technique has been reported, but the long-term efficacy is not clear. In the present study, we investigated the long-term analgesic efficacy of this technique. METHODS This multicenter, retrospective, observational study reviewed the medical records of patients who underwent neurolytic splanchnic nerve block (NSNB) via the transintervertebral disc approach for intractable cancer pain at five tertiary hospitals in Japan from April 2005 to October 2020. The primary outcome was the long-term analgesic efficacy of a one-time NSNB via the transintervertebral disc approach. RESULTS In total, 76 patients were included in the analysis. The median lowest numerical rating scale (NRS) score was 1 within 14 days. At 1, 2, 3, and 6 months after the nerve block, the median NRS score was also ≤ 2, while the median equivalent oral morphine dose did not show any clinically noticeable increase at those times. CONCLUSION The long-term analgesic efficacy of NSNB via the transintervertebral disc approach in patients with intractable cancer pain has been demonstrated.
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Affiliation(s)
- Ryota Yanaizumi
- Department of Anesthesiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Yusuke Nagamine
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan.
| | | | - Tomoko Kuramochi
- Department of Palliative Care, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Shuhei Ota
- Department of Palliative Medicine, Kanagawa Cancer Center, Kanagawa, Japan
| | - Yoichiro Abe
- Department of Pain Clinic, NTT Medical Center Tokyo, Tokyo, Japan
| | | | - Kenya Kamijima
- Department of Pain Clinic, NTT Medical Center Tokyo, Tokyo, Japan
| | - Maya Hayashi
- Department of Pain Clinic, NTT Medical Center Tokyo, Tokyo, Japan
| | - Toshiharu Tazawa
- Department of Anesthesiology, Saint Marianna University School of Medicine, Kawasaki, Japan
| | - Kenichi Ogawa
- Kugenuma Palliative Care Internal Medicine, Fujisawa, Japan
| | - Takahisa Goto
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan
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Matsumoto T, Yoshimatsu R, Osaki M, Miyatake K, Yamanishi T, Yamagami T. Computed tomography-guided single celiac plexus neurolysis analgesic efficacy and safety: a systematic review and meta-analysis. ABDOMINAL RADIOLOGY (NEW YORK) 2022; 47:3892-3906. [PMID: 36087117 DOI: 10.1007/s00261-022-03670-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 08/26/2022] [Accepted: 08/27/2022] [Indexed: 01/18/2023]
Abstract
PURPOSE To perform a systematic review and meta-analysis of published studies to evaluate the analgesic efficacy and safety of computed tomography (CT)-guided single celiac plexus neurolysis (CPN) with the injection of a neurolytic agent into the celiac plexus in one session (CT-guided single CPN). METHODS PubMed, the Cochrane Library, and Ichushi-Web were searched for English or Japanese articles published up to February 2022, which reported findings about patients who underwent CT-guided single CPN. The outcome measures assessed in the systematic review and meta-analysis were the pain measurement scales from 0 to 10 before and after the intervention and the rate of minor and major complications. RESULTS The pooled pain measurement scales at pre-intervention and 1- or 2-, 7-, 30-, 60-, 90-, and 180-day post-intervention was 6.72 (95% confidence interval [CI], 4.77-9.46, I2 = 98%), 2.31 (95% CI 2.31-4.44, I2 = 92%), 2.84 (95% CI 1.39-5.79, I2 = 95%), 3.36 (95% CI 1.66-6.77, I2 = 98%), 3.19 (95% CI 1.44-7.08, I2 = 59%), 3.87 (95% CI 1.88-7.97, I2 = 0%), and 3.40 (95% CI 3.02-3.83, I2 = not applicable), respectively. The pooled minor complication rates of diarrhea, hypotension, nausea or vomiting, and pain associated with the procedure were 18% (95% CI 8-37%, I2 = 45%), 16% (95% CI 2-58%, I2 = 76%), 6% (95% CI 2-16%, I2 = 1%), and 7% (95% CI 2-21%, I2 = 17%), respectively. There was no major complication in the included studies. CONCLUSION CT-guided single CPN can be performed safely and provides immediate analgesic efficacy although the amount of heterogeneity is characterized as large. Further investigation of its long-term analgesic efficacy is required.
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Affiliation(s)
- Tomohiro Matsumoto
- Department of Diagnostic and Interventional Radiology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan.
| | - Rika Yoshimatsu
- Department of Diagnostic and Interventional Radiology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Marina Osaki
- Department of Diagnostic and Interventional Radiology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Kana Miyatake
- Department of Diagnostic and Interventional Radiology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Tomoaki Yamanishi
- Department of Diagnostic and Interventional Radiology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Takuji Yamagami
- Department of Diagnostic and Interventional Radiology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
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Mercadante S. Commentary: Interpreting Data of Celiac Plexus Block in Patients with Pancreatic Pain: Timing, Patients, Survival. Pain Ther 2022; 11:747-751. [PMID: 35622239 PMCID: PMC9314495 DOI: 10.1007/s40122-022-00396-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/06/2022] [Indexed: 01/11/2023] Open
Abstract
Although celiac plexus block (CPB) is a well known technique that has been performed for years, only in the last 30 years controlled studies, demonstrated its efficacy and safety. A historical pathway of literature regarding CPB and a critical analysis may help understand some points which remain still controversial, for a better interpretation of data.
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Affiliation(s)
- Sebastiano Mercadante
- Chair of Anesthetics & Main Regional Center for Pain Relief & Palliative/Supportive Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146 Palermo, Italy ,Regional Home Palliative Care Program, SAMOT Palermo, Palermo, Italy
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Okita M, Otani K, Gibo N, Matsui S. Systematic review and meta-analysis of celiac plexus neurolysis for abdominal pain associated with unresectable pancreatic cancer. Pain Pract 2022; 22:652-661. [PMID: 35748531 DOI: 10.1111/papr.13143] [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] [Received: 01/29/2022] [Revised: 04/08/2022] [Accepted: 05/09/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Celiac plexus neurolysis (CPN) has been developed as adjunctive therapy to medical management (MM) of abdominal pain associated with unresectable pancreatic cancer. We aimed to conduct a systematic review and meta-analysis to obtain updated and more accurate evidence on the efficacy of additional types of CPN, including endoscopic ultrasound-guided CPN (EUS-CPN). METHODS On March 16, 2021, we performed searches of PubMed, Web of Science, and CENTRAL for original randomized controlled trials (RCTs). We defined the primary outcome as a standardized pain intensity score with a range of 0-10, and evaluated the mean difference between the CPN + MM and MM groups at 4, 8, and 12 weeks after the initiation of treatment. We used a random-effects model to synthesize the mean differences across RCTs. RESULTS We selected 10 RCTs involving 646 individuals. The synthesized mean difference in the pain intensity score between the CPN + MM and MM groups was -0.58 (95% confidence interval [CI]: -1.09 to -0.07) (p = 0.034) in favor of CPN + MM at 4 weeks, -0.46 (95%CI: -1.00 to 0.08) (p = 0.081) at 8 weeks, and - 1.35 (95%CI: -3.61 to 0.92) (p = 0.17) at 12 weeks. CONCLUSIONS This updated meta-analysis of CPN demonstrates its efficacy for managing abdominal pain at 4 weeks. Although there are various limitations, when abdominal pain in patients with unresectable pancreatic cancer is poorly controlled with MM alone, CPN should be an option even if the duration of effect is short-lived, taking into account the absence of serious adverse events.
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Affiliation(s)
- Muneyori Okita
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuki Otani
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Noriaki Gibo
- Department of Gastroenterology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shigeyuki Matsui
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Jacobson G, Fluss R, Dany-BenShushan A, Golan T, Meron T, Zimmermann C, Dawson LA, Barry A, Miszczyk M, Buckstein M, Diaz Pardo D, Aguiar A, Hammer L, Dicker AP, Ben-Ailan M, Morag O, Hausner D, Symon Z, Lawrence YR. Coeliac plexus radiosurgery for pain management in patients with advanced cancer : study protocol for a phase II clinical trial. BMJ Open 2022; 12:e050169. [PMID: 35332036 PMCID: PMC8948399 DOI: 10.1136/bmjopen-2021-050169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Pancreatic cancer is characterised by severe mid-back and epigastric pain caused by tumour invasion of the coeliac nerve plexus. This pain is often poorly managed with standard treatments. This clinical trial investigates a novel approach in which high-dose radiation (radiosurgery) is targeted to the retroperitoneal coeliac plexus nerve bundle. Preliminary results from a single institution pilot trial are promising: pain relief is substantial and side effects minimal. The goals of this study are to validate these findings in an international multisetting, and investigate the impact on quality of life and functional status among patients with terminal cancer. METHODS AND ANALYSIS A single-arm prospective phase II clinical trial. Eligible patients are required to have severe coeliac pain of at least five on the 11-point BPI average pain scale and Eastern Cooperative Oncology Group performance status of two or better. Non-pancreatic cancers invading the coeliac plexus are also eligible. The intervention involves irradiating the coeliac plexus using a single fraction of 25 Gy. The primary endpoint is the complete or partial pain response at 3 weeks. Secondary endpoints include pain at 6 weeks, analgesic use, hope, qualitative of life, caregiver burden and functional outcomes, all measured using validated instruments. The protocol is expected to open at a number of cancer centres across the globe, and a quality assurance programme is included. The protocol requires that 90 evaluable patients" be accrued, based upon the assumption that a third of patients are non-evaluable (e.g. due to death prior to 3-weeks post-treatment assessment, or spontaneous improvement of pain pre-treatment), it is estimated that a total of 120 patients will need to be accrued. Supported by Gateway for Cancer Research and the Israel Cancer Association. ETHICS AND DISSEMINATION Ethic approval for this study has been obtained at eight academic medical centres located across the Middle East, North America and Europe. Results will be disseminated through conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT03323489.
