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Efficacy of EUS-guided celiac plexus neurolysis in combination with EUS-guided celiac ganglia neurolysis for pancreatic cancer-associated pain: a multicenter prospective trial. Int J Clin Oncol 2022; 27:1196-1201. [PMID: 35412211 DOI: 10.1007/s10147-022-02160-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/29/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVES This study evaluated the efficacy of endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) in combination with EUS-guided celiac ganglia neurolysis (EUS-CGN) for pancreatic cancer-associated pain. METHODS This multicenter prospective trial was registered in the University Hospital Medical Information Network (UMIN000031228). Fifty-one consecutive patients with pancreatic cancer-associated pain who presented at one of five Japanese referral centers between February 2018 and March 2021 were enrolled. EUS-CGN was added in cases of visible celiac ganglia. The primary endpoint was effectiveness, defined as a decrease in the numerical rating scale (NRS) by ≥ 3 points. NRS data were prospectively acquired at 1 week after the procedure to evaluate its effectiveness and the extent of pain relief. RESULTS The technical success rates of EUS-CPN and EUS-CGN were 100% and 80.4%, respectively. The overall efficacy rate was 82.4% [90% confidence interval (CI) 71.2-90.5, P < 0.0001]. The complete pain relief rate was 27.4%. The adverse events rate was 15.7%. The average pain relief period was 72 days. The efficacy rate was higher in the EUS-CPN plus EUS-CGN group than in the EUS-CPN alone group. EUS-CPN plus EUS-CGN was superior to EUS-CPN alone for achieving complete pain relief (P = 0.045). EUS-CGN did not improve the average length of the pain relief period. CONCLUSIONS EUS-CPN combined with EUS-CGN is safe, feasible, and effective for pain relief in patients with pancreatic cancer. The patients who received additional EUS-CGN had a better short-term response. CLINICAL TRIAL NUMBER UMIN000031228.
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Kazmi SSH, Safi N, Berge ST, Kazmi M, Sundhagen JO, Hisdal J. Laparoscopic Surgery for Median Arcuate Ligament Syndrome (MALS): A Prospective Cohort of 52 Patients. Vasc Health Risk Manag 2022; 18:139-151. [PMID: 35356549 PMCID: PMC8959725 DOI: 10.2147/vhrm.s350841] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/17/2022] [Indexed: 12/23/2022] Open
Abstract
Background The selection of patients with MALS for surgical treatment depends upon the reliability of the symptom interpretation and the diagnostic work-up. We aimed to follow up the results of the laparoscopic decompression of the patients with MALS. Patients and Methods In a single-center, 52 consecutive MALS patients were followed-up, prospectively, after transperitoneal laparoscopic decompression. MALS was diagnosed with a computed tomography angiography (CTA) verified stenosis, ≥50% of the celiac artery (CA), and with duplex ultrasound, a peak systolic velocity (PSV) ≥2.0 m/s. Postoperative, CTA, and duplex ultrasound were performed, and the patients were followed-up at 3, 6, 12 months, and yearly after that. Results Mean age of the patients was 47 ±21 years, and 65% were females. The patients had a mean weight loss of 8.4 ±7.2 kg. Fifty-one patients had the laparoscopic operation with a mean operation time of 102 ± 28 minutes. Forty-seven patients (90%) achieved relief from the symptoms either completely (67%) or partially (23%) at 3–6 months of follow-up. Significant improvement in postoperative PSV was found compared to the preoperative values, p<0.001. Five patients (10%) with no immediate effect of the operation, but two of them became free from symptoms during the mean study follow-up of 2.4 ± 2 years. Five patients (10%) had operative complications, including one trocar injury to the liver, one pneumothorax, and three cases of bleeding from the branches of CA. Two patients died of cancer disease during the study period. Only two patients (4%) had symptoms relapse, both later treated successfully. Conclusion Laparoscopic transperitoneal decompression provides most of the patients a persistent relief from MALS symptoms.
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Affiliation(s)
- Syed Sajid Hussain Kazmi
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Nathkai Safi
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Simen Tveten Berge
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Vascular Surgery, Innlandet Hospital Trust, Hamar, Norway
| | - Marryam Kazmi
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.,Faculty 2, Poznan University of Medical Sciences, Poznan, Poland
| | - Jon Otto Sundhagen
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Jonny Hisdal
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Chary A, Edalat F. Celiac Plexus Cryoneurolysis. Semin Intervent Radiol 2022; 39:138-141. [PMID: 35781989 DOI: 10.1055/s-0042-1745762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Intractable, chronic abdominal pain from upper abdominal malignant and benign diseases is a significant challenge for healthcare providers and burden on the healthcare system. While opioid analgesics are commonly used to provide pain relief, the adverse effects of chronic opioid use cannot be overlooked. Celiac plexus neurolysis via chemical or thermal means represents an alternative minimally invasive approach to provide palliative pain relief and increase patients' quality of life. Through the use of computed tomography guidance, celiac plexus neurolysis can be performed by accurately targeting the celiac plexus, while minimizing risks to adjacent structures. Historically, celiac plexus neurolysis was performed via instillation of ethanol or phenol; however, within the past decade cryoablation has gained increasing use with potentially fewer side effects.
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Affiliation(s)
- Aron Chary
- MidSouth Imaging, Vascular Interventional Physicians, Memphis, Tennessee
| | - Faramarz Edalat
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
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4
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Neuwersch-Sommeregger S, Köstenberger M, Stettner H, Pipam W, Breschan C, Feigl G, Likar R, Egger M. CT-Guided Coeliac Plexus Neurolysis in Patients with Intra-Abdominal Malignancy: A Retrospective Evaluation of 52 Palliative In-Patients. Pain Ther 2021; 10:1593-1603. [PMID: 34546553 PMCID: PMC8586091 DOI: 10.1007/s40122-021-00317-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/02/2021] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Prevalence rates of chronic abdominal pain (CAP) and breakthrough cancer pain (BTcP) are high in patients with intra-abdominal malignancies. As part of a multimodal approach, CT-guided coeliac plexus blockade (CPB) and CT-guided coeliac plexus neurolysis (CPN) are commonly used pain management strategies. The aim of this study was to evaluate pain outcomes among patients with intra-abdominal malignancies who underwent CPB and/or CPN. METHODS Patients with intra-abdominal malignancies who underwent CPB and/or CPN for pain control at the general hospital Klagenfurt am Wörthersee from 2010 to 2019 were enrolled. RESULTS A total of 84 procedures (24 CPB and 60 CPN) were performed on 52 patients; 62% of these patients had pancreatic cancer. CPN led to significant pain reduction and decreased BTcP intensity. Patients receiving repeated CPN showed higher individual pain reduction. Higher pre-procedural pain intensity was correlated with higher pain reduction. No difference in pain reduction in patients receiving a diagnostic CPB prior to CPN compared to patients without a diagnostic CPB was found. Higher pain reduction after CPN led to longer-lasting pain relief. The time frame from diagnosis to CPN was 472 (± 416) days. Patients experienced a mean duration of pain prior to CPN of 330 (± 53) days. The time frame from diagnosis to CPN was shorter in patients with pancreatic cancer compared to other intra-abdominal malignancies. In 58% of patients pain medication was stable or was reduced after CPN; 16% of patients complained about pain during the procedure; no major complications occurred. There was no correlation between median survival after CPN and pain outcomes. CONCLUSIONS In patients with intra-abdominal malignancy-related CAP, CPN is a safe and effective procedure which can provide long-lasting significant relief of background pain and BTcP. As part of a multimodal approach, CPN should be considered as an earlier option for pain management in these patients.
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Affiliation(s)
- Stefan Neuwersch-Sommeregger
- Center for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt am Wörthersee, Feschnigstrasse 11, 9020, Klagenfurt am Wörthersee, Austria.
- Medical University of Graz, Graz, Austria.
