Is there a role for celiac plexus block for chronic pancreatitis?

Outcomes after Frey's procedure for chronic pancreatitis: a 8-year single-center experience in Colombia

BACKGROUND

Chronic pancreatitis is an inflammatory disease characterized by irreversible morphological changes due to chronic pancreatic fibrosis. The treatment goals are to relieve pain, preserve function, and prevent further pathological consequences. Endoscopic treatment, surgery, or both are options for untreatable pain or suspected malignancy. Frey procedure is a reasonable surgical intervention because of its hybrid character, combining resection and drainage. Unfortunately, there is limited information about the outcomes of this procedure in Latin America, and few cases described in Colombia. This study aims to describe the experience of a pancreatic surgery reference center in the management of patients undergoing Frey's surgery for chronic pancreatitis.

METHODS

A retrospective review of a prospectively collected database of patients who underwent a Frey procedure due to chronic pancreatitis between January 2014 to February 2022 in a hospital in Bogotá, Colombia, was made. A demographic, clinical, and postoperative outcome description was performed. Mann-Whitney Willcoxon test was performed between operative variables and long-term outcomes.

RESULTS

Eighteen patients met the inclusion criteria. 55.5% of patients were male. Chronic pancreatitis etiology in most cases (83.3% n = 15) was idiopathic. The median duration of symptoms and chronic pancreatitis diagnosis before surgery was 6.15 months (IQR 5;97). Overall morbidity was 38.88%. One patient died at 30 days of follow-up. The median follow-up time was 42.5 (IQR 19;65 months). The median pain reduction was 3 points according to the visual analog score. Six patients were diagnosed with malignant conditions after surgery (mean 27.8 ± 7.5 months). Wirsung's duct size was statistically related with malignancy presentation after Frey's procedure (Z = 2.54; P = 0.01).

CONCLUSION

According to our data, Frey's procedure remains safe and feasible, with acceptable outcomes in terms of pain relief and pancreatic function. The study confirms the importance of a longstanding follow-up due to an inherent risk of pancreatic malignancy. Our data suggest that pancreatic duct size could be related with the malignancy diagnosis after Frey's procedure; however, further prospective studies with a larger sample size would be helpful to confirm these results.

Surgical approach and short-term outcomes in adults and children undergoing total pancreatectomy with islet autotransplantation: A report from the Prospective Observational Study of TPIAT

BACKGROUND

Total pancreatectomy with islet autotransplantation (TPIAT) is a viable option for treating debilitating recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) in adults and children. No data is currently available regarding variation in approach to operation.

METHODS

We evaluated surgical techniques, islet isolation and infusion approaches, and outcomes and complications, comparing children (n = 84) with adults (n = 195) enrolled between January 2017 and April 2020 by 11 centers in the United States in the Prospective Observational Study of TPIAT (POST), which was launched in 2017 to collect standard history and outcomes data from patients undergoing TPIAT for RAP or CP.

RESULTS

Children more commonly underwent splenectomy (100% versus 91%, p = 0.002), pylorus preservation (93% versus 67%; p < 0.0001), Roux-en-Y duodenojejunostomy reconstruction (92% versus 35%; p < 0.0001), and enteral feeding tube placement (93% versus 63%; p < 0.0001). Median islet equivalents/kg transplanted was higher in children (4577; IQR 2816-6517) than adults (2909; IQR 1555-4479; p < 0.0001), with COBE purification less common in children (4% versus 15%; p = 0.0068). Median length of hospital stay was higher in children (15 days; IQR 14-22 versus 11 days; IQR 8-14; p < 0.0001), but 30-day readmissions were lower in children (13% versus 26%, p = 0.018). Rate of portal vein thrombosis was significantly lower in children than in adults (2% versus 10%, p = 0.028). There were no mortalities in the first 90 days post-TPIAT.

CONCLUSIONS

Pancreatectomy techniques differ between children and adults, with islet yields higher in children. The rates of portal vein thrombosis and early readmission are lower in children.

Antioxidant Therapy in Pancreatitis

Pancreatitis is pathologic inflammation of the pancreas characterized by acinar cell destruction and oxidative stress. Repeated pancreatic insults can result in the development of chronic pancreatitis, characterized by irreversible fibrosis of the pancreas and many secondary sequelae, ultimately leading to the loss of this important organ. We review acute pancreatitis, chronic pancreatitis, and pancreatitis-related complications. We take a close look at the pathophysiology with a focus on oxidative stress and how it contributes to the complications of the disease. We also take a deep dive into the evolution and current status of advanced therapies for management including dietary modification, antioxidant supplementation, and nuclear factor erythroid-2-related factor 2-Kelch-like ECH-associated protein 1(Nrf2-keap1) pathway activation. In addition, we discuss the surgeries aimed at managing pain and preventing further endocrine dysfunction, such as total pancreatectomy with islet auto-transplantation.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Celiac Plexus Block and Neurolysis in the Management of Chronic Upper Abdominal Pain

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.