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Affiliation(s)
- Galia Jacobson
- Radiation Oncology, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
- Radiation Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Ronen Fluss
- Gertner Institute, Sheba Mediacal Center, Tel Hashomer, Tel Aviv, Israel
| | - Amira Dany-BenShushan
- Israeli Center for Cardiovascular Research, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Talia Golan
- Oncology, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
- Sackler School of Medicine, Tel aviv University, Tel Aviv, Israel
| | - Tikva Meron
- Oncology, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Laura A Dawson
- Radiation Oncology, Princess Margaret Hospital Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Aisling Barry
- Radiation Oncology, Princess Margaret Hospital Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Marcin Miszczyk
- IIIrd Radiotherapy and Chemotherapy Department, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Michael Buckstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dayssy Diaz Pardo
- Department of Radiation Oncology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Artur Aguiar
- Radiation Oncology, Portuguese Institute of Oncology of Porto, Porto, Portugal
| | - Liat Hammer
- Radiation Oncology, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
- Radiatin Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Adam P Dicker
- Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Maoz Ben-Ailan
- Radiation Oncology, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Ofir Morag
- Cancer Pain Unit, Institute of Oncology, Sheba Medical Center, Tel Aviv, Israel
| | - David Hausner
- Cancer Center, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Zvi Symon
- Radiation Oncology, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
- Sackler School of Medicine, Tel aviv University, Tel Aviv, Israel
| | - Yaacov R Lawrence
- Radiation Oncology, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
- Sackler School of Medicine, Tel aviv University, Tel Aviv, Israel
- Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Ye L, Schorn S, Pergolini I, Safak O, Demir E, Istvanffy R, Friess H, Ceyhan GO, Demir IE. The Effect of Celiac Neurolysis and Splanchnicectomy on Survival in Unresectable Pancreatic Cancer: A Systematic Review and Meta-Analysis. Dig Surg 2021; 39:51-59. [PMID: 34903684 DOI: 10.1159/000520456] [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: 08/05/2021] [Accepted: 10/14/2021] [Indexed: 12/10/2022]
Abstract
BACKGROUND Intractable pancreatic pain is one of the most common symptoms of patients with pancreatic ductal adenocarcinoma (PDAC). Celiac neurolysis (CN) and splanchnicectomy were already described as effective methods to manage abdominal pain in unresectable PDAC, but their impact on overall survival (OS) has not yet been established. OBJECTIVE We aimed to investigate the impact of CN and splanchnicectomy on the survival of patients with unresectable pancreatic cancer. METHODS A systematic review of PubMed and Cochrane Library according to predefined searching terms was conducted in March 2020. Hazard ratios (HR) of OS data were calculated using the Mantel-Haenszel model for random effects or fixed effects. RESULT Four randomized-controlled trials (RCTs) and 2 non-RCTs with a total of 2,507 patients were identified. The overall pooled HR did not reveal any relevant effect of CN and splanchnicectomy on OS (HR: 1.03; 95% CI: 0.81-1.32), which was also underlined by the sensitivity analysis of RCTs (HR: 1.0; 95% CI: 0.72-1.39) and non-RCTs (HR: 1.07; 95% CI: 0.71-1.63). However, subgroup analyses depending on tumor stage revealed that CN or splanchnicectomy was associated with a worsened OS in AJCC (American Joint Committee on Cancer) stage III patients with unresectable PDAC (HR: 1.22; 95% CI: 1.03-1.45), but nor for AJCC stage IV patients (HR: 1.27; 95% CI: 0.9-1.80). CONCLUSION Although only few data are currently available, this systematic review with meta-analysis showed that in unresectable PDAC, CN or splanchnicectomy is associated with a worsened survival in stage III PDAC patients, with no effect on stage IV PDAC patients. These data call for caution in the usage of CN or splanchnicectomy in stage III PDAC and for further studies addressing this observation.
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Affiliation(s)
- Linhan Ye
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany,
| | - Stephan Schorn
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Ilaria Pergolini
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Okan Safak
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Elke Demir
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Rouzanna Istvanffy
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site, Munich, Germany.,CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
| | - Helmut Friess
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site, Munich, Germany.,CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
| | - Güralp O Ceyhan
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Ihsan Ekin Demir
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site, Munich, Germany.,CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany.,Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey.,Else Kröner Clinician Scientist Professor for "Translational Pancreatic Surgery", Munich, Germany
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Coveler AL, Mizrahi J, Eastman B, Apisarnthanarax SJ, Dalal S, McNearney T, Pant S. Pancreas Cancer-Associated Pain Management. Oncologist 2021; 26:e971-e982. [PMID: 33885205 PMCID: PMC8176967 DOI: 10.1002/onco.13796] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 04/02/2021] [Indexed: 12/12/2022] Open
Abstract
Pain is highly prevalent in patients with pancreas cancer and contributes to the morbidity of the disease. Pain may be due to pancreatic enzyme insufficiency, obstruction, and/or a direct mass effect on nerves in the celiac plexus. Proper supportive care to decrease pain is an important aspect of the overall management of these patients. There are limited data specific to the management of pain caused by pancreatic cancer. Here we review the literature and offer recommendations regarding multiple modalities available to treat pain in these patients. The dissemination and adoption of these best supportive care practices can improve quantity and quality of life for patients with pancreatic cancer. IMPLICATIONS FOR PRACTICE: Pain management is important to improve the quality of life and survival of a patient with cancer. The pathophysiology of pain in pancreas cancer is complex and multifactorial. Despite tumor response to chemotherapy, a sizeable percentage of patients are at risk for ongoing cancer-related pain and its comorbid consequences. Accordingly, the management of pain in patients with pancreas cancer can be challenging and often requires a multifaceted approach.
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Affiliation(s)
- Andrew L Coveler
- Department of Medical Oncology, University of Washington, Seattle, Washington, USA
| | - Jonathan Mizrahi
- Department of Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bory Eastman
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | | | - Shalini Dalal
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Shubham Pant
- Department of Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Impact of Early Intervention in Pain Management in Cancer Patients: A Randomized Controlled Study in a Tertiary Care Cancer Hospital. Clin J Pain 2021; 37:259-264. [PMID: 33555696 DOI: 10.1097/ajp.0000000000000919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 01/18/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The present study aimed to assess the role of early intervention of nerve blocks in the management of cancer pain. We also aimed to study its effect on the quality of life and the opioid requirement. MATERIALS AND METHODS Sixty patients with cancer having pain, 18 to 75 years were randomised and divided into an intervention group and analgesic titration with opioids group. Patients in the intervention group received nerve block and residual pain managed with opioids. Control group patients were managed with opioids alone. RESULTS The mean visual analog scale score showed statistically significant improvement in both the groups (8.56±1.07 to 2.5±0.63 in the intervention group, 9.3±0.74 to 3.3±0.75 in the control group at 1 month (P=0.000). This was associated with a decrease in the opioid requirement in the intervention group at 1 week (P=0.014) with only 4 patients receiving morphine at the end of 1 month.The change in the Karnofsky scale was statistically significant from baseline to 1 month in both groups. DISCUSSION Interventional pain management has a definitive role in palliative setup for pain management. Pain relief was obtained in both groups, but the quality of pain relief was better in the intervention group with an associated reduction in the opioid requirement.
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11
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Gupta R, Madanat L, Jindal V, Gaikazian S. Celiac Plexus Block Complications: A Case Report and Review of the Literature. J Palliat Med 2021; 24:1409-1412. [PMID: 33395560 DOI: 10.1089/jpm.2020.0530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Celiac plexus block (CPB) has been widely used as a treatment option for chronic intractable abdominal pain resulting from intra-abdominal malignancies as well as benign conditions. Complications resulting from CPB have been long reported and include diarrhea, back pain, paraplegia, postural hypotension, pneumothorax, and local anesthesia toxicity. Diarrhea and postural hypotension are two most common complications with studies reporting incidences occurring in 44% to 60% and 10% to 52% of patients, respectively. Diarrhea is most often transient, resolving within 48 hours; however, literature reports cases in which diarrhea was chronic, debilitating, and in some instances life threatening. Persistent diarrhea proves difficult to treat. We report a case of a 76-year-old male with unresectable pancreatic adenocarcinoma who underwent computed tomography-guided CBP complicated by persistent diarrhea and fecal incontinence. After conventional antidiarrheal failed to improve the symptoms, octreotide proved to be beneficial and the patient reported significant improvement in symptoms.