| | - Markus Köstenberger
- Center for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt am Wörthersee, Feschnigstrasse 11, 9020, Klagenfurt am Wörthersee, Austria
- Medical University of Graz, Graz, Austria
| | - Haro Stettner
- Department of Statistics, Alpen-Adria University Klagenfurt, Klagenfurt am Wörthersee, Austria
| | - Wofgang Pipam
- Center for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt am Wörthersee, Feschnigstrasse 11, 9020, Klagenfurt am Wörthersee, Austria
| | - Christian Breschan
- Center for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt am Wörthersee, Feschnigstrasse 11, 9020, Klagenfurt am Wörthersee, Austria
- Medical University of Graz, Graz, Austria
| | - Georg Feigl
- Institute for Anatomy and Clinical Morphology, Witten/Herdecke University, Witten, Germany
| | - Rudolf Likar
- Center for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt am Wörthersee, Feschnigstrasse 11, 9020, Klagenfurt am Wörthersee, Austria
| | - Markus Egger
- Center for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt am Wörthersee, Feschnigstrasse 11, 9020, Klagenfurt am Wörthersee, Austria
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Celiac plexus neurolysis for abdominal cancers: going beyond pancreatic cancer pain. Pain Rep 2021; 6:e930. [PMID: 34712884 PMCID: PMC8546843 DOI: 10.1097/pr9.0000000000000930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 03/19/2021] [Accepted: 04/03/2021] [Indexed: 02/07/2023] Open
Abstract
Celiac plexus neurolysis is primarily used for pancreatic cancer pain, but other symptoms and other cancers may also benefit from this intervention. Introduction: Celiac plexus neurolysis (CPN) has been verified for mitigating pancreatic cancer pain. However, information regarding CPN's use beyond this remains limited. Objectives: Identify which cancers benefit from CPN, which symptoms improve, and when symptoms improve. Methods: Retrospective analysis was conducted on 173 patients who received CPN for pain caused by various malignancies. Mean symptom changes on the MD Anderson Symptom Inventory (MDASI) from baseline to 2 weeks, 1 month, and 2 months after CPN were analyzed overall and then by cancer type: pancreatic (all stages and stages III–IV), hepatobiliary, and nonpancreatic, nonhepatobiliary gastrointestinal (NPNH-gastrointestinal). Results: Eighty-two pancreatic, 43 NPNH-gastrointestinal, 14 hepatobiliary, and 34 patients with other cancers met inclusion criteria. Statistically significant changes included decrease in the pain score at 1 month by 1.01 points for all cancers, 1.65 points for all pancreatic cancers, and 1.88 points for late-stage pancreatic cancers. At 2 months, pain decreased by 1.50 points for all cancers, 1.68 points for all pancreatic cancers, 2.37 points for late-stage pancreatic cancers, and 1.50 points in NPNH-gastrointestinal cancers. At 2 months, quality of life improved by 1.07 points for all cancers and 1.53 points for all pancreatic cancers. Sleep improved at 2 months for all cancers by 0.73 points and 1.60 points in late-stage pancreatic cancers. At 2 months, pancreatic cancer patients improved in general activity by 0.93 points, walking by 1.00 points, and working by 1.12 points. Conclusion: Celiac plexus neurolysis can decrease cancer symptom burden beyond pain including quality of life and sleep for pancreatic and nonpancreatic cancers, as well as general activity for pancreatic cancers.
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Hickman K, Godfrey E, Ajithkumar T. Endoscopic ultrasound-guided neurolysis in advanced pancreatic cancer: current status. BMJ Support Palliat Care 2021; 12:22-28. [PMID: 34635545 DOI: 10.1136/bmjspcare-2021-002905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 07/11/2021] [Indexed: 11/04/2022]
Abstract
Pancreatic cancer has a very poor prognosis with patients often presenting with locally advanced, inoperable or metastatic disease. A significant proportion of patients have visceral pain due to perineural infiltration or coeliac plexus involvement by the tumour. This pain is difficult to control and may become refractory to conventional pain management. Therefore, coeliac plexus neurolysis (CPN) has been proposed to ablate the neuronal transmission pathway of pain permanently. CPN is recommended for those who have uncontrolled pain, are experiencing unacceptable opioid adverse effects or are receiving escalating doses of analgesics. It is not known whether CPN performed at diagnosis as the first-line treatment ('early') would impact short-term and long-term pain control and quality of life. NICE has recommended (2018) a randomised trial comparing early endoscopic ultrasound-guided coeliac plexus neurolysis (EUS-CPN) with on-demand EUS-CPN in pancreatic cancer. In this context, we will review the current evidence on its clinical benefits.
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Affiliation(s)
- Katy Hickman
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Edmund Godfrey
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Thankamma Ajithkumar
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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7
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Kwon HJ, Jang K, Leem JG, Shin JW, Kim DH, Choi SS. Factors associated with successful response to neurolytic celiac plexus block in patients with upper abdominal cancer-related pain: a retrospective study. Korean J Pain 2021; 34:479-486. [PMID: 34593666 PMCID: PMC8494952 DOI: 10.3344/kjp.2021.34.4.479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/05/2021] [Accepted: 07/13/2021] [Indexed: 12/04/2022] Open
Abstract
Background Prior studies have reported that 40%-90% of the patients with celiac plexus-mediated visceral pain benefit from the neurolytic celiac plexus block (NCPB), but the predictive factors of response to NCPB have not been evaluated extensively. This study aimed to identify the factors associated with the immediate analgesic effectiveness of NCPB in patients with intractable upper abdominal cancer-related pain. Methods A retrospective review was performed of 513 patients who underwent NCPB for upper abdominal cancer-related pain. Response to the procedure was defined as (1) a decrease of ≥ 50% or ≥ 4 points on the numerical rating scale (NRS) in pain intensity from the baseline without an increase in opioid requirement, or (2) a decrease of ≥ 30% or ≥ 2 points on the NRS from the baseline with simultaneously reduced opioid consumption after NCPB. Logistic regression analysis was performed to determine the factors associated with successful responses to NCPB. Results Among the 513 patients included in the analysis, 255 (49.8%) and 258 (50.2%) patients were in the non-responder and responder group after NCPB, respectively. Multivariable logistic regression analysis showed that diabetes (odds ratio [OR] = 0.644, P = 0.035), history of upper abdominal surgery (OR = 0.691, P = 0.040), and celiac metastasis (OR = 1.496, P = 0.039) were the independent factors associated with response to NCPB. Conclusions Celiac plexus metastases, absence of diabetes, and absence of prior upper abdominal surgery may be independently associated with better response to NCPB for upper abdominal cancer-related pain.
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Affiliation(s)
- Hyun-Jung Kwon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyunghwan Jang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Gil Leem
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Woo Shin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Doo-Hwan Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong-Soo Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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8
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Yousaf MN, Chaudhary FS, Ehsan A, Suarez AL, Muniraj T, Jamidar P, Aslanian HR, Farrell JJ. Endoscopic ultrasound (EUS) and the management of pancreatic cancer. BMJ Open Gastroenterol 2021; 7:bmjgast-2020-000408. [PMID: 32414753 PMCID: PMC7232396 DOI: 10.1136/bmjgast-2020-000408] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 12/13/2022] Open
Abstract
Pancreatic cancer is one of the leading causes of cancer-related mortality in western countries. Early diagnosis of pancreatic cancers plays a key role in the management by identification of patients who are surgical candidates. The advancement in the radiological imaging and interventional endoscopy (including endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreatography and endoscopic enteral stenting techniques) has a significant impact in the diagnostic evaluation, staging and treatment of pancreatic cancer. The multidisciplinary involvement of radiology, gastroenterology, medical oncology and surgical oncology is central to the management of patients with pancreatic cancers. This review aims to highlight the diagnostic and therapeutic role of EUS in the management of patients with pancreatic malignancy, especially pancreatic ductal adenocarcinoma.
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Affiliation(s)
- Muhammad Nadeem Yousaf
- Department of Medicine, Section Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA .,Department of Internal Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA.,Department of Internal Medicine, MedStar Good Samaritan Hospital, Baltimore, Maryland, USA.,Department of Internal Medicine, MedStar Franklin Square Medical Center, Baltimore, Maryland, USA
| | - Fizah S Chaudhary
- Department of Internal Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA.,Department of Internal Medicine, MedStar Good Samaritan Hospital, Baltimore, Maryland, USA.,Department of Internal Medicine, MedStar Franklin Square Medical Center, Baltimore, Maryland, USA
| | - Amrat Ehsan
- Department of Internal Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA.,Department of Internal Medicine, MedStar Good Samaritan Hospital, Baltimore, Maryland, USA.,Department of Internal Medicine, MedStar Franklin Square Medical Center, Baltimore, Maryland, USA
| | - Alejandro L Suarez
- Department of Medicine, Section Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Thiruvengadam Muniraj
- Department of Medicine, Section Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Priya Jamidar
- Department of Medicine, Section Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Harry R Aslanian
- Department of Medicine, Section Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - James J Farrell
- Department of Medicine, Section Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
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Aman MM, Mahmoud A, Deer T, Sayed D, Hagedorn JM, Brogan SE, Singh V, Gulati A, Strand N, Weisbein J, Goree JH, Xing F, Valimahomed A, Pak DJ, El Helou A, Ghosh P, Shah K, Patel V, Escobar A, Schmidt K, Shah J, Varshney V, Rosenberg W, Narang S. The American Society of Pain and Neuroscience (ASPN) Best Practices and Guidelines for the Interventional Management of Cancer-Associated Pain. J Pain Res 2021; 14:2139-2164. [PMID: 34295184 PMCID: PMC8292624 DOI: 10.2147/jpr.s315585] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/18/2021] [Indexed: 12/17/2022] Open
Abstract
Moderate to severe pain occurs in many cancer patients during their clinical course and may stem from the primary pathology, metastasis, or as treatment side effects. Uncontrolled pain using conservative medical therapy can often lead to patient distress, loss of productivity, shorter life expectancy, longer hospital stays, and increase in healthcare utilization. Various publications shed light on strategies for conservative medical management for cancer pain and a few international publications have reviewed limited interventional data. Our multi-institutional working group was assembled to review and highlight the body of evidence that exists for opioid utilization for cancer pain, adjunct medication such as ketamine and methadone and interventional therapies. We discuss neurolysis via injections, neuromodulation including targeted drug delivery and spinal cord stimulation, vertebral tumor ablation and augmentation, radiotherapy and surgical techniques. In the United States, there is a significant variance in the interventional treatment of cancer pain based on fellowship training. As a first of its kind, this best practices and interventional guideline will offer evidenced-based recommendations for reducing pain and suffering associated with malignancy.