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Affiliation(s)
- Ruby Gupta
- Department of Hematology and Medical Oncology, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Luai Madanat
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Vishal Jindal
- Department of Hematology and Medical Oncology, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Susanna Gaikazian
- Department of Hematology and Medical Oncology, William Beaumont Hospital, Royal Oak, Michigan, USA
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12
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Jain P. Interventional management for cancer pain. INDIAN JOURNAL OF PAIN 2021. [DOI: 10.4103/ijpn.ijpn_17_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Dolly A, Singh S, Prakash R, Bogra J, Malik A, Singh V. Comparative evaluation of different volumes of 70% alcohol in celiac plexus block for upper abdominal malignsancies. South Asian J Cancer 2020; 5:204-209. [PMID: 28032091 PMCID: PMC5184761 DOI: 10.4103/2278-330x.195346] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Context: Celiac plexus block (CPB) (is an effective way to reduce cancer-associated pain in upper abdominal malignancies. Aims: To evaluate the efficacy and safety of different volumes of 70% alcohol in CPB. Settings and Design: Prospective, randomized, controlled clinical study. Subjects and Methods: Thirty patients of carcinoma gall bladder were randomly divided into three groups (n = 10) to receive 20, 30, and 40 ml of 70% alcohol in CPB. Statistical Analysis Used: All the continuous data were assessed analysis of variance followed by post-hoc tests (Tukey's Honestly Significant Difference test). Ordinal data were compared using Kruskal–Wallis H-test followed by Mann–Whitney U-test. Categorical comparisons were performed using Chi-square test. Results: A significant difference in visual analog scale (VAS) score of Group I, Group I and Group III was observed from week 6 onward until the end of the study. At all these time intervals, VAS scores in Group I was higher than both Groups II and III during this time interval. VAS scores in Group III were significantly lower as compared to Group II from week 10 onward until the end of the study. As compared to baseline, at all the follow-up intervals, mean morphine requirement was significantly lower in Group II and Group III. A quality of life (QOL) score of Group III were higher as compared to Group I. Between Group II and Group III, significant difference was observed at week 16 only when Group III had a higher score as compared to Group II. Conclusions: VAS score, QOL, and reduction in morphine consumption were increased on increasing the volume of alcohol in CPB, 40 ml being most effective.
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Affiliation(s)
- Archana Dolly
- Department of Anesthesiology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Sarita Singh
- Department of Anesthesiology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Ravi Prakash
- Department of Anesthesiology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Jaishri Bogra
- Department of Anesthesiology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Anita Malik
- Department of Anesthesiology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Vinita Singh
- Department of Anesthesiology, King George Medical University, Lucknow, Uttar Pradesh, India
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Comlek S. Pain Control with Splanchnic Neurolysis in Pancreatic Cancer Patients Unresponsive to Celiac Plexus Neurolysis. J Pain Res 2020; 13:2023-2031. [PMID: 32848449 PMCID: PMC7429208 DOI: 10.2147/jpr.s266689] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 07/23/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND/AIMS In most instances of abdominal pain associated with pancreatic cancer, pain may become refractory to increasing doses of narcotics. Celiac plexus neurolysis represents an option; however, altered celiac plexus anatomy may render this treatment infeasible or ineffective, where splanchnic nerve neurolysis may represent another option. This study aimed to investigate the outcomes of splanchnic neurolysis in pancreatic cancer patients not responsive to celiac plexus neurolysis. PATIENTS AND METHODS Among all 84 patients who underwent celiac plexus neurolysis for pancreatic cancer pain during the study period, 34 patients did not respond and underwent splanchnic nerve neurolysis under fluoroscopic guidance and thus included in this retrospective study. Stage IV, III, and II disease was present in 38.2%, 47.1%, and 14.7% of the patients. During the study, 88.2% were receiving chemotherapy, whereas none were on radiotherapy. Data for daily narcotic dose equivalents and Visual Analogue Scale (VAS) scores during outpatient visits at baseline, 2 weeks, 2 months, and 3 months were extracted. RESULTS Pain response rates were 76.5%, 84.4%, and 71.0%, at 2 weeks, 2 months, and 3 months, respectively. A significant and dramatic reduction was seen in VAS scores at 2 weeks (2.8±1.2 versus 6.3±1.1, p<0.001), and this significant decline was maintained for 3 months. Similarly, a significant and dramatic reduction was seen in daily narcotic need at 2 weeks (20.8±32.9 versus 93.4±86.2 mg, p<0.001), which was also maintained during the 3-month follow-up. The procedure was generally well tolerated. CONCLUSION Findings of this study suggest that splanchnic neurolysis represents a durable and effective option for pain control in pancreatic cancer patients in whom the neurolysis of the celiac plexus is ineffective. However, these conclusions refer to only preliminary single-center results in a selected patient group; thus, further large studies are warranted.
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Affiliation(s)
- Savas Comlek
- Gayrettepe Florence Nightingale Hospital, Department of Anesthesiology and Reanimation, Istanbul, Besiktas 34349, Turkey
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Kanno Y, Koshita S, Masu K, Ogawa T, Kusunose H, Murabayashi T, Sakai T, Kozakai F, Ito K. Efficacy of EUS-guided celiac plexus neurolysis compared with medication alone for unresectable pancreatic cancer in the oxycodone/fentanyl era: a prospective randomized control study. Gastrointest Endosc 2020; 92:120-130. [PMID: 31953188 DOI: 10.1016/j.gie.2020.01.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 01/02/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The efficacy of celiac plexus neurolysis (CPN) with EUS guidance (EUS-CPN) has not been confirmed in the era of developed opioids. The aim of this study was to evaluate the efficacy of EUS-CPN for patients with pancreatic cancer-associated pain to compare medication using oxycodone and/or fentanyl with and without EUS-CPN. METHODS In this randomized control study involving patients who underwent EUS-CPN and those who did not, pain, quality of life (QOL), and opioid consumption were compared. Standard medicinal treatment using oxycodone and/or fentanyl was performed for both groups. The primary endpoint was defined as the pain evaluated by using a visual analog scale (VAS) rated from a 0 to 10, 4 weeks after the baseline. RESULTS For 48 registered patients, the outcomes of 24 patients in the EUS-CPN group and 22 patients in the control group were analyzed. EUS-CPN was successfully performed and did not induce severe procedure-related adverse events for all patients in the EUS-CPN group. Although the average pain VAS scores for both groups significantly decreased in comparison with baseline, scores were not statistically different between the groups at week 4 (1.3 ± 1.3 for the EUS-CPN group vs 2.3 ± 2.3 for the control group, P = .10). There was no statistical difference or tendency in favor of EUS-CPN at evaluation points of weeks 1, 2, 8, and 12. Moreover, the average VAS scores for QOL and the average opioid consumption between the groups were not different at all evaluation points. CONCLUSIONS EUS-CPN for patients with pancreatic cancer-associated pain did not appear to improve pain, QOL, or opioid consumption compared with those who did not undergo EUS-CPN and medicated with oxycodone/fentanyl. Although EUS-CPN can be an option, it was not found to have a large enough impact to be routinely performed for all patients with pain. (Clinical trial registration number: UMIN 000037172.).
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Affiliation(s)
- Yoshihide Kanno
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Shinsuke Koshita
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Kaori Masu
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Takahisa Ogawa
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Hiroaki Kusunose
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Toji Murabayashi
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Toshitaka Sakai
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Fumisato Kozakai
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Kei Ito
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
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Lohse I, Brothers SP. Pathogenesis and Treatment of Pancreatic Cancer Related Pain. Anticancer Res 2020; 40:1789-1796. [PMID: 32234867 DOI: 10.21873/anticanres.14133] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 02/08/2023]
Abstract
Pancreatic cancer is often diagnosed due to the patient seeking medical attention for abdominal pain. It is among the most painful cancers, with pain severity strongly correlating with prognosis. Perineural invasion is a prominent feature of pancreatic cancer and often the first route of metastasis resulting in neuropathic pain. While surgical pain is present, it is generally short-lived; chemo- and radio-therapy associated side effect pain is often longer lasting and more difficult to manage. Treatment-induced mucositis in response to chemotherapy occurs throughout the GI tract resulting in infection-prone ulcers on the lip, buccal mucosa, palate or tongue. Cisplatin treatment is associated with axonal neuropathy in the dorsal root ganglion, although other large sensory fibers can be affected. Opioid-induced hyperalgesia can also emerge in patients. Along with traditional means to address pain, neurolytic celiac plexus block of afferent nociceptive fibers has been reported to be effective in 74% of patients. Moreover, as cancer treatments become more effective and result in improved survival, treatment-related side effects become more prevalent. Here, pancreatic cancer and treatment associated pain are reviewed along with current treatment strategies. Potential future therapeutic strategies to target the pathophysiology underlying pancreatic cancer and pain induction are also presented.
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Affiliation(s)
- Ines Lohse
- Center for Therapeutic Innovation, Miller School of Medicine, University of Miami, Miami, FL, U.S.A.,Department of Psychiatry and Behavioral Sciences, University of Miami, FL, U.S.A.,Molecular Therapeutics Shared Resource, Sylvester Comprehensive Cancer Center, University of Miami, FL, U.S.A
| | - Shaun P Brothers
- Center for Therapeutic Innovation, Miller School of Medicine, University of Miami, Miami, FL, U.S.A. .,Department of Psychiatry and Behavioral Sciences, University of Miami, FL, U.S.A.,Molecular Therapeutics Shared Resource, Sylvester Comprehensive Cancer Center, University of Miami, FL, U.S.A
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17
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Ahmed A, Thota RS, Chatterjee A, Jain P, Ramanjulu R, Bhatnagar S, Salins N, Bhattacharya D. Indian Society for Study of Pain, Cancer Pain Special Interest Group Guidelines on Interventional Management for Cancer Pain. Indian J Palliat Care 2020; 26:203-209. [PMID: 32874034 PMCID: PMC7444568 DOI: 10.4103/0973-1075.285696] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The Indian Society for Study of Pain (ISSP), Cancer Pain Special Interest Group guidelines on interventional management for cancer pain in adults provide a structured, stepwise approach which will help to improve the management of cancer pain and to provide the patients with minimally acceptable quality of life. The guidelines have been developed based on the available literature and evidence, to suit the needs, patient population, and situations in India. A questionnaire based on the key elements of each sub draft addressing certain inconclusive areas where evidence was lacking was made available on the ISSP website and circulated by e-mail to all the ISSP and Indian Association of Palliative Care members. We recommend using interventional management when conventional therapy fails to offer adequate benefits or causes undesirable side effects. Vertebroplasty should be offered to patients with uncontrolled bone pain when expertise is available.
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Affiliation(s)
- Arif Ahmed
- Department of Anaesthesia, Critical Care and Pain Management, CK Birla Hospital for Women, Gurugram, Haryana, India
| | - Raghu S Thota
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Aparna Chatterjee
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Parmanand Jain
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Raghavendra Ramanjulu
- Department of Pain and Palliative Care, Cytecare Hospital, Bengaluru, Karnataka, India
| | - Sushma Bhatnagar
- Department of Onco-anaesthesia and Palliative Medicine, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Manipal Comprehensive Cancer Care Centre, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Dipasri Bhattacharya
- Department of Anaesthesiology, Critical Care and Pain, R.G. Kar Medical College, Kolkata, West Bengal, India
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Interventional Techniques to Management of Cancer-Related Pain: Clinical and Critical Aspects. Cancers (Basel) 2019; 11:cancers11040443. [PMID: 30934870 PMCID: PMC6520967 DOI: 10.3390/cancers11040443] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 03/14/2019] [Accepted: 03/26/2019] [Indexed: 01/20/2023] Open
Abstract
Interventional techniques to manage cancer-related pain may be efficient treatment modalities in patients unresponsive or unable to tolerate systemic opioids. However, indication and selection of the right technique demand knowledge, which is still incipient among clinicians. The present article summarizes the current evidence regarding the five most essential groups of interventional techniques to treat cancer-related pain: Neuraxial analgesia, minimally invasive procedures for vertebral pain, sympathetic blocks for abdominal cancer pain, peripheral nerve blocks, and percutaneous cordotomy. Furthermore, indication, mechanism, drug agents, contraindications, and complications of the main techniques of each group are discussed.
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19
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Tepelenis K, Tsimogiannis KE, Zikos N, Koulas S, Pappas-Gogos G, Benetatos N, Tsimogiannis I, Tsimoyiannis EC. Laparoscopic versus open approach to neurolytic celiac plexus block in inoperable pancreatic cancer. ANZ J Surg 2018; 88:E767-E771. [PMID: 29763984 DOI: 10.1111/ans.14560] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 03/22/2018] [Accepted: 03/25/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Neurolytic celiac plexus block (NCPB) is an effective method of palliative pain control. The purpose of this study was to evaluate the feasibility and effectiveness of the laparoscopic NCPB versus open approach. METHODS Eight patients (Group A) underwent diagnostic laparoscopy which revealed an inoperable pancreatic cancer. Forty millilitres of solution (20 mL of 95% ethanol mixed with 20 mL of xylocaine) was injected into either side of para-aortic soft tissue. The same solution was injected in 10 patients (Group B), with inoperable pancreatic body cancer diagnosed during laparotomy. RESULTS There were no intraoperative or post-operative, NCPB related, complications. Patients in both groups, reported significant pain relief in the early post-operative period. Using the visual analogue scale preoperatively, in second post-operative day, first and third post-operative month, no significant different was observed between the two groups. The mean hospital stay in both groups was 2.1 versus 5.2 (P = 0.0005) and the mean survival 8.1 versus 7.9 months (ns). CONCLUSIONS The NCPB is feasible method for palliation in inoperable pancreatic cancer. Laparoscopic NCPB gives excellent results and could still be considered in selected cases, as an effective alternative during staging laparoscopy.
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Affiliation(s)
- Kostas Tepelenis
- Department of Surgery, General Hospital of Ioannina 'G. Hatzikosta', Ioannina, Greece
| | | | - Nikolaos Zikos
- Department of Surgery, General Hospital of Ioannina 'G. Hatzikosta', Ioannina, Greece
| | - Spyridon Koulas
- Department of Surgery, General Hospital of Ioannina 'G. Hatzikosta', Ioannina, Greece
| | - George Pappas-Gogos
- Department of Surgery, General Hospital of Ioannina 'G. Hatzikosta', Ioannina, Greece
| | - Nikolaos Benetatos
- Department of Surgery, General Hospital of Ioannina 'G. Hatzikosta', Ioannina, Greece
| | - Ioannis Tsimogiannis
- Department of Surgery, General Hospital of Ioannina 'G. Hatzikosta', Ioannina, Greece
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Mercadante S, Fulfaro F, Casuccio A. Pain Mechanisms Involved and Outcome in Advanced Cancer Patients with Possible Indications for Celiac Plexus Block and Superior Hypogastric Plexus Block. TUMORI JOURNAL 2018; 88:243-5. [PMID: 12195764 DOI: 10.1177/030089160208800311] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims and Background There is controversy about the role of neurolytic sympathetic blocks in advanced cancer, when pain syndromes may assume other characteristics, with a possible involvement of structures other than visceral. The aim of the present study was to assess the pain characteristics and the analgesic response of a consecutive sample of home care patients with pancreatic and pelvic pain, which would have possible indications for a celiac plexus block and a superior hypogastric block, respectively. Methods From January 1999 to December 1999, 400 consecutive advanced cancer patients were surveyed for a prospective longitudinal survey. We considered only patients who had pancreatic cancer or pelvic cancer with pain. Results Thirty-six patients were surveyed: 22 patients had pelvic cancers and 14 had pancreatic cancer. Patients with pelvic cancers showed a longer survival than those with pancreatic cancer (P = 0.019). Patients with pelvic cancers more frequently showed a neuropathic component associated with a visceral or somatic mechanism than patients with pain due to pancreatic cancer (P = 0.019). When the pain mechanism was taken into consideration, patients with pelvic cancers with a neuropathic component showed worse pain relief than patients with pain due to pancreatic cancer (P = 0.040). Conclusions Sympathetic procedures for pain conditions due to pancreatic and pelvic cancers should be intended as adjuvant techniques to reduce the analgesic consumption, and not as a panacea, given that multiple pain mechanisms are often involved because progression of disease is able to change the underlying pain mechanisms. Pancreatic pain seems to maintain visceral characteristics amenable to sympathetic block more than pain due to pelvic cancer.
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Affiliation(s)
- Sebastiano Mercadante
- Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Home Palliative Care Program, SAMOT (Società per l'Assistenza al Malato Oncologico Terminale), Palermo, Italy.
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21
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Rosland JH, Geitung JT. CT guided neurolytic blockade of the coeliac plexus in patients with advanced and intractably painful pancreatic cancer. Scand J Pain 2018; 18:247-251. [DOI: 10.1515/sjpain-2017-0185] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 01/30/2018] [Indexed: 01/28/2023]
Abstract
Abstract
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.
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Affiliation(s)
- Jan Henrik Rosland
- Department of Medicine , Haraldsplass Deaconess Hospital , Bergen , Norway
- Department of Clinical Medicine , University of Bergen , Bergen , Norway
| | - Jonn Terje Geitung
- Department of Clinical Medicine , University of Oslo , Oslo , Norway
- Department of Radiology , Akershus University Hospital , Oslo , Norway
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22
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Yousefshahi F, Tahmasebi M. Long-Lasting Orthostatic Hypotension and Constipation After Celiac Plexus Block; A Case Report. Anesth Pain Med 2018; 8:e63221. [PMID: 29868459 PMCID: PMC5970361 DOI: 10.5812/aapm.63221] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 02/07/2018] [Accepted: 02/17/2018] [Indexed: 11/16/2022] Open
Abstract
This case report presents a 55 years old man, presented with abdominal pain and diagnosed with a metastatic pancreatic tumor, who developed long lasting orthostatic hypotension and constipation following a celiac plexus block.
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Affiliation(s)
- Fardin Yousefshahi
- Department of Anesthesiology and Pain Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mamak Tahmasebi
- Cancer Research Centre, Cancer Research Institute, Palliative Medicine Unit, Tehran University of Medical Sciences, Tehran, Iran
- Corresponding author: Mamak Tahmasebi, MD, Cancer Research Centre, Cancer Research Institute, Palliative Medicine Unit, Tehran University of Medical Sciences, Tehran, Iran. Tel: +98-2161192530, E-mail:
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Cornman-Homonoff J, Holzwanger DJ, Lee KS, Madoff DC, Li D. Celiac Plexus Block and Neurolysis in the Management of Chronic Upper Abdominal Pain. Semin Intervent Radiol 2017; 34:376-386. [PMID: 29249862 DOI: 10.1055/s-0037-1608861] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Chronic upper abdominal pain occurs as a complication of various malignant and benign diseases including pancreatic cancer and chronic pancreatitis, and when present may contribute to lower quality of life and higher mortality. Though various pain management strategies are available as part of a multimodal approach, they are often incompletely effective and accompanied by side effects. Pain originating in upper abdominal viscera is transmitted through the celiac plexus, which is an autonomic plexus located in the retroperitoneum at the root of the celiac trunk. Direct intervention at the level of the plexus, referred to as celiac plexus block or neurolysis depending on the injectate, is a minimally invasive therapeutic strategy which has been demonstrated to decrease pain, improve function, and reduce opiate dependence. Various percutaneous techniques have been reported, but, with appropriate preprocedural planning, use of image guidance (usually computed tomography), and postprocedural care, the frequency and severity of complications is low and the success rate high regardless of approach. The main benefit of the intervention may be in reduced opiate dependence and opiate-associated side effects, which in turn improves quality of life. Celiac plexus block and neurolysis are safe and effective treatments for chronic upper abdominal pain and should be considered early in patients experiencing such symptoms.