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Affiliation(s)
- Mansoor M Aman
- Department of Anesthesiology, Division of Pain Medicine, Advocate Aurora Health, Oshkosh, WI, USA
| | - Ammar Mahmoud
- Department of Anesthesiology, Division of Pain Medicine, Northern Light Health Eastern Maine Medical Center, Bangor, ME, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Dawood Sayed
- Department of Anesthesiology, Pain and Perioperative Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shane E Brogan
- Department of Anesthesiology, Division of Pain Medicine, University of Utah, Salt Lake City, UT, USA
| | - Vinita Singh
- Department of Anesthesiology, Division of Pain Medicine, Emory University, Atlanta, GA, USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Natalie Strand
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Jacqueline Weisbein
- Department of Anesthesiology, Chronic Pain Division, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Johnathan H Goree
- Interventional Pain Medicine, Napa Valley Orthopedic Medical Group, Napa, CA, USA
| | - Fangfang Xing
- Swedish Pain Services, Swedish Health Services, Seattle, WA, USA
| | - Ali Valimahomed
- Gramercy Pain Center, Holmdel, NJ, & Advanced Orthopedics Sports Medicine Institute, Freehold, NJ, USA
| | - Daniel J Pak
- Department of Anesthesiology, Division of Pain Medicine, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA
| | - Antonios El Helou
- Department of Neurosciences, Division of Neurosurgery, The Moncton Hospital, Moncton, NB. Assistant Professor, Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | | | - Krishna Shah
- Assistant Professor of Anesthesiology, Baylor St. Luke’s Medical Center, Baylor College of Medicine, Houston, TX, USA
| | - Vishal Patel
- Department of Anesthesiology, Division of Pain Medicine, Advocate Aurora Health, Oshkosh, WI, USA
| | - Alexander Escobar
- Department of Anesthesiology and Pain Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Keith Schmidt
- AMITA Neurosciences Institute, Comprehensive Pain Management Program, St. Alexius Medical Center, Hoffman Estates, IL, USA
| | - Jay Shah
- SamWell Institute for Pain Management, Colonia, NJ, USA
| | - Vishal Varshney
- Department of Anesthesia, Providence Healthcare, Vancouver, BC, Canada & Department of Anesthesiology, Pharmacology, Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - William Rosenberg
- Center for the Relief of Pain, Midwest Neurosurgery Associates, Kansas City, Missouri, USA
| | - Sanjeet Narang
- Department of Anesthesiology, Pain and Perioperative Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Fudim M, Ponikowski PP, Burkhoff D, Dunlap ME, Sobotka PA, Molinger J, Patel MR, Felker GM, Hernandez AF, Litwin SE, Borlaug BA, Bapna A, Sievert H, Reddy VY, Engelman ZJ, Shah SJ. Splanchnic nerve modulation in heart failure: mechanistic overview, initial clinical experience, and safety considerations. Eur J Heart Fail 2021; 23:1076-1084. [PMID: 33886137 PMCID: PMC8298285 DOI: 10.1002/ejhf.2196] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/23/2021] [Accepted: 04/18/2021] [Indexed: 12/20/2022] Open
Abstract
Volume recruitment from the splanchnic compartment is an important physiological response to stressors such as physical activity and blood loss. In the setting of heart failure (HF), excess fluid redistribution from this compartment leads to increased cardiac filling pressures with limitation in exercise capacity. Recent evidence suggests that blocking neural activity of the greater splanchnic nerve (GSN) could have significant benefits in some patients with HF by reducing cardiac filling pressures and improving exercise capacity. However, to date the long-term safety of splanchnic nerve modulation (SNM) in the setting of HF is unknown. SNM is currently used in clinical practice to alleviate some forms of chronic abdominal pain. A systematic review of the series where permanent SNM was used as a treatment for chronic abdominal pain indicates that permanent SNM is well tolerated, with side-effects limited to transient diarrhoea or abdominal colic and transient hypotension. The pathophysiological role of the GSN in volume redistribution, the encouraging findings of acute and chronic pilot SNM studies and the safety profile from permanent SNM for pain provides a strong basis for continued efforts to study this therapeutic target in HF.
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11
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Interventional Therapies for Pain in Cancer Patients: a Narrative Review. Curr Pain Headache Rep 2021; 25:44. [PMID: 33961156 DOI: 10.1007/s11916-021-00963-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW Pain is a prevalent symptom in the lives of patients with cancer. In light of the ongoing opioid epidemic and increasing awareness of the potential for opioid abuse and addiction, clinicians are progressively turning to interventional therapies. This article reviews the interventional techniques available to mitigate the debilitating effects that untreated or poorly treated pain have in this population. RECENT FINDINGS A range of interventional therapies and technical approaches are available for the treatment of cancer-related pain. Many of the techniques described may offer effective analgesia with less systemic toxicity and dependency than first- and second-line oral and parenteral agents. Neuromodulatory techniques including dorsal root ganglion stimulation and peripheral nerve stimulation are increasingly finding roles in the management of oncologic pain. The goal of this pragmatic narrative review is to discuss interventional approaches to cancer-related pain and the potential of such therapies to improve the quality of life of cancer patients.
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12
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Chalian M, Hoang D, Rozen S, Chhabra A. Role of magnetic resonance neurography in intercostal neuralgia; diagnostic utility and efficacy. Br J Radiol 2021; 94:20200603. [PMID: 33960822 DOI: 10.1259/bjr.20200603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To evaluate the utility and efficacy of MR neurography (MRN) in the diagnostic work-up for intercostal neuralgia and to assess the treatment course and outcomes in MRN-imaged clinically suspected intercostal neuropathy cases of chronic chest and abdominal wall pain syndromes. METHODS Following a retrospective cross-sectional study, a consecutive series of patients who underwent MRN of torso for suspected intercostal neuralgia were included. Patient demographics, pain location/level/duration, previous work-up for the same indication, MRN imaging results, and MRN cost per patient were recorded. An inter-reader reliability assessment was performed on the MRN findings using Cohen's weighted κ analysis. Post-MRN treatment choice, as well as success rates of MRN directed perineural injections and surgical management were also evaluated. RESULTS A total of 28 patients (mean ± SD age, 48.3 ± 18.0 years, female/male = 3.0) were included. Pain and/or numbness in the right upper quadrant were the most common complaints. The mean maximum pain level experienced was 7.4 ± 2.5 on a 1 (lowest pain level) - 10 (highest pain level) visual analog scale. The duration of pain before MRN work-up was 36.9 ± 37.9 months. The patients had seen an average of 5 ± 2.8 physicians for such syndromes. 20 (71%) patients had one or multiple other imaging studies for prior work-up. MRN identified positive intercostal nerve abnormality in 19 cases with clinical symptoms of intercostal neuralgia. From the inter-reader reliability assessment, a Cohen's weighted κ value of 0.78 was obtained. The costs of work-up was about one-third with MRN for diagnostic purposes with less financial and psychological harm. Among the MRN-positive cases, 9/19 patients received perineural injections, of which 6 reported improvement after their first round, lasting an average of 41.1 ± 83 days. Among the nine MRN-negative cases, two received perineural injections, of which none reported improvement. Surgical management was mostly successful with a positive outcome in six out of seven operated cases (85.7%). CONCLUSION MRN is useful in diagnostic algorithm of intercostal neuralgia and MRN-positive cases demonstrate favorable treatment response to perineural injections and subsequent surgical management. ADVANCES IN KNOWLEDGE The use of MRN in intercostal neuralgia is an application that has not been previously explored in the literature. This study demonstrates that MRN offers superior visualization of pathology in intercostal neuralgia and confirms that treatment directed at MRN identified neuropathy results in good outcomes while maintaining cost efficiency.
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Affiliation(s)
- Majid Chalian
- Department of Radiology, Musculoskeletal Imaging and Intervention, University of Washington, Seattle, WA, USA
| | - Diana Hoang
- Department of Radiology, Musculoskeletal Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Shai Rozen
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Avneesh Chhabra
- Department of Radiology, Musculoskeletal Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Department of Orthopedics, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Han CQ, Tang XL, Zhang Q, Nie C, Liu J, Ding Z. Predictors of pain response after endoscopic ultrasound-guided celiac plexus neurolysis for abdominal pain caused by pancreatic malignancy. World J Gastroenterol 2021; 27:69-79. [PMID: 33505151 PMCID: PMC7789068 DOI: 10.3748/wjg.v27.i1.69] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 08/15/2020] [Accepted: 11/12/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) has gained popularity as a minimally invasive approach and is currently widely used to treat pancreatic cancer-associated pain. However, response to treatment is variable.
AIM To identify the efficacy of EUS-CPN and explore determinants of pain response in EUS-CPN for pancreatic cancer-associated pain.
METHODS A retrospective study of 58 patients with abdominal pain due to inoperable pancreatic cancer who underwent EUS-CPN were included. The efficacy for palliation of pain was evaluated based on the visual analog scale pain score at 1 wk and 4 wk after EUS-CPN. Univariable and multivariable logistic regression analyses were performed to explore predictors of pain response.
RESULTS A good pain response was obtained in 74.1% and 67.2% of patients at 1 wk and 4 wk, respectively. Tumors located in the body/tail of the pancreas and patients receiving bilateral treatment were weakly associated with a good outcome. Multivariate analysis revealed patients with invisible ganglia and metastatic disease were significant factors for a negative response to EUS-CPN at 1 wk and 4 wk, respectively, particularly for invasion of the celiac plexus (odds ratio (OR) = 13.20, P = 0.003 for 1 wk and OR = 15.11, P = 0.001 for 4 wk). No severe adverse events were reported.