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Affiliation(s)
- Joshua Cornman-Homonoff
- Department of Radiology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Daniel J Holzwanger
- Department of Radiology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Kyungmouk S Lee
- Department of Radiology, Division of Interventional Radiology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - David C Madoff
- Department of Radiology, Division of Interventional Radiology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - David Li
- Department of Radiology, Division of Interventional Radiology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
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Abstract
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.
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Affiliation(s)
- Osman Hakan Gunduz
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Ozge Kenis-Coskun
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Marmara University, Istanbul, Turkey
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Dababou S, Marrocchio C, Rosenberg J, Bitton R, Pauly KB, Napoli A, Hwang JH, Ghanouni P. A meta-analysis of palliative treatment of pancreatic cancer with high intensity focused ultrasound. J Ther Ultrasound 2017; 5:9. [PMID: 28373906 PMCID: PMC5376281 DOI: 10.1186/s40349-017-0080-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 01/06/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Pancreatic adenocarcinoma is currently the fourth-leading cause of cancer-related death. Up to 60-90% of patients with advanced disease suffer cancer-related pain, severely impacting their quality of life. Current management involves primarily pharmacotherapy with opioid narcotics and celiac plexus neurolysis; unfortunately, both approaches offer transient relief and cause undesired side-effects. High intensity focused ultrasound (HIFU) is a non-invasive thermal ablation technique that has been used to treat pancreatic cancer. This meta-analysis aims to evaluate the role of HIFU in pain palliation of advanced unresectable pancreatic adenocarcinoma. METHODS An electronic search was performed in PubMed Medline database up to the end of July 2016, for unresectable pancreatic cancer pain palliation with HIFU. Pertinent studies were identified through the PubMed search engine using the following keywords: HIFU, pancreas, pancreatic cancer, pain and palliation. Additional studies were included after manual search of the selected bibliographies. Pain palliation results reported in each study were analyzed using a logit-transformed random-effects model using the inverse variance method, with the DerSimonian-Laird estimator for τ2, and Cochran's Q test for heterogeneity among studies. The I2 was calculated to assess the percentage of the total variability in the different effect size estimates that can be attributed to heterogeneity among the true effects. A rank correlation test of funnel plot asymmetry was done to assess possible publication bias. RESULTS The meta-analysis includes a total number of 23 studies with 865 patients, 729 with pancreatic cancer. The population enrolled ranges from 3 patients in the smallest series, up to 61 in the largest study. τ2 (variance among studies) was 0.195, and I2 (percentage of variation among studies) was 40% (95% CI: 1-64%); the Q test p-value was 0.026, indicating significant heterogeneity among studies. Among 639 patients treated with HIFU, 567 complained of pancreatic pain before the treatment and 459 patients experienced partial or complete pain relief after treatment. The random effects estimate of the proportion of patients with pain reduction was 0.81 (95% CI: 0.76-86). CONCLUSIONS HIFU appears to be an effective tool for pain palliation in advanced pancreatic cancer. Studies assessing treatment in patients with pancreatic adenocarcinoma are limited by factors such as small sample sizes and heterogeneity in clinical definitions and assessments. Prospective randomized and standardized studies are necessary to confirm the effectiveness of HIFU in relieving pain, and to evaluate for any potential impact on tumor control and patient survival.
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Affiliation(s)
- Susan Dababou
- Medical Student, Sapienza University of Rome, School of Medicine, V.le Regina Elena, 324, 00180 Rome, Italy
| | - Cristina Marrocchio
- Medical Student, Sapienza University of Rome, School of Medicine, V.le Regina Elena, 324, 00180 Rome, Italy
| | - Jarrett Rosenberg
- Department of Radiology, Lucas Center for Imaging, Stanford University School of Medicine, 1201 Welch Road, Stanford, CA 94305 USA
| | - Rachelle Bitton
- Department of Radiology, Lucas Center for Imaging, Stanford University School of Medicine, 1201 Welch Road, Stanford, CA 94305 USA
| | - Kim Butts Pauly
- Department of Radiology, Lucas Center for Imaging, Stanford University School of Medicine, 1201 Welch Road, Stanford, CA 94305 USA
| | - Alessandro Napoli
- Department of Radiological Sciences, MRgFUS & Cardiovascular Imaging Unit, Sapienza University of Rome, School of Medicine, V.le Regina Elena, 324, 00180 Rome, Italy
| | - Joo Ha Hwang
- Gastroenterology Section, Harborview Medical Center, Bioengineering and Radiology, University of Washington, Box 359773, 325 Ninth Avenue, Seattle, WA 98104 USA
| | - Pejman Ghanouni
- Department of Radiology, Lucas Center for Imaging, Stanford University School of Medicine, 1201 Welch Road, Stanford, CA 94305 USA
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Ahmed A, Arora D. Fluoroscopy-guided Neurolytic Splanchnic Nerve Block for Intractable Pain from Upper Abdominal Malignancies in Patients with Distorted Celiac Axis Anatomy: An Effective Alternative to Celiac Plexus Neurolysis - A Retrospective Study. Indian J Palliat Care 2017; 23:274-281. [PMID: 28827930 PMCID: PMC5545952 DOI: 10.4103/ijpc.ijpc_28_17] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Introduction: The pain from upper gastrointestinal malignancy leads to considerable morbidity. The celiac plexus and splanchnic nerve neurolysis are good therapeutic options. Although splanchnic nerve neurolysis less frequently performed, but it has an edge over celiac plexus as it can be performed in patients with altered celiac plexus anatomy by enlarged lymph nodes. Methods: The fluoroscopy-guided splanchnic nerve neurolysis was done in about 21 patients with intractable upper abdominal pain with pain intensity of ≥7 in numerical rating scale (NRS) from upper gastrointestinal cancers with distorted celiac plexus anatomy from enlarged celiac lymph nodes as seen by computed tomography scan after positive diagnostic splanchnic nerve neurolysis. The demographic features, pain intensity, daily opioid dose, functional status and quality of life was measured at baseline and 1 week, 1 and 3 months after the procedure. Results: There was a significant improvement in pain intensity, opioid requirement, functional status, and physical components quality of life after the neurolysis (P < 0.05) and this improvement had continued till 3 months. There were also more than 50% reduction in pain intensity and significant decrease in opioid requirement in all the patients after neurolysis. Conclusion: The fluoroscopy-guided splanchnic nerve neurolysis results significant pain relief, decrease in opioid intake, improvement in functional status, and quality of life for up to 3 months in upper abdominal pain from gastrointestinal cancers in patients with distorted celiac lymph node anatomy not amenable to celiac plexus neurolysis.
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Affiliation(s)
- Arif Ahmed
- Department of Anesthesiology and Pain Medicine, Asian Institute of Medical Sciences, Faridabad, India
| | - Divesh Arora
- Department of Anesthesiology and Pain Medicine, Asian Institute of Medical Sciences, Faridabad, India
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Mercadante S, Klepstad P, Kurita GP, Sjøgren P, Giarratano A. Sympathetic blocks for visceral cancer pain management: A systematic review and EAPC recommendations. Crit Rev Oncol Hematol 2015; 96:577-83. [PMID: 26297518 DOI: 10.1016/j.critrevonc.2015.07.014] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 05/27/2015] [Accepted: 07/28/2015] [Indexed: 01/28/2023] Open
Abstract
The neurolytic blocks of sympathetic pathways, including celiac plexus block (CPB) and superior hypogastric plexus block (SHPB) , have been used for years. The aim of this review was to assess the evidence to support the performance of sympathetic blocks in cancer patients with abdominal visceral pain. Only comparison studies were included. All data from the eligible trials were analyzed using the GRADE system. Twenty-seven controlled studies were considered. CPB, regardless of the technique used, improved analgesia and/or decrease opioid consumption, and decreased opioid-induced adverse effects in comparison with a conventional analgesic treatment. In one study patients treated with superior hypogastric plexus block (SHPB) had a decrease in pain intensity and a less morphine consumption, while no statistical differences in adverse effects were found. The quality of these studies was generally poor due to several limitations, including sample size calculation, allocation concealment, no intention to treat analysis. However, at least two CPB studies were of good quality. Data regarding the comparison of techniques or other issues were sparse and of poor quality, and evidence could not be analysed. On the basis of existing evidence, CPB has a strong recommendation in patients with pancreatic cancer pain. There is a weak recommendation for SHPB, that should be based on individual conditions. Data regarding the choice of the technique are sparse and unfit to provide any recommendation.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy; Department Anesthesia, Intensive Care & Emergencies, University of Palermo, Italy.
| | - Pål Klepstad
- Department Intensive Care Medicine, St. Olavs University Hospital, Trondheim, Norway; Department Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Geana Paula Kurita
- Section of Palliative Medicine, Department Oncology, Rigshospitalet-Copenhagen University Hospital, Denmark; Multidisciplinary Pain Centre, Department Neuroanaesthesiology, Rigshospitalet-Copenhagen University Hospital, Denmark.
| | - Per Sjøgren
- Department Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Section of Palliative Medicine, Department Oncology, Rigshospitalet-Copenhagen University Hospital, Denmark.
| | - Antonino Giarratano
- Chair of Anesthesiology, Intensive care and pain therapy, University of Palermo, Italy.
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Fujii-Lau LL, Bamlet WR, Eldrige JS, Chari ST, Gleeson FC, Abu Dayyeh BK, Clain JE, Pearson RK, Petersen BT, Rajan E, Topazian MD, Vege SS, Wang KK, Wiersema MJ, Levy MJ. Impact of celiac neurolysis on survival in patients with pancreatic cancer. Gastrointest Endosc 2015; 82:46-56.e2. [PMID: 25800661 PMCID: PMC6017988 DOI: 10.1016/j.gie.2014.12.036] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 12/01/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pancreatic cancer (PC) often produces pain that is difficult to control. Celiac neurolysis (CN) is performed with the goal of improving pain control and quality of life while reducing opioid-related side effects. OBJECTIVE We aimed to evaluate whether CN provides a survival advantage for PC patients. DESIGN Retrospective case-control study. SETTING Single tertiary-care referral center. PATIENTS Review of a prospectively maintained database identified patients with unresectable PC who underwent CN over a 12-year period. Each patient was matched to 2 control patients with unresectable PC. INTERVENTION CN, which included both celiac plexus neurolysis (CPN) and celiac ganglia neurolysis (CGN). MAIN OUTCOME MEASUREMENTS Median survival in Kaplan-Meier curves and hazard ratios. RESULTS A total of 417 patients underwent CN and were compared with 840 controls with PC. Baseline characteristics were similar except the CN group had greater weight loss and pain requiring opioids. A mean of 16.6 ± 5.8 mL of alcohol was administered. For patients who underwent CN, the median survival from the time of presentation was shorter compared with controls (193 vs 246 days; hazard ratio 1.32; 95% confidence interval, 1.13-1.54). There was no difference in survival with unilateral or bilateral injection. However, EUS-guided CN was associated with longer survival compared with non-EUS approaches, and those who received CPN had longer survival compared with CGN. LIMITATIONS Single center, retrospective. CONCLUSION Our study suggests that CN is an independent predictor of shortened survival in PC patients. A prospective study is needed to verify the findings and determine whether shortened survival results from CN or from other features such as performance status and tumor-related characteristics. It is also imperative to verify our finding that EUS-guided CN provides a survival advantage over other approaches and whether CPN prolongs survival compared with CGN.
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Abstract
BACKGROUND Pain originating from the organs of the upper abdomen, especially in patients suffering from inoperable carcinoma of the pancreas or advanced inflammatory conditions, is difficult to treat in a significant number of patients. STANDARD RADIOLOGICAL PROCEDURES Computed tomography (CT) guided neurolysis is the most commonly used technique for neurolysis of the celiac plexus. Ethanol is used to destroy the nociceptive fibers passing through the plexus and provides an effective means of diminishing pain arising from the upper abdomen. METHODS Using either an anterior or posterior approach, a 22 G Chiba needle is advanced to the antecrural space and neurolysis is achieved by injecting a volume of 20-50 ml of ethanol together with a local anesthetic and contrast medium. PERFORMANCE In up to 80% of patients suffering from tumors of the upper abdomen, CT-guided celiac plexus neurolysis diminishes pain or allows a reduction of analgesic medication; however, in some patients the effect may only be temporary necessitating a second intervention. In inflammatory conditions, celiac neurolysis is often less effective in reducing abdominal pain. PRACTICAL RECOMMENDATIONS The CT-guided procedure for neurolysis of the celiac plexus is safe and effective in diminishing pain especially in patients suffering from tumors of the upper abdomen. The procedure can be repeated if the effect is only temporary.
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A prospective, randomized, double-blind, placebo controlled trial on the efficacy of ethanol celiac plexus neurolysis in patients with operable pancreatic and periampullary adenocarcinoma. J Am Coll Surg 2014; 220:497-508. [PMID: 25667135 PMCID: PMC4448126 DOI: 10.1016/j.jamcollsurg.2014.12.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 12/09/2014] [Indexed: 12/16/2022]
Abstract
Background Ethanol celiac plexus neurolysis (ECPN) has been shown to be effective in reducing cancer-related pain in patients with locally advanced pancreatic and periampullary adenocarcinoma (PPA). This study examined its efficacy in patients undergoing PPA resection. Study Design 485 patients participated in this prospective, randomized, double blind placebo controlled trial. Patients were stratified by preoperative pain and disease resectability. They received either ECPN (50% ethanol) or 0.9% normal saline placebo control. The primary endpoint was short and long-term pain and secondary endpoints included postoperative morbidity, QOL and overall survival. Results Data from 467 patients were analyzed. The primary endpoint, the percentage of PPA patients experiencing a worsening of pain compared to preoperative baseline for resectable patients, was not different between the ethanol and saline groups in either the resectable/pain stratum (22% vs 18%, RR 1.23 (0.34, 4.46)), or the resectable/no pain stratum (37% vs 34%, RR 1.10 (0.67, 1.81)). On multivariable analysis of resected pancreatic ductal adenocarcinoma (PDA) patients, there was a significant reduction in pain in the resectable/pain group, suggesting that surgical resection of the malignancy alone (independent of ECPN) decrements pain to a significant degree. Conclusions In this study, we have demonstrated a significant reduction in pain following surgical resection of PPA. However the addition of ECPN did not synergize to result in a further reduction in pain, and in fact its effect may have been masked by surgical resection. Given this, we cannot recommend the use of ECPN to mitigate cancer related pain in resectable PPA patients.
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Dai F, Silverman DG, Chelly JE, Li J, Belfer I, Qin L. Integration of Pain Score and Morphine Consumption in Analgesic Clinical Studies. THE JOURNAL OF PAIN 2013; 14:767-77.e8. [DOI: 10.1016/j.jpain.2013.04.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Revised: 04/05/2013] [Accepted: 04/11/2013] [Indexed: 11/29/2022]
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Nagels W, Pease N, Bekkering G, Cools F, Dobbels P. Celiac plexus neurolysis for abdominal cancer pain: a systematic review. PAIN MEDICINE 2013; 14:1140-63. [PMID: 23802777 DOI: 10.1111/pme.12176] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE This systematic review assesses the effectiveness and side effects of celiac plexus neurolysis (CPN) in the treatment of upper abdominal cancer pain, and evaluates whether there are any differences between the percutaneous and endoscopic ultrasound-guided (EUS) denervation techniques. METHODS Five databases were searched, expanded by assessing the reference lists of all retrieved papers. Sixty-six publications fulfilled the inclusion/exclusion criteria and were included in the systematic review. Randomized controlled trials were available for the percutaneous CPN, and therefore meta-analyses were performed for pain, opioid consumption, and specific side effects. The quality of life data were too heterogeneous to be assessed by a meta-analysis, and evidence for EUS CPN could only be evaluated by observational studies. RESULTS Meta-analyses show that percutaneous CPN significantly improves pain in patients with upper abdominal cancer, with a decrease in opioid consumption and side effects. It is unclear whether there is any change in quality of life. Case series suggest that EUS CPN improves pain. No conclusion can be made about EUS CPN's influence on opioid consumption. Although CPN is a safe procedure, side effects and complications can occur with both the percutaneous and EUS techniques. CONCLUSIONS Following this review, evidence suggests that CPN should be considered in patients with upper abdominal cancer where the pain is not adequately controlled with systemic analgesics or when significant opioid-induced side effects are present. The percutaneous approach remains the standard technique as robust evidence for EUS CPN is lacking.
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Affiliation(s)
- Werner Nagels
- Department of Anesthesiology and Pain Management, Heilig-Hart Hospital Roeselare-Menen, Roeselare, Belgium.
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Zhong W, Yu Z, Zeng JX, Lin Y, Yu T, Min XH, Yuan YH, Chen QK. Celiac plexus block for treatment of pain associated with pancreatic cancer: a meta-analysis. Pain Pract 2013; 14:43-51. [PMID: 23682788 DOI: 10.1111/papr.12083] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 04/12/2013] [Indexed: 01/01/2023]
Abstract
Pancreatic ductal adenocarcinoma has a high rate of neural invasion (80 to 100%) and can be associated with moderate to severe pain in pancreatic cancer. Treatment of pain with celiac plexus blockage (CPB) combined with the three-step ladder utilization of pharmaceutical analgesics following WHO guidelines is used, but the evidence in randomized controlled trials is inconsistent. This meta-analysis identified and compared seven randomized control trials of pain relief from pancreatic cancer, by treatment with medical management alone to celiac plexus blockade with medical management. While no evidence of potential publication bias was detected, group size and statistical power may account for some of the inconsistent conclusions. The combined CPB groups had a significantly lower pain score at 4 weeks, but significance was not maintained at 8 weeks. The combined CPB groups required significantly less drug use compared to the combined control groups treated with pharmaceutical analgesics.