CONCLUSION EUS-CPN is a safe and effective form of treatment for intractable pancreatic cancer-associated pain. Invisible ganglia, distant metastasis, and invasion of the celiac plexus were predictors of less effective response in EUS-CPN for pancreatic cancer-related pain. For these patients, efficacy warrants attention.
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Affiliation(s)
- Chao-Qun Han
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Xue-Lian Tang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Qin Zhang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Chi Nie
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Jun Liu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Zhen Ding
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
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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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15
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Uysal A, Unal E, Karaosmanoglu AD, Arellano R, Ciftci TT, Akinci D, Akhan O. The role of interventional radiology in the treatment of patients with pancreatic cancer. Br J Radiol 2020; 94:20200702. [PMID: 33156695 DOI: 10.1259/bjr.20200702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Interventional radiology (IR) provides minimally invasive therapeutic and palliative options for the treatment of pancreatic cancer depending on the stage of the disease. IR plays a critical, and also a very effective role, in both pre- and post-operative care of the patients with early stage resectable disease and also in palliative treatment of the patients with locally advanced or metastatic disease. In this article, we aimed to present the capability and the limitations of IR procedures including: local treatment options of primary and metastatic pancreatic cancer, palliation of biliary and intestinal obstructions, minimally invasive treatment of post-operative complications, and pain management.
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Affiliation(s)
- Aycan Uysal
- Department of Radiology, Gulhane Training and Research Hospital, Ankara, Turkey
| | - Emre Unal
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
| | | | - Ronald Arellano
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Turkmen Turan Ciftci
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Devrim Akinci
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Okan Akhan
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
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16
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Sample J, Hammad F, Ghazaleh S, Burlen J, Nawras A. A Rare Complication of Ileus Following Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis: A Case Report. Cureus 2020; 12:e10963. [PMID: 33209522 PMCID: PMC7667610 DOI: 10.7759/cureus.10963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Pancreatic cancer patients experience debilitating pain, which makes pain management an integral part of the treatment plan. Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-guided CPN) is an alternative palliative therapy for patients with pain due to pancreatic cancer. We report a patient who developed paralytic ileus after undergoing EUS-guided CPN. A 77-year-old male patient presented with nausea, vomiting, and abdominal pain of one-day duration. He was diagnosed with stage IV pancreatic adenocarcinoma three weeks prior to presentation for which he underwent EUS-guided CPN. He had a 30-pack-year smoking history and quit 31 years ago. He reported moderate alcohol use and denied illicit drug use. In the emergency department, vital signs demonstrated normal blood pressure, heart rate, respiratory rate, and temperature. Abdominal exam was significant for minimal epigastric tenderness without guarding or rebound. Complete blood count (CBC), basic metabolic panel (BMP), and liver function tests were unremarkable. Computed tomography (CT) scan of the abdomen showed significant gastric distension. Esophagogastroduodenoscopy (EGD) showed large amounts of fluids within the gastric fundus and body. Upper gastrointestinal series showed delayed gastric emptying of the contrast, but contrast was seen in the third part of the duodenum and jejunum. Push enteroscopy showed no obstruction or mucosal abnormalities in the third or fourth parts of the duodenum. Small bowel obstruction was ruled out, and the diagnosis of ileus was made. The patient received ondansetron and polyethylene glycol as needed, and his diet was advanced slowly. His symptoms improved over the course of a few days, and he experienced a return of normal bowel activity. He eventually tolerated a regular diet and was discharged home in a stable condition. Although EUS-guided CPN is a safe procedure, the procedure resulted in an unexpected ileus that has rarely been reported in the literature. Future studies with large sample sizes are recommended to capture the occurrence of the rare side effects of EUS-guided CPN.
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Affiliation(s)
- Jack Sample
- Internal Medicine, University of Toledo, Toledo, USA
| | - Faris Hammad
- Internal Medicine, Saint Vincent Charity Medical Center, Cleveland, USA
| | - Sami Ghazaleh
- Internal Medicine, University of Toledo, Toledo, USA
| | - Jordan Burlen
- Gastroenterology and Hepatology, University of Toledo, Toledo, USA
| | - Ali Nawras
- Gastroenterology and Hepatology, University of Toledo, Toledo, USA
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17
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Shi R, Ma D, Yang Y, Wang Y. <p>A Case Report of an Ultrasound-Guided and Fluoroscopy-Assisted Posterior Approach for Celiac Plexus Neurolysis in a Patient with Pancreatic Cancer-Associated Abdominal Pain</p>. J Pain Res 2020; 13:2561-2566. [PMID: 33116798 PMCID: PMC7568612 DOI: 10.2147/jpr.s270343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/13/2020] [Indexed: 11/23/2022] Open
Abstract
Background Imaging-guided celiac plexus neurolysis using ultrasound (US) guidance via a transabdominal approach and endoscopic-ultrasound (EUS) has been increasingly applied for the treatment of pancreatic cancer-associated abdominal pain. Objective To investigate the application of ultrasound-guided and fluoroscopy-assisted celiac plexus neurolysis in a patient with advanced pancreatic cancer suffering from refractory abdominal pain for which oral opioid treatment was ineffective. Case Report We report a case of ultrasound-guided and fluoroscopy-assisted celiac plexus neurolysis in a patient with advanced pancreatic cancer with refractory abdominal pain. With the patient in the prone position, celiac plexus neurolysis was performed under real-time US guidance. The transducer was placed below the costal margin and a puncture needle with an ultrasound enhancement tip was inserted in-plane aiming for the lateral anterior end of the vertebral body. The correct needle tip position was confirmed by the C-arm with contrast material located anterior to the vertebral body and posterior to the diaphragm. Conclusion We highlight the use of an US-guided and fluoroscopy-assisted posterior approach for use in celiac plexus neurolysis procedures, particularly in patients suffering from contraindications from the US or EUS-guided anterior approaches.
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Affiliation(s)
- Rong Shi
- Department of Anesthesia and Pain Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing100020, People’s Republic of China
| | - Danxu Ma
- Department of Anesthesia and Pain Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing100020, People’s Republic of China
| | - Yinan Yang
- Department of Anesthesia and Pain Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing100020, People’s Republic of China
| | - Yun Wang
- Department of Anesthesia and Pain Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing100020, People’s Republic of China
- Correspondence: Yun WangDepartment of Anesthesia and Pain Medicine, Beijing Chaoyang Hospital, Capital Medical University, No. 8, Gongtinan Road, Chaoyang District, Beijing100020, People’s Republic of China Email
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18
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Agarwal A, Gautam A, Rastogi S, Malviya D, Das PK, Harjai M. Effect of Celiac Plexus Neurolysis for Pain Relief in Patients with Upper Abdominal Malignancy: A Retrospective Observational Study and Review of Literature. Indian J Palliat Care 2020; 26:512-517. [PMID: 33623314 PMCID: PMC7888415 DOI: 10.4103/ijpc.ijpc_37_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 05/14/2020] [Accepted: 07/01/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Abdominal pain from primary cancer or metastatic disease is a significant cause of pain for patients undergoing treatment for the disease. Patient's pain may be resistant or non-responsive to the pharmacological management, hence minimal invasive pain intervention like celiac plexus neurolysis or splanchnic nerve rhizolysis may be required to relieve pain of such patients. Objective: The aim of this retrospective study is to assess the effect of celiac plexus neurolysis for pain relief in patients with upper gastro-intestinal malignancies. Study Design: This is a retrospective, observational study with short review. Methods: This retrospective observational study was done in the Pain Medicine unit from 2016 and November 2018. Ninety-four patients with upper abdominal malignancy and unrelenting pain, non-responsive or poorly responsive to pharmacological treatment as per WHO ladder of analgesics, received fluoroscopy-guided celiac plexus neurolysis (CPN). All the patients underwent celiac plexus neurolysis through Trans-Aortic approach and the primary outcome measure was pain as assessed with Visual Analogue Scale (VAS) ranging from 0 to 10; the secondary outcome measures were morphine consumption per day (M), quality of life (QOL) as assessed by comparing the percent of positive responses and complications, if any. These were noted and analyzed prior to intervention and then on day 1, and months 1, 2, 3, 4, 5, 6 following CPN. Results: Follow up was completed 6 months after the procedure. VAS score, daily morphine consumption, and the quality of life showed improvement for the duration of the study. There was some relapse in pain and deterioration in QOL during the fourth to sixth month of pain intervention due to disease progression. Some transient known side effects also occurred. Conclusion: Trans-Aortic celiac plexus neurolysis with low volume of alcohol is a safe procedure providing up to 6 months of pain relief and is an effective, well established, minimally invasive procedure for abdominal pain due to primary malignancy or metastatic spread.
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Affiliation(s)
- Anurag Agarwal
- Department of Anesthesiology, CCM and Pain Medicine, Dr RMLIMS, Lucknow, Uttar Pradesh, India
| | - Anuj Gautam
- Department of Anesthesiology, CCM and Pain Medicine, Dr RMLIMS, Lucknow, Uttar Pradesh, India
| | - Shivani Rastogi
- Department of Anesthesiology, CCM and Pain Medicine, Dr RMLIMS, Lucknow, Uttar Pradesh, India
| | - Deepak Malviya
- Department of Anesthesiology, CCM and Pain Medicine, Dr RMLIMS, Lucknow, Uttar Pradesh, India
| | - Praveen Kumar Das
- Department of Anesthesiology, CCM and Pain Medicine, Dr RMLIMS, Lucknow, Uttar Pradesh, India
| | - Mamta Harjai
- Department of Anesthesiology, CCM and Pain Medicine, Dr RMLIMS, Lucknow, Uttar Pradesh, India
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19
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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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20
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Grubert RM, Tibana TK, Missirian LA, Neves TMHD, Nunes TF. Computed tomography-guided percutaneous neurolysis of celiac plexus: technical description. Radiol Bras 2020; 53:114-115. [PMID: 32336827 PMCID: PMC7170578 DOI: 10.1590/0100-3984.2019.0005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Renata Motta Grubert
- Hospital Universitário Maria Aparecida Pedrossian da Universidade Federal de Mato Grosso do Sul (HUMAP-UFMS), Campo Grande, MS, Brazil
| | - Tiago Kojun Tibana
- Hospital Universitário Maria Aparecida Pedrossian da Universidade Federal de Mato Grosso do Sul (HUMAP-UFMS), Campo Grande, MS, Brazil
| | - Larissa Araújo Missirian
- Hospital Universitário Maria Aparecida Pedrossian da Universidade Federal de Mato Grosso do Sul (HUMAP-UFMS), Campo Grande, MS, Brazil
| | | | - Thiago Franchi Nunes
- Hospital Universitário Maria Aparecida Pedrossian da Universidade Federal de Mato Grosso do Sul (HUMAP-UFMS), Campo Grande, MS, Brazil
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21
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Pain Relieving Effect of Intraoperative Chemical Splanchnicectomy of Celiac Ganglions in Patients with Resectable Pancreatic or Gastric Masses: A Randomized Clinical Trial. Pain Res Manag 2020; 2020:2675940. [PMID: 32300382 PMCID: PMC7132578 DOI: 10.1155/2020/2675940] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 02/27/2020] [Indexed: 11/17/2022]
Abstract
Background Trials of intraoperative chemical splanchnicectomy during resection of pancreatic and gastric masses resulted in significant difference in a patient's postoperative pain. This study aims to determine if splanchnicectomy by alcohol neurolysis can relieve postoperative pain after gastrectomy and Whipple surgery. The study explores differences in outcomes at first four months after surgery. Methods Fifty-eight patients with gastric and 60 patients with pancreatic resectable masses were included (28 were lost to follow-up). Each randomized in control and intervention subgroups. Intervention subgroups underwent chemical blockage of celiac ganglions by ethanol injection at both sides of suprapancreatic aorta. Participants were asked to report their pain intensity according to the Visual Analogue Scale (VAS) at specific times. Result The overall postoperative pain of injected Whipple and gastrectomy subgroups was lower than the noninjected Whipple and gastrectomy subgroups (p < 0.001). The pain-modifying effect of the injection was not different between Whipple and gastrectomy groups (p=0.125). Conclusion Splanchnicectomy is recommended for pain reduction after abdominal operations. Perspective. This article presents positive effect of intraoperative chemical splanchnicectomy during resection of pancreatic and gastric masses on postoperative pain. This is an easy, effective, safe, and inexpensive procedure recommended for all operable gastric or pancreatic masses to palliate the pain degree.
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22
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Saletta GA, Sprott H. Bedside Neurolysis for Palliative Care of Critically Ill Patients With Pancreatic Cancer. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:1907-1911. [PMID: 30480337 DOI: 10.1002/jum.14881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 10/22/2018] [Indexed: 06/09/2023]
Affiliation(s)
| | - Haiko Sprott
- University of Zurich, Zurich, Switzerland
- Arztpraxis Zurich-Hottingen, Zurich, Switzerland
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23
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Ahmad I, Ahmed MM, Ahsraf MF, Naeem A, Tasleem A, Ahmed M, Farooqi MS. Pain Management in Metastatic Bone Disease: A Literature Review. Cureus 2018; 10:e3286. [PMID: 30443456 PMCID: PMC6235631 DOI: 10.7759/cureus.3286] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 09/11/2018] [Indexed: 11/29/2022] Open
Abstract
Cancer means an uncontrolled division of abnormal cells in the body. It is a leading cause of death today. Not only the disease itself but its complications are also adding to the increase in mortality rate. One of the major complications is the pain due to metastasis of cancer. Pain is a complex symptom which has physical, psychological, and emotional impacts that influence the daily activities as well as social life. Pain acts as an alarm sign, telling the body that something is wrong. Pain can manifest in a multitude fashion. Management of bone pain due to metastasis involves different modes with some specific treatments according to the type of primary cancer. Over the years various treatment modalities have been tried and tested to improve the pain management including the use of non-steroidal anti-inflammatory drugs (NSAIDs), opioids, bisphosphonates, tricyclic antidepressants, corticosteroids, growth factors and signaling molecules, ET-1 receptor antagonists, radiotherapy as well as surgical management. The topic of discussion will cover each one of these in detail.
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Affiliation(s)
- Imama Ahmad
- Internal Medicine, King Edward Medical University, Mayo Hospital, Lahore, PAK
| | - Munis M Ahmed
- Internal Medicine, King Edward Medical University, Mayo Hospital, Lahore, PAK
| | | | - Anika Naeem
- Graduate, Allama Iqbal Medical College, Lahore, Pakistan, Lahore, PAK
| | - Azka Tasleem
- Internal Medicine, King Edward Medical University, Lahore, PAK
| | - Moeed Ahmed
- Internal Medicine, King Edward Medical University, Mayo Hospital, Lahore, PAK
| | - Muhammad S Farooqi
- Internal Medicine, King Edward Medical University, Mayo Hospital, Lahore, PAK
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24
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Oguz G, Senel G, Kocak N. Transient paraplegia after neurolytic splanchnic block in a patient with metastatic colon carcinoma. Korean J Pain 2018; 31:50-53. [PMID: 29372026 PMCID: PMC5780216 DOI: 10.3344/kjp.2018.31.1.50] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 11/08/2017] [Accepted: 11/09/2017] [Indexed: 11/05/2022] Open
Abstract
We present a patient with metastatic colon carcinoma who developed paraplegia following a neurolytic splanchnic block. A 41-year old man with metastatic adenocarcinoma of the colon received a splanchnic neurolytic block using alcohol because of severe abdominal pain. Bilateral motor weakness and a sensorial deficit in both legs developed after the procedure. Diffusion magnetic resonance imaging revealed spinal cord ischemia between T8 and L1. The motor and sensorial deficits were almost completely resolved at the end of the third month. We think that anterior spinal artery syndrome due to reversible spasms of the lumbar radicular arteries using alcohol have resulted in transient paraplegia. The retrograde spread of alcohol to neural structures may have also contributed.
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Affiliation(s)
- Gonca Oguz
- Department of Anesthesiology, Pain and Palliative Care Clinic, Dr AY Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Gulcin Senel
- Department of Anesthesiology, Pain and Palliative Care Clinic, Dr AY Ankara Oncology Education and Research Hospital, Ankara, Turkey
| | - Nesteren Kocak
- Department of Anesthesiology, Pain and Palliative Care Clinic, Dr AY Ankara Oncology Education and Research Hospital, Ankara, Turkey
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25
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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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26
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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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27
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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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Hockley JRF, González-Cano R, McMurray S, Tejada-Giraldez MA, McGuire C, Torres A, Wilbrey AL, Cibert-Goton V, Nieto FR, Pitcher T, Knowles CH, Baeyens JM, Wood JN, Winchester WJ, Bulmer DC, Cendán CM, McMurray G. Visceral and somatic pain modalities reveal Na V 1.7-independent visceral nociceptive pathways. J Physiol 2017; 595:2661-2679. [PMID: 28105664 DOI: 10.1113/jp272837] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 01/16/2017] [Indexed: 12/17/2022] Open
Abstract
KEY POINTS Voltage-gated sodium channels play a fundamental role in determining neuronal excitability. Specifically, voltage-gated sodium channel subtype NaV 1.7 is required for sensing acute and inflammatory somatic pain in mice and humans but its significance in pain originating from the viscera is unknown. Using comparative behavioural models evoking somatic and visceral pain pathways, we identify the requirement for NaV 1.7 in regulating somatic (noxious heat pain threshold) but not in visceral pain signalling. These results enable us to better understand the mechanisms underlying the transduction of noxious stimuli from the viscera, suggest that the investigation of pain pathways should be undertaken in a modality-specific manner and help to direct drug discovery efforts towards novel visceral analgesics. ABSTRACT Voltage-gated sodium channel NaV 1.7 is required for acute and inflammatory pain in mice and humans but its significance for visceral pain is unknown. Here we examine the role of NaV 1.7 in visceral pain processing and the development of referred hyperalgesia using a conditional nociceptor-specific NaV 1.7 knockout mouse (NaV 1.7Nav1.8 ) and selective small-molecule NaV 1.7 antagonist PF-5198007. NaV 1.7Nav1.8 mice showed normal nociceptive behaviours in response to intracolonic application of either capsaicin or mustard oil, stimuli known to evoke sustained nociceptor activity and sensitization following tissue damage, respectively. Normal responses following induction of cystitis by cyclophosphamide were also observed in both NaV 1.7Nav1.8 and littermate controls. Loss, or blockade, of NaV 1.7 did not affect afferent responses to noxious mechanical and chemical stimuli in nerve-gut preparations in mouse, or following antagonism of NaV 1.7 in resected human appendix stimulated by noxious distending pressures. However, expression analysis of voltage-gated sodium channel α subunits revealed NaV 1.7 mRNA transcripts in nearly all retrogradely labelled colonic neurons, suggesting redundancy in function. By contrast, using comparative somatic behavioural models we identify that genetic deletion of NaV 1.7 (in NaV 1.8-expressing neurons) regulates noxious heat pain threshold and that this can be recapitulated by the selective NaV 1.7 antagonist PF-5198007. Our data demonstrate that NaV 1.7 (in NaV 1.8-expressing neurons) contributes to defined pain pathways in a modality-dependent manner, modulating somatic noxious heat pain, but is not required for visceral pain processing, and advocate that pharmacological block of NaV 1.7 alone in the viscera may be insufficient in targeting chronic visceral pain.