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Affiliation(s)
- Wa Zhong
- Department of Gastroenterology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
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Bahn BM, Erdek MA. Celiac Plexus Block and Neurolysis for Pancreatic Cancer. Curr Pain Headache Rep 2013; 17:310. [DOI: 10.1007/s11916-012-0310-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis in Pancreatic Cancer: A Prospective Pilot Study of Safety Using 10 mL versus 20 mL Alcohol. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2013; 2013:327036. [PMID: 23365492 PMCID: PMC3556397 DOI: 10.1155/2013/327036] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 12/07/2012] [Accepted: 12/07/2012] [Indexed: 01/17/2023]
Abstract
Background. The dose of alcohol used in EUS-CPN is not standardized. The objective was to compare the safety of 20 mL alcohol versus 10 mL alcohol during EUS-CPN for patients with pancreatic cancer-related pain. Methods. 20 patients were selected to receive 10 mL or 20 mL of alcohol during EUS-CPN. Followup was done at baseline, 24 hours, and weekly. Health-related quality of life (HRQoL) was assessed at baseline, week 2, week 4, and every 4 weeks thereafter until pain returned. Results. There were no major complications in both groups. Minor self-limited adverse effects were seen in 6 (30%) subjects and included lightheadedness in 1 (5%), transient diarrhea in 2 (10%), and transient nausea and vomiting in 3. Pain relief was similar in both groups: 80% in the 10 mL group and 100% in the 20 mL group (P = 0.21). The mean (± SD) duration of pain relief in the 10 mL and 20 mL groups was 7.9 ± 10.8 and 8.4 ± 9.2 weeks, respectively. 30% of patients in each group had complete pain relief. Conclusions. EUS-CPN using 20 mL of alcohol is safe. Similar clinical outcomes were seen in both groups. Further investigations to confirm these findings are warranted.
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Teixeira MJ, Neto ER, da Nóbrega JCM, Dos Ângelos JS, Martin MS, de Monaco BA, Fonoff ET. Celiac plexus neurolysis for the treatment of upper abdominal cancer pain. Neuropsychiatr Dis Treat 2013; 9:1209-12. [PMID: 23983470 PMCID: PMC3751497 DOI: 10.2147/ndt.s43730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Optimal treatment of oncologic pain is a challenge to all professionals who deal with cancer and its complications. The management of upper abdominal pain is usually difficult and it is often refractory to conservative therapies. In this context, celiac plexus neurolysis (CPN) appears to be an important and indispensable tool because it alleviates pain, gives comfort to patients and is a safe procedure. In this study, the importance of CPN is reviewed by a retrospective study of 74 patients with pain due to upper abdominal cancer. Almost all cases evaluated (94.6%) had an excellent result after CPN and the majority of side effects were transitory.
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Affiliation(s)
- Manoel Jacobsen Teixeira
- Department of Neurology, Division of Functional Neurosurgery of the Institute of Psychiatry, University of São Paulo School of Medicine, São Paulo, Brazil
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de Courcy J. Interventional Techniques for Cancer Pain Management. Clin Oncol (R Coll Radiol) 2011; 23:407-17. [DOI: 10.1016/j.clon.2011.04.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Revised: 12/13/2010] [Accepted: 04/05/2011] [Indexed: 12/11/2022]
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Arcidiacono PGG, Calori G, Carrara S, McNicol ED, Testoni PA. Celiac plexus block for pancreatic cancer pain in adults. Cochrane Database Syst Rev 2011; 2011:CD007519. [PMID: 21412903 PMCID: PMC6464722 DOI: 10.1002/14651858.cd007519.pub2] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pancreatic cancer causes severe pain in 50 to 70% of patients and is often difficult to treat. Celiac plexus block (CPB) is thought to be a safe and effective technique for reducing the severity of pain. OBJECTIVES To determine the efficacy and safety of celiac plexus neurolysis in reducing pancreatic cancer pain, and to identify adverse effects and differences in efficacy between the different techniques. SEARCH STRATEGY We searched Cochrane CENTRAL, MEDLINE, GATEWAY and EMBASE from 1990 to December 2010. SELECTION CRITERIA Randomised controlled trials (RCTs) of CPB by the percutaneous approach or endoscopic ultrasonography (EUS)-guided neurolysis in adults with pancreatic cancer at any stage, with a minimum of four weeks follow-up. DATA COLLECTION AND ANALYSIS We recorded details of study design, participants, disease, setting, outcome assessors, pain intensity (visual analogue scale (VAS)) and methods of calculation. MAIN RESULTS The search identified 102 potentially eligible studies. Judged from the information in the title and abstract six of these concerning the percutaneous block, involving 358 participants, fulfilled the inclusion criteria and were included in the review. All were RCTs in which the participants were followed for at least four weeks. We excluded studies published only as abstracts. We identified one RCT comparing EUS-guided or computed tomography (CT) -guided CPB but its aim was to assess efficacy in controlling chronic abdominal pain associated with chronic pancreatitis rather than pancreatic cancer, so it was excluded.For pain (VAS) at four weeks the mean difference was -0.42 in favour of CPB (95% confidence interval (CI) -0.70 to - 0.13, P = 0.004, fixed-effect model). At eight weeks the mean difference was -0.44 (95% CI -0.89 to - 0.01, random-effects model). At eight weeks there was significant heterogeneity (I(2) = 89%).Opioid consumption was significantly lower in the CPB group than the control group (P < 0.00001). AUTHORS' CONCLUSIONS Although statistical evidence is minimal for the superiority of pain relief over analgesic therapy, the fact that CPB causes fewer adverse effects than opioids is important for patients. Further studies and RCTs are recommended to demonstrate the potential efficacy of a less invasive technique under EUS guidance.
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Affiliation(s)
- Paolo Giorgio G Arcidiacono
- San Raffaele Scientific Institute, Vita Salute UniversityPancreato‐Biliary Endoscopy and Endosonography DivisionVia Olgettina 60MilanLombardiaItaly21032
| | - Giliola Calori
- San Raffaele InstituteClinical Research UnitVia Olgettina 60MilanoLombardiaItaly20132
| | | | - Ewan D McNicol
- Tufts Medical CenterDepartment of Anesthesiology and Perioperative MedicineBostonMAUSA
| | - Pier A Testoni
- San Raffaele InstituteGastroenterology and Gastrointestinal EndoscopyVia Olgettina 60MilanoLombardiaItaly20132
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Ascunce G, Ribeiro A, Reis I, Rocha-Lima C, Sleeman D, Merchan J, Levi J. EUS visualization and direct celiac ganglia neurolysis predicts better pain relief in patients with pancreatic malignancy (with video). Gastrointest Endosc 2011; 73:267-74. [PMID: 21295640 DOI: 10.1016/j.gie.2010.10.029] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2009] [Accepted: 10/19/2010] [Indexed: 12/12/2022]
Abstract
BACKGROUND EUS-guided celiac plexus neurolysis (EUS-CPN) improves pain control in patients with pancreatic cancer. EUS allows visualization of the celiac ganglion. OBJECTIVE To determine predictors of response to EUS-CPN in a cohort of 64 patients with pancreatic malignancy. DESIGN Retrospective analysis of prospective database. SETTING Academic medical center. PATIENTS Sixty-four patients with pancreatic cancer referred for EUS between March 2008 and January 2010. INTERVENTIONS EUS-CPN injected directly into celiac ganglia when visible by linear EUS or bilateral injection at the celiac vascular trunk. MAIN OUTCOME MEASUREMENTS Predictors of pain improvement at week 1 by univariate and multivariate analysis. RESULTS At week 1, 32 patients (50%) had a symptomatic response. In a multivariate model with 8 potential predictors, visualization of the ganglia was the best predictor of response; patients with visible ganglia were >15 times more likely to respond (odds ratio 15.7; P<.001). Tumors located outside the head of the pancreas and patients with a higher baseline pain level were weakly associated with a good response. LIMITATIONS Retrospective design and lack of blinding. CONCLUSIONS Visualization of celiac ganglia with direct injection is the best predictor of response to EUS-CPN in patients with pancreatic malignancy.
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Affiliation(s)
- Gil Ascunce
- Department of Epidemiology and Public Health, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
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Hameed M, Hameed H, Erdek M. Pain management in pancreatic cancer. Cancers (Basel) 2010; 3:43-60. [PMID: 24212605 PMCID: PMC3756348 DOI: 10.3390/cancers3010043] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 11/25/2010] [Accepted: 12/20/2010] [Indexed: 12/15/2022] Open
Abstract
A majority of pancreatic cancer patients present with pain at the time of diagnosis. Pain management can be challenging in light of the aggressive nature of this cancer. Apart from conventional pharmacotherapy, timely treatment with neurolytic celiac plexus block (NCPB) has been shown to be of benefit. NCPB has demonstrated efficacious pain control in high quality studies with analgesic effects lasting one to two months. NCPB has also shown to decrease the requirements of narcotics, and thus decrease opioid related side effects. Another option for the control of moderate to severe pain is intrathecal therapy (IT). Delivery of analgesic medications intrathecally allows for lower dosages of medications and thus reduced toxicity. Both of the above mentioned interventional procedures have been shown to have low complication rates, and be safe and effective. Ultimately, comprehensive pancreatic cancer pain management necessitates understanding of pain mechanisms and delivery of sequential validated therapeutic interventions within a multidisciplinary patient care model.