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Affiliation(s)
- James R F Hockley
- Neuroscience and Pain Research Unit, Pfizer Ltd., The Portway Building, Granta Science Park, Cambridge, CB21 6GS, UK
| | - Rafael González-Cano
- Department of Pharmacology, Biomedical Research Centre (CIBM) and Institute of Neuroscience, Faculty of Medicine, University of Granada, Granada, Spain
| | - Sheridan McMurray
- Neuroscience and Pain Research Unit, Pfizer Ltd., The Portway Building, Granta Science Park, Cambridge, CB21 6GS, UK
| | - Miguel A Tejada-Giraldez
- Department of Pharmacology, Biomedical Research Centre (CIBM) and Institute of Neuroscience, Faculty of Medicine, University of Granada, Granada, Spain
| | - Cian McGuire
- National Centre for Bowel Research and Surgical Innovation, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, E1 2AT, UK
| | - Antonio Torres
- Department of Biochemistry, Biomedical Research Centre (CIBM) and Institute of Neuroscience, Faculty of Medicine, University of Granada, Granada, Spain
| | - Anna L Wilbrey
- Neuroscience and Pain Research Unit, Pfizer Ltd., The Portway Building, Granta Science Park, Cambridge, CB21 6GS, UK
| | - Vincent Cibert-Goton
- National Centre for Bowel Research and Surgical Innovation, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, E1 2AT, UK
| | - Francisco R Nieto
- Department of Pharmacology, Biomedical Research Centre (CIBM) and Institute of Neuroscience, Faculty of Medicine, University of Granada, Granada, Spain
| | - Thomas Pitcher
- Neuroscience and Pain Research Unit, Pfizer Ltd., The Portway Building, Granta Science Park, Cambridge, CB21 6GS, UK
| | - Charles H Knowles
- National Centre for Bowel Research and Surgical Innovation, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, E1 2AT, UK
| | - José Manuel Baeyens
- Department of Pharmacology, Biomedical Research Centre (CIBM) and Institute of Neuroscience, Faculty of Medicine, University of Granada, Granada, Spain
| | - John N Wood
- Molecular Nociception Group, Department of Biology, University College London, Gower Street, London, WC1E 6BT, UK
| | - Wendy J Winchester
- Neuroscience and Pain Research Unit, Pfizer Ltd., The Portway Building, Granta Science Park, Cambridge, CB21 6GS, UK
| | - David C Bulmer
- National Centre for Bowel Research and Surgical Innovation, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, E1 2AT, UK
| | - Cruz Miguel Cendán
- Department of Pharmacology, Biomedical Research Centre (CIBM) and Institute of Neuroscience, Faculty of Medicine, University of Granada, Granada, Spain
| | - Gordon McMurray
- Neuroscience and Pain Research Unit, Pfizer Ltd., The Portway Building, Granta Science Park, Cambridge, CB21 6GS, UK
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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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30
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Abstract
CLINICAL ISSUE Increasing understanding of the anatomy and physiology of neural structures has led to the development of surgical and percutaneous neurodestructive methods in order to target and destroy various components of afferent nociceptive pathways. The dorsal root ganglia and in particular the ganglia of the autonomous nervous system are targets for radiological interventions. The autonomous nervous system is responsible for the regulation of organ functions, sweating, visceral and blood vessel-associated pain. STANDARD RADIOLOGICAL METHODS Ganglia of the sympathetic chain and non-myelinized autonomous nerves can be irreversibly destroyed by chemical and thermal ablation. PERFORMANCE Computed tomography (CT)-guided sympathetic nerve blocks are well established interventional radiological procedures which lead to vasodilatation, reduction of sweating and reduction of pain associated with the autonomous nervous system. ACHIEVEMENTS AND PRACTICAL RECOMMENDATIONS Sympathetic blocks are applied for the treatment of various vascular diseases including critical limb ischemia. Other indications for thoracic and lumbar sympathectomy include complex regional pain syndrome (CRPS), chronic tumor associated pain and hyperhidrosis. Neurolysis of the celiac plexus is an effective palliative pain treatment particularly in patients suffering from pancreatic cancer. Percutaneous dorsal root ganglion rhizotomy can be performed in selected patients with radicular pain that is resistant to conventional pharmacological and interventional treatment.
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Affiliation(s)
- R Bale
- Sektion für Mikroinvasive Therapie Universitätsklinik für Radiologie, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich.
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31
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McAninch SA, Raizada MS, Kelly SM. Pulmonary embolism following celiac plexus block and neurolysis. Proc (Bayl Univ Med Cent) 2016; 29:329-30. [PMID: 27365890 DOI: 10.1080/08998280.2016.11929458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Treatment of acute pain in chronic disease requires the physician to choose from an arsenal of pain management techniques tailored to the individual patient. Celiac plexus block and neurolysis are commonly employed for the management of chronic abdominal pain, especially in debilitating conditions such as cancer or chronic pancreatitis. The procedure is safe, well tolerated, and produces few complications. We present a case of pulmonary embolism following a celiac plexus block and neurolysis procedure. Further study is required to determine if celiac plexus ablation, alone or in combination with other risk factors, may contribute to increased risk for pulmonary embolism in patients seeking treatment for chronic upper abdominal pain conditions.
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Affiliation(s)
- Scott A McAninch
- Department of Emergency Medicine, Baylor Scott and White Hospital, Temple, Texas (McAninch, Raizada); and Texas A&M Health Science Center College of Medicine, Temple, Texas (McAninch, Raizada, Kelly)
| | - Miles S Raizada
- Department of Emergency Medicine, Baylor Scott and White Hospital, Temple, Texas (McAninch, Raizada); and Texas A&M Health Science Center College of Medicine, Temple, Texas (McAninch, Raizada, Kelly)
| | - Seth M Kelly
- Department of Emergency Medicine, Baylor Scott and White Hospital, Temple, Texas (McAninch, Raizada); and Texas A&M Health Science Center College of Medicine, Temple, Texas (McAninch, Raizada, Kelly)
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32
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Choi EJ, Choi YM, Jang EJ, Kim JY, Kim TK, Kim KH. Neural Ablation and Regeneration in Pain Practice. Korean J Pain 2016; 29:3-11. [PMID: 26839664 PMCID: PMC4731549 DOI: 10.3344/kjp.2016.29.1.3] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 11/26/2015] [Accepted: 12/22/2015] [Indexed: 11/18/2022] Open
Abstract
A nerve block is an effective tool for diagnostic and therapeutic methods. If a diagnostic nerve block is successful for pain relief and the subsequent therapeutic nerve block is effective for only a limited duration, the next step that should be considered is a nerve ablation or modulation. The nerve ablation causes iatrogenic neural degeneration aiming only for sensory or sympathetic denervation without motor deficits. Nerve ablation produces the interruption of axonal continuity, degeneration of nerve fibers distal to the lesion (Wallerian degeneration), and the eventual death of axotomized neurons. The nerve ablation methods currently available for resection/removal of innervation are performed by either chemical or thermal ablation. Meanwhile, the nerve modulation method for interruption of innervation is performed using an electromagnetic field of pulsed radiofrequency. According to Sunderland's classification, it is first and foremost suggested that current neural ablations produce third degree peripheral nerve injury (PNI) to the myelin, axon, and endoneurium without any disruption of the fascicular arrangement, perineurium, and epineurium. The merit of Sunderland's third degree PNI is to produce a reversible injury. However, its shortcoming is the recurrence of pain and the necessity of repeated ablative procedures. The molecular mechanisms related to axonal regeneration after injury include cross-talk between axons and glial cells, neurotrophic factors, extracellular matrix molecules, and their receptors. It is essential to establish a safe, long-standing denervation method without any complications in future practices based on the mechanisms of nerve degeneration as well as following regeneration.
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Affiliation(s)
- Eun Ji Choi
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Yun Mi Choi
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Eun Jung Jang
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Ju Yeon Kim
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Tae Kyun Kim
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Kyung Hoon Kim
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
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33
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Jones WB, Jordan P, Pudi M. Pain management of pancreatic head adenocarcinomas that are unresectable: celiac plexus neurolysis and splanchnicectomy. J Gastrointest Oncol 2015; 6:445-51. [PMID: 26261731 DOI: 10.3978/j.issn.2078-6891.2015.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 04/24/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Pancreatic adenocarcinoma is often incurable at the time of diagnosis. For patients with unresectable or recurrent disease, palliation of pain is a key component of care. Medical management with narcotics has numerous side effects and may be ineffective. Interventions for pain control include celiac plexus neurolysis (CPN) and splanchnicectomy. The purpose of this review is to outline pertinent anatomy, techniques, side effects, complications, and efficacy of interventions for palliation of pain from pancreatic cancer. METHODS We reviewed current literature, as well as our own patients, to assess the role and outcomes of CPN and splanchnicectomy. Short descriptions of procedural techniques and functional illustrations are provided. RESULTS Both CPN and splanchnicectomy have excellent outcomes with regard to pain control. Quality of life and survival, however, have not been conclusively demonstrated to improve with either technique. Data regarding head-to-head comparisons of the two interventions is lacking. CONCLUSIONS Patients with incurable pancreatic carcinoma should be offered either CPN or splanchnicectomy when medical management with narcotics has failed.
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Affiliation(s)
- Wesley B Jones
- School of Medicine, University of South Carolina, Greenville, SC 29605, USA
| | - Phillip Jordan
- School of Medicine, University of South Carolina, Greenville, SC 29605, USA
| | - Maya Pudi
- School of Medicine, University of South Carolina, Greenville, SC 29605, USA
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34
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Bhatnagar S, Gupta M. Evidence-based Clinical Practice Guidelines for Interventional Pain Management in Cancer Pain. Indian J Palliat Care 2015; 21:137-47. [PMID: 26009665 PMCID: PMC4441173 DOI: 10.4103/0973-1075.156466] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Intractable cancer pain not amenable to standard oral or parenteral analgesics is a horrifying truth in 10-15% of patients. Interventional pain management techniques are an indispensable arsenal in pain physician's armamentarium for severe, intractable pain and can be broadly classified into neuroablative and neuromodulation techniques. An array of neurolytic techniques (chemical, thermal, or surgical) can be employed for ablation of individual nerve fibers, plexuses, or intrathecalneurolysis in patients with resistant pain and short life-expectancy. Neuraxial administration of drugs and spinal cord stimulation to modulate or alter the pain perception constitutes the most frequently employed neuromodulation techniques. Lately, there is a rising call for early introduction of interventional techniques in carefully selected patients simultaneously or even before starting strong opioids. After decades of empirical use, it is the need of the hour to head towards professionalism and standardization in order to secure credibility of specialization and those practicing it. Even though the interventional management has found a definite place in cancer pain, there is a dearth of evidence-based practice guidelines for interventional therapies in cancer pain. This may be because of paucity of good quality randomized controlled trials (RCTs) evaluating their safety and efficacy in cancer pain. Laying standardized guidelines based on existing and emerging evidence will act as a foundation step towards strengthening, credentialing, and dissemination of the specialty of interventional cancer pain management. This will also ensure an improved decision-making and quality of life (QoL) of the suffering patients.
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Affiliation(s)
- Sushma Bhatnagar
- Department of Onco-Anaesthesia, Pain and Palliative Care, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Maynak Gupta
- Department of Anaesthesia, Shri Guru Rai Institute of Medical and Health Sciences, Shri Mahant Indiresh Hospital, Dehradun, Uttarakhand, India
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35
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An JW, Choi EK, Park CH, Choi JB, Ko DK, Lee YW. Alternative Method of Retrocrural Approach during Celiac Plexus Block Using a Bent Tip Needle. Korean J Pain 2015; 28:109-15. [PMID: 25852832 PMCID: PMC4387455 DOI: 10.3344/kjp.2015.28.2.109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 01/19/2015] [Accepted: 01/28/2015] [Indexed: 11/08/2022] Open
Abstract
Background This study sought to determine safe ranges of oblique angle, skin entry point and needle length by reviewing computed tomography (CT) scans and to evaluate the usefulness of a bent tip needle during celiac plexus block (CPB). Methods CT scans of 60 CPB patients were reviewed. Image of the uppermost margin of L2 vertebral body was used to measure the minimal and maximal oblique angles and the distances from the midline to skin puncture point. The imaginary needle trajectory distance was calculated by three-dimensional measurement. When the procedure was performed by using a 10° bent tip needle under a 20° oblique X-ray fluoroscopic view, the distance (GF/G'F) from the midline to the actual puncture site was measured. Results The imaginary safe oblique angle range was 26.4-34.2° and 27.7-36.0° on the right and left, respectively. The distance from the midline to skin puncture point was 6.1-7.6 cm on the right and 6.3-7.6 cm on the left. The needle trajectory distance at minimal angle was 9.6-11.6 cm on the right and 9.5-11.5 cm on the left. The distance of GF/G'F was 5.1-6.5 cm and 5.0-6.4 cm on the right and left, respectively. All imaginary parameters were correlated with BMI except for GF/G'F. All complications were mild and transient. Conclusions We identified safe values of angles and distances using a straight needle. Furthermore, using a bent tip needle under a 20° oblique fluoroscopic view, we could safely perform CPB with smaller parameter values.
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Affiliation(s)
- Ji Won An
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Kyeong Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Chol Hee Park
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Bum Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Dong-Kyun Ko
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Youn-Woo Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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36
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Pereira GAM, Lopes PTC, Dos Santos AMPV, Pozzobon A, Duarte RD, Cima ADS, Massignan Â. Celiac plexus block: an anatomical study and simulation using computed tomography. Radiol Bras 2015; 47:283-7. [PMID: 25741102 PMCID: PMC4341398 DOI: 10.1590/0100-3984.2013.1881] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 03/10/2014] [Indexed: 01/09/2023] Open
Abstract
Objective To analyze anatomical variations associated with celiac plexus complex by means of
computed tomography simulation, assessing the risk for organ injury as the
transcrural technique is utilized. Materials and Methods One hundred eight transaxial computed tomography images of abdomen were analyzed.
The aortic-vertebral, celiac trunk (CeT)-vertebral, CeT-aortic and
celiac-aortic-vertebral topographical relationships were recorded. Two needle
insertion pathways were drawn on each of the images, at right and left, 9 cm and
4.5 cm away from the midline. Transfixed vital organs and gender-related
associations were recorded. Results Aortic-vertebral - 45.37% at left and 54.62% in the middle; CeT-vertebral - T12,
36.11%; T12-L1, 32.4%; L1, 27.77%; T11-T12, 2.77%; CeT-aortic - 53.7% at left and
46.3% in the middle; celiac-aortic-vertebral - L-l, 22.22%; M-m, 23.15%; L-m,
31.48%; M-l, 23.15%. Neither correspondence on the right side nor significant
gender-related associations were observed. Conclusion Considering the wide range of abdominal anatomical variations and the
characteristics of needle insertion pathways, celiac plexus block should not be
standardized. Imaging should be performed prior to the procedure in order to
reduce the risks for injuries or for negative outcomes to patients. Gender-related
anatomical variations involved in celiac plexus block should be more deeply
investigated, since few studies have addressed the subject.
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Affiliation(s)
| | | | | | - Adriane Pozzobon
- PhD, Human Anatomy Professor, Centro Universitário Univates, Lajeado, RS, Brazil
| | | | - Alexandre da Silveira Cima
- MDs, Undergraduates, Specialization Program, Radiology and Imaging Diagnosis, Fundação Serdil/Saint Pastous, Porto Alegre, RS, Brazil
| | - Ângela Massignan
- MDs, Undergraduates, Specialization Program, Radiology and Imaging Diagnosis, Fundação Serdil/Saint Pastous, Porto Alegre, RS, Brazil
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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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38
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Casteleijn NF, Visser FW, Drenth JPH, Gevers TJG, Groen GJ, Hogan MC, Gansevoort RT. A stepwise approach for effective management of chronic pain in autosomal-dominant polycystic kidney disease. Nephrol Dial Transplant 2014; 29 Suppl 4:iv142-53. [PMID: 25165181 DOI: 10.1093/ndt/gfu073] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Chronic pain, defined as pain existing for >4-6 weeks, affects >60% of patients with autosomal-dominant polycystic disease (ADPKD). It can have various causes, indirectly or directly related to the increase in kidney and liver volume in these patients. Chronic pain in ADPKD patients is often severe, impacting physical activity and social relationships, and frequently difficult to manage. This review provides an overview of pathophysiological mechanisms that can lead to pain and discusses the sensory innervation of the kidneys and the upper abdominal organs, including the liver. In addition, the results of a systematic literature search of ADPKD-specific treatment options are presented. Based on pathophysiological knowledge and evidence derived from the literature an argumentative stepwise approach for effective management of chronic pain in ADPKD is proposed.