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Affiliation(s)
- Mariam Hameed
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, 600 N. Wolfe St., Phipps 160, Baltimore, MD 21287, USA; E-Mails: (M.H.); (H.H.)
| | - Haroon Hameed
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, 600 N. Wolfe St., Phipps 160, Baltimore, MD 21287, USA; E-Mails: (M.H.); (H.H.)
| | - Michael Erdek
- Division of Pain Medicine, Department of Anesthesia and Critical Care Medicine, Johns Hopkins University, School of Medicine, 550 North Broadway St., Suite 301, Baltimore, MD 21205, USA
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Lujan HL, Palani G, Peduzzi JD, DiCarlo SE. Targeted ablation of mesenteric projecting sympathetic neurons reduces the hemodynamic response to pain in conscious, spinal cord-transected rats. Am J Physiol Regul Integr Comp Physiol 2010; 298:R1358-65. [PMID: 20219868 PMCID: PMC2867526 DOI: 10.1152/ajpregu.00755.2009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Accepted: 03/05/2010] [Indexed: 11/22/2022]
Abstract
Individuals with spinal cord injuries above thoracic level 6 (T(6)) experience episodic bouts of life-threatening hypertension as part of a condition termed autonomic dysreflexia. The paroxysmal hypertension can be caused by a painful stimulus below the level of the injury. Targeted ablation of mesenteric projecting sympathetic neurons may reduce the severity of autonomic dysreflexia by reducing sympathetic activity. Therefore, cholera toxin B subunit (CTB) conjugated to saporin (SAP; a ribosomal inactivating protein that binds to and inactivates ribosomes) was injected into the celiac ganglion to test the hypothesis that targeted ablation of mesenteric projecting sympathetic neurons reduces the pressor response to pain in conscious, spinal cord-transected rats. Nine Sprague-Dawley male rats underwent a spinal cord transection between thoracic vertebrae 4 and 5. Following recovery (5 wk), all rats were instrumented with a radio telemetry device for recording arterial pressure and bilateral catheters in the gluteus maximus muscles for the infusion of hypertonic saline (hNa(+)Cl(-)). Subsequently, the hemodynamic responses to intramuscular injection of hNa(+)Cl(-) (100 microl and 250 microl, in random order) were determined. Following the experiments in the no celiac ganglia injected condition (NGI), rats received injections of CTB-SAP (n = 5) or CTB (n = 3) into the celiac ganglia. CTB-SAP rats, compared with NGI and CTB rats, had reduced pressor responses to hNa(+)Cl(-). Furthermore, the number of stained neurons in the celiac ganglia and spinal cord (segments T(6)-T(12)), was reduced in CTB-SAP rats. Thus, CTB-SAP retrogradely transported from the celiac ganglia is effective at ablating mesenteric projecting sympathetic neurons and reducing the pressor response to pain in spinal cord-transected rats.
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MESH Headings
- Animals
- Autonomic Dysreflexia/etiology
- Autonomic Dysreflexia/physiopathology
- Autonomic Dysreflexia/therapy
- Blood Pressure/drug effects
- Blood Pressure/physiology
- Cholera Toxin/pharmacology
- Consciousness
- Disease Models, Animal
- Ganglia, Spinal/drug effects
- Ganglia, Spinal/physiology
- Ganglia, Sympathetic/drug effects
- Ganglia, Sympathetic/physiopathology
- Heart Rate/drug effects
- Heart Rate/physiology
- Injections, Intramuscular
- Male
- Pain/complications
- Pain/physiopathology
- Rats
- Rats, Sprague-Dawley
- Ribosome Inactivating Proteins, Type 1/pharmacology
- Saline Solution, Hypertonic/pharmacology
- Saporins
- Spinal Cord Injuries/complications
- Spinal Cord Injuries/physiopathology
- Sympathectomy, Chemical
- Thoracic Vertebrae
- Visceral Afferents/drug effects
- Visceral Afferents/physiology
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Affiliation(s)
- Heidi L Lujan
- Department of Physiology, Wayne State University School of Medicine, 540 E. Canfield Ave., Detroit, MI 48201, USA
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EUS-guided celiac plexus block for chronic pancreatitis: a placebo-controlled trial should be the first priority. Gastrointest Endosc 2010; 71:430-1; author reply 431. [PMID: 20152323 DOI: 10.1016/j.gie.2009.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Accepted: 05/03/2009] [Indexed: 02/08/2023]
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Johnson CD, Berry DP, Harris S, Pickering RM, Davis C, George S, Imrie CW, Neoptolemos JP, Sutton R. An open randomized comparison of clinical effectiveness of protocol-driven opioid analgesia, celiac plexus block or thoracoscopic splanchnicectomy for pain management in patients with pancreatic and other abdominal malignancies. Pancreatology 2010; 9:755-63. [PMID: 20090396 DOI: 10.1159/000199441] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2008] [Accepted: 01/23/2009] [Indexed: 12/11/2022]
Abstract
UNLABELLED In inoperable malignancy, pain relief with opioids is often inadequate. Nerve block procedures may improve symptom control. Our aim was to assess celiac plexus block (CPB) and thoracoscopic splanchnicectomy (TS) in patients receiving appropriate medical management (MM). METHODS Patients with confirmed irresectable malignancy of the pancreas or upper abdominal viscera who required opioid analgesia were randomized to MM alone, MM+CPB, or MM+TS. Randomization was stratified by treatment centre, tumour type and previous opioid medication. The primary endpoint was pain relief at 2 months. RESULTS 65 patients (58 pancreas cancer) were randomized, 18 withdrew or died within 2 months. Effective pain relief was achieved in only one third of subjects at 2 weeks, and just under half at 2 months (MM: 6/19 and 5/12 evaluable patients; CPB: 5/14 and 5/9; TS 4/14 and 4/11). There were no significant differences between the groups in pain scores or opioid consumption, and there was no correlation between continued use of opioids and effective pain relief. DISCUSSION Previous randomized studies have shown small differences in pain scores, but no difference in opioid consumption and quality of life. The absence of any benefit from interventions in the present study questions their value.
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Affiliation(s)
- Colin D Johnson
- University Surgical Unit (816), Southampton General Hospital, Southampton, UK.
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Tay W, Ho KY. The Role of Interventional Therapies in Cancer Pain Management. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2009. [DOI: 10.47102/annals-acadmedsg.v38n11p989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Cancer pain is complex and multifactorial. Most cancer pain can be effectively controlled using analgesics in accordance to the WHO analgesic ladder. However, in a small but significant percentage of cancer patients, systemic analgesics fail to provide adequate control of cancer pain. These cancer patients can also suffer from intolerable adverse effects of drug therapy or intractable cancer pain in advance disease. Though the prognosis of these cancer patients is often very limited, the pain relief, reduced medical costs and improvement in function and quality of life from a wide variety of available interventional procedures is extremely invaluable. These interventions can be used as sole agents or as useful adjuncts to supplement analgesics. This review will discuss interventional procedures such as epidural and intrathecal drug infusions, intrathecal neurolysis, sympathetic nervous system blockade, nerve blocks, vertebroplasty and the more invasive neurosurgical procedures. Intrathecal medications including opioids, local anaesthetics, clonidine, and ziconotide will also be discussed.
Key words: Intractable pain, Intrathecal analgesia, Neurolysis
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Jain PN, Shrikhande SV, Myatra SN, Sareen R. Neurolytic Celiac Plexus Block. J Pain Palliat Care Pharmacother 2009. [DOI: 10.1080/j354v19n03_04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Affiliation(s)
- Amitabh Chak
- University Hospitals of Cleveland, Cleveland, Ohio, USA
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Tei Y, Morita T, Nakaho T, Takigawa C, Higuchi A, Suga A, Tajima T, Ikenaga M, Higuchi H, Shimoyama N, Fujimoto M. Treatment efficacy of neural blockade in specialized palliative care services in Japan: a multicenter audit survey. J Pain Symptom Manage 2008; 36:461-7. [PMID: 18504097 DOI: 10.1016/j.jpainsymman.2007.11.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2006] [Revised: 11/10/2007] [Accepted: 11/23/2007] [Indexed: 10/22/2022]
Abstract
More than 85% of cancer-related pain is pharmacologically controllable, but some patients require interventional treatments. Although audit assessment of these interventions is of importance to clarify the types of patients likely to receive benefits, there have been no multicenter studies in Japan. The primary aims of this study were (1) to clarify the frequency of neural blockade in certified palliative care units and palliative care teams, (2) determine the efficacy of interventions, and (3) explore the predictors of successful or unsuccessful intervention. All patients who received neural blockade were consecutively recruited from seven certified palliative care units and five hospital palliative care teams in Japan. Primary responsible physicians reported pain intensity on the Support Team Assessment Schedule, performance status, communication levels on the Communication Capacity Scale, presence or absence of delirium, opioid consumption, and adverse effects before and one week after the procedure on the basis of retrospective chart review. A total of 162 interventions in 136 patients were obtained, comprising 3.8% of all patients receiving specialized palliative care services during the study period. Common procedures were epidural nerve block with local anesthetic and/or opioids (n = 84), neurolytic sympathetic plexus block (n = 24), and intrathecal nerve block with phenol (n = 21). There were significant differences in the frequency of neural blockade between palliative care units and palliative care teams (3.1% vs. 4.6%, respectively, P = 0.018), and between institutions whose leading physicians are anesthesiologists or have other specialties (4.8% vs. 1.5%, respectively, P < 0.001). Pain intensity measured on the Support Team Assessment Schedule (2.9 +/- 0.8 to 1.7 +/- 0.9, P < 0.001), performance status (2.7 +/- 1.0 to 2.4 +/- 1.0, P < 0.001), and opioid consumption (248 +/- 348 to 186 +/- 288 mg morphine equivalent/day, P < 0.001) were significantly improved after interventions. There was a tendency toward improvement in the communication level measured on the Communication Capacity Scale. There was no significant improvement in the prevalence of delirium, but six patients (32%) recovered from delirium after interventions. Adverse effects occurred in 9.2%, but all were predictable or transient. No fatal complications were reported. Pain intensity was significantly more improved in patients who survived 28 days or longer than others (P = 0.002). There were no significant correlations of changes in pain intensity with the performance status or previous opioid consumption. In conclusion, neural blockade was performed in 3.8% of cancer patients who received specialized palliative care services in Japan. Neural blockade could contribute to the improvement of pain intensity, performance service status, and opioid consumption without unpredictable serious side effects.
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Affiliation(s)
- Yo Tei
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
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