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Affiliation(s)
- Niek F Casteleijn
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Folkert W Visser
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Tom J G Gevers
- Department of Gastroenterology and Hepatology, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Gerbrand J Groen
- Pain Centre, Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marie C Hogan
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ron T Gansevoort
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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39
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How to improve the efficacy of endoscopic ultrasound-guided celiac plexus neurolysis in pain management in patients with pancreatic cancer: analysis in a single center. Surg Laparosc Endosc Percutan Tech 2014; 24:31-5. [PMID: 24487155 PMCID: PMC4196780 DOI: 10.1097/sle.0000000000000032] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Visceral pain secondary to pancreatic cancer is often difficult to control and poses a challenge to the physician. We retrospectively analyzed the efficacy and safety of endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) in patients with unresectable pancreatic cancer. Forty-one patients with severe pain despite treatment with opioids underwent EUS-CPN with absolute alcohol. Patients scored their pain on a scale of 0 to 10 and were interviewed after the procedure. Of the 41 patients, 33, 37, and 25 patients reported improvement in their pain within 3 days, at 1 week, and at 3 months, respectively, following the procedure. Of all the patients, 19 patients reported substantial improvement and 4 patients showed complete disappearance of pain. Complication appeared in 2 patients with transient hypotension. In our study, EUS-CPN is a safe and effective form of treatment for intractable pain secondary to advanced pancreatic cancer.
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40
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Abstract
Abdominal pain is a principal and in many cases, the only observable symptom of chronic pancreatitis. Like all chronic pain conditions, managing abdominal pain in chronic pancreatitis remains an onerous task for health care providers. Different mechanisms have been postulated in trying to better understand the pathogenesis of pain in chronic pancreatitis. This review seeks to take a broad look at the various options that are available to providers in trying to achieve pain relief and a better quality of life for chronic pancreatitis patients.
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Affiliation(s)
- Chijioke Enweluzo
- Section on Hospital Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
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41
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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: 86] [Impact Index Per Article: 7.8] [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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42
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Jang HY, Cha SW, Lee BH, Jung HE, Choo JW, Cho YJ, Ju HY, Cho YD. Hepatic and splenic infarction and bowel ischemia following endoscopic ultrasound-guided celiac plexus neurolysis. Clin Endosc 2013; 46:306-9. [PMID: 23767046 PMCID: PMC3678073 DOI: 10.5946/ce.2013.46.3.306] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Revised: 07/07/2012] [Accepted: 07/18/2012] [Indexed: 12/13/2022] Open
Abstract
Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) is a well-established intervention to palliate malignant pain. We report a patient who developed hepatic and splenic infarction and bowel ischemia following EUS-CPN. A 69-year-old man with known lung cancer and pancreatic metastasis was transferred for debilitating, significant epigastric pain for several months. The patient underwent EUS-CPN to palliate the pain. After the procedure, the patient complained continuously of abdominal pain, nausea, and vomiting; hematemesis and hematochezia were newly developed. Abdominal computed tomography revealed infarction of the liver and spleen and ischemia of the stomach and proximal small bowel. On esophagogastroduodenoscopy, hemorrhagic gastroduodenitis, and multiple gastric ulcers were noted without active bleeding. The patient expired on postoperative day 27 despite the best supportive care.
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Affiliation(s)
- Hee Yoon Jang
- Institute for Digestive Research, Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
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43
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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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44
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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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45
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Yang FR, Wu BS, Lai GH, Wang Q, Yang LQ, He MW, Ni JX. Assessment of Consecutive Neurolytic Celiac Plexus Block (NCPB) Technique Outcomes in the Management of Refractory Visceral Cancer Pain. PAIN MEDICINE 2012; 13:518-21. [DOI: 10.1111/j.1526-4637.2012.01332.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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46
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The endoscopic management of pain in chronic pancreatitis. Gastroenterol Res Pract 2012; 2012:860879. [PMID: 22550479 PMCID: PMC3328929 DOI: 10.1155/2012/860879] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 01/26/2012] [Accepted: 02/10/2012] [Indexed: 12/16/2022] Open
Abstract
Pain resulting from chronic pancreatitis is often debilitating and difficult to manage. Many approaches have been used to treat these patients, including narcotic analgesia, antidepressants, pancreatic enzymes, octreotide, denervation procedures, such as celiac plexus block, and various palliative, decompression, or drainage procedures. Many of these procedures can be performed endoscopically, while others require a more invasive, surgical approach. The effectiveness of these therapies is not only highly variable but also often controversial. This review will discuss the endoscopic options for pain management in patients with chronic pancreatitis and their utility in treating this difficult disease.
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47
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The efficacy and safety of endoscopic ultrasound-guided celiac plexus neurolysis for treatment of pain in patients with pancreatic cancer. Gastroenterol Res Pract 2012; 2012:503098. [PMID: 22474439 PMCID: PMC3296278 DOI: 10.1155/2012/503098] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 10/23/2011] [Indexed: 12/13/2022] Open
Abstract
Introduction. Celiac plexus neurolysis is used in pain management of patients with advanced and unresectable pancreatic cancer. We retrospectively analyzed efficacy and safety of endoscopic ultrasound- (EUS-) guided celiac plexus neurolysis in patients treated in our unit. Methods. Twenty nine subjects with unresectable pancreatic cancer and severe pain despite pharmacological treatment underwent EUS-guided celiac plexus neurolysis with 98% ethanol. Patients scored their pain according to a 0-10 point scale and were interviewed 1-2 weeks and 2-3 months after the procedure. Results. Twenty five (86%) patients reported improvement in their pain at 1-2 weeks following the procedure. Of these, 7 (24%) reported substantial improvement (decrease in pain by more than 50%) and 4 (14%) complete disappearance of pain. Pain relief was still present in 76% of patients after 2-3 months. Treatment-related side effects included hypotonia in 1 patient, severe pain immediately postprocedure in 2 patients, and short episodes of diarrhea in 3 patients. Conclusion. Endoscopic ultrasound- (EUS-) guided celiac plexus neurolysis is a safe and effective treatment of severe pain from advanced pancreatic cancer.
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48
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Rana S, Gupta R, Chaudhary P, Khurana D, Mishra S, Bhatnagar S. Cancer pain management: basic information for the young pain physicians. Indian J Palliat Care 2011; 17:127-30. [PMID: 21976852 PMCID: PMC3183601 DOI: 10.4103/0973-1075.84533] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Cancer pain is multifactorial and complex. The impact of cancer pain is devastating, with increased morbidity and poor quality of life, if not treated adequately. Cancer pain management is a challenging task both due to disease process as well as a consequence of treatment-related side-effects. Optimization of analgesia with oral opioids, adjuvant analgesics, and advanced pain management techniques is the key to success for cancer pain. Early access of oral opioid and interventional pain management techniques can overcome the barriers of cancer pain, with improved quality of life. With timely and proper anticancer therapy, opioids, nerve blocks, and other non-invasive techniques like psychosocial care, satisfactory pain relief can be achieved in most of the patients. Although the WHO Analgesic Ladder is effective for more than 80% cancer pain, addition of appropriate adjuvant drugs along with early intervention is needed for improved Quality of Life. Effective cancer pain treatment requires a holistic approach with timely assessment, measurement of pain, pathophysiology involved in causing particular type of pain, and understanding of drugs to relieve pain with timely inclusion of intervention. Careful evaluation of psychosocial and mental components with good communication is necessary. Barriers to cancer pain management should be overcome with an interdisciplinary approach aiming to provide adequate analgesia with minimal side-effects. Management of cancer pain should comprise not only a physical component but also psychosocial and mental components and social need of the patient. With risk–benefit analysis, interventional techniques should be included in an early stage of pain treatment. This article summarizes the need for early and effective pain management strategies, awareness regarding pain control, and barriers of cancer pain.
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Affiliation(s)
- Sps Rana
- Department of Unit of Anaesthesiology (IRCH), Dr. BRA IRCH, AIIMS, New Delhi, India
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49
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Abstract
The technical advances in endoscopic ultrasonograpy (EUS) and accessories have enabled performing EUS-guided intervention in the pancreas and biliary tract. Many research centers have been performing or investigating EUS-guided drainage, EUS-guided celiac plexus neurolysis and block, EUS-guided anastomosis that includes choledocho-enterostomy and choledocho-gastrostomy, EUS-guided ablation and injection therapy mainly for pancreatic neoplasm, EUS-guided photodynamic therapy and EUS-guided brachytherapy. Some of these are currently clinical applications and others are under investigations in clinical studies or animal models. Further detailed randomized controlled clinical trials and the development of materials will bring us into a new era of therapeutic EUS.
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Affiliation(s)
- Kwang Hyuck Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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50
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Lee KH, Lee JK. Interventional endoscopic ultrasonography: present and future. Clin Endosc 2011; 44:6-12. [PMID: 22741106 PMCID: PMC3363050 DOI: 10.5946/ce.2011.44.1.6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 09/18/2011] [Accepted: 09/19/2011] [Indexed: 12/22/2022] Open
Abstract
The technical advances in endoscopic ultrasonograpy (EUS) and accessories have enabled performing EUS-guided intervention in the pancreas and biliary tract. Many research centers have been performing or investigating EUS-guided drainage, EUS-guided celiac plexus neurolysis and block, EUS-guided anastomosis that includes choledocho-enterostomy and choledocho-gastrostomy, EUS-guided ablation and injection therapy mainly for pancreatic neoplasm, EUS-guided photodynamic therapy and EUS-guided brachytherapy. Some of these are currently clinical applications and others are under investigations in clinical studies or animal models. Further detailed randomized controlled clinical trials and the development of materials will bring us into a new era of therapeutic EUS.
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Affiliation(s)
- Kwang Hyuck Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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