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West T, Pogu S, Wanderman R, Olatoye O. Possible Transient Anterior Spinal Artery Syndrome After a Celiac Plexus Neurolytic Block. Cureus 2023; 15:e43771. [PMID: 37731414 PMCID: PMC10506893 DOI: 10.7759/cureus.43771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2023] [Indexed: 09/22/2023] Open
Abstract
Celiac plexus blocks have been utilized to treat chronic abdominal pain of various etiologies that are refractory to medication management. This procedure is considered relatively safe; however, one rare complication is anterior spinal artery syndrome, which can result in temporary or permanent paralysis of the lower extremities. A 67-year-old male with a history of metastatic esophageal adenocarcinoma and chronic pain refractory to high doses of opioids presented for a celiac plexus neurolytic block. The block was performed successfully with a test block containing 2% lidocaine and 0.5% bupivacaine, after which neurolysis with alcohol was completed. The patient had a syncopal episode in the post-anesthesia care unit (PACU), which resolved with fluid resuscitation without requiring advanced cardiovascular life support (ACLS). He was then discharged. On the evening of discharge, the patient had progressive lower extremity weakness to the point where he was unable to walk even with significant assistance from a family member. He went to the emergency department where a complete spine MRI was done which did not show any spinal cord defect. His physical exam showed preserved proprioception and vibration sensation with upper motor neuron exam signs. The remainder of his sensory exam was inconsistent with both reported intact sensation to pinprick and temperature with intermittently reported hyperalgesia in his lower extremities. Over the next day of admission, his weakness slowly improved. Unfortunately, the patient developed a bowel perforation during hospitalization that was non-operable, and he passed away on hospital day five. This patient likely had anterior spinal artery vasospasm causing temporary lower extremity weakness. Given his overall debility, his physical exam was difficult, although he had intact proprioception and vibration sensation with upper motor neuron exam findings suggestive of an anterior cord process. Vasospasm could be secondary to needle placement near the artery of Adamkiewicz, alcohol, or epinephrine. This case emphasizes the importance of recognizing anterior spinal artery syndrome despite its rarity in patients undergoing celiac plexus neurolysis. Regardless of the rarity of various complications, it is imperative that physicians discuss potential devastating complications of procedures with patients to allow for individualized decision-making. Additionally, there should be a low threshold for overnight admission after celiac plexus neurolytic blocks in patients with severe underlying systemic disease processes.
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Affiliation(s)
- Tyler West
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, USA
| | - Summer Pogu
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, USA
| | | | - Oludare Olatoye
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, USA
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2
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Forbes N, Coelho-Prabhu N, Al-Haddad MA, Kwon RS, Amateau SK, Buxbaum JL, Calderwood AH, Elhanafi SE, Fujii-Lau LL, Kohli DR, Pawa S, Storm AC, Thosani NC, Qumseya BJ. Adverse events associated with EUS and EUS-guided procedures. Gastrointest Endosc 2022; 95:16-26.e2. [PMID: 34711402 DOI: 10.1016/j.gie.2021.09.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 09/09/2021] [Indexed: 02/07/2023]
Affiliation(s)
| | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | | | - Richard S Kwon
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Stuart K Amateau
- Division of Gastroenterology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Audrey H Calderwood
- Section of Gastroenterology and Hepatology, Department of Medicine, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Sherif E Elhanafi
- Department of Internal Medicine, Texas Tech University, Paul L Foster School of Medicine, El Paso, TX, USA
| | | | - Divyanshoo R Kohli
- Division of Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, MO, USA
| | - Swati Pawa
- Department of Medicine, Section on Gastroenterology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Andrew C Storm
- Department of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - Nirav C Thosani
- Center for Interventional Gastroenterology (iGUT), McGovern Medical School, UTHealth, Houston, TX, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, University of Florida, Gainesville, FL, USA
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3
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Gupta R, Madanat L, Jindal V, Gaikazian S. Celiac Plexus Block Complications: A Case Report and Review of the Literature. J Palliat Med 2021; 24:1409-1412. [PMID: 33395560 DOI: 10.1089/jpm.2020.0530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Celiac plexus block (CPB) has been widely used as a treatment option for chronic intractable abdominal pain resulting from intra-abdominal malignancies as well as benign conditions. Complications resulting from CPB have been long reported and include diarrhea, back pain, paraplegia, postural hypotension, pneumothorax, and local anesthesia toxicity. Diarrhea and postural hypotension are two most common complications with studies reporting incidences occurring in 44% to 60% and 10% to 52% of patients, respectively. Diarrhea is most often transient, resolving within 48 hours; however, literature reports cases in which diarrhea was chronic, debilitating, and in some instances life threatening. Persistent diarrhea proves difficult to treat. We report a case of a 76-year-old male with unresectable pancreatic adenocarcinoma who underwent computed tomography-guided CBP complicated by persistent diarrhea and fecal incontinence. After conventional antidiarrheal failed to improve the symptoms, octreotide proved to be beneficial and the patient reported significant improvement in symptoms.
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Affiliation(s)
- Ruby Gupta
- Department of Hematology and Medical Oncology, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Luai Madanat
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Vishal Jindal
- Department of Hematology and Medical Oncology, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Susanna Gaikazian
- Department of Hematology and Medical Oncology, William Beaumont Hospital, Royal Oak, Michigan, USA
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4
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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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5
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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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Shin SK, Kweon TD, Ha SH, Yoon KB. Ejaculatory failure after unilateral neurolytic celiac plexus block. Korean J Pain 2010; 23:274-7. [PMID: 21217894 PMCID: PMC3000627 DOI: 10.3344/kjp.2010.23.4.274] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Revised: 11/03/2010] [Accepted: 11/03/2010] [Indexed: 12/15/2022] Open
Abstract
Abdominal pain associated with chronic pancreatitis is often difficult to control with analgesics and can be severely debilitating with significant impairment of quality of life. In these patients, neurolytic celiac plexus block (NCPB) is an effective treatment option with a low complication rate. However, there is a risk of ejaculatory failure after NCPB, which may be a problem in patients with a long life expectancy. We report a case of ejaculatory failure after unilateral NCPB in a patient with chronic pancreatitis.
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Affiliation(s)
- Seo Kyung Shin
- Department of Anesthesiology and Pain Medicine, Yonsei University Health System, Seoul, Korea
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Loukas M, Klaassen Z, Merbs W, Tubbs RS, Gielecki J, Zurada A. A review of the thoracic splanchnic nerves and celiac ganglia. Clin Anat 2010; 23:512-22. [PMID: 20235178 DOI: 10.1002/ca.20964] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Anatomical variation of the thoracic splanchnic nerves is as diverse as any structure in the body. Thoracic splanchnic nerves are derived from medial branches of the lower seven thoracic sympathetic ganglia, with the greater splanchnic nerve comprising the more cranial contributions, the lesser the middle branches, and the least splanchnic nerve usually T11 and/or T12. Much of the early anatomical research of the thoracic splanchnic nerves revolved around elucidating the nerve root level contributing to each of these nerves. The celiac plexus is a major interchange for autonomic fibers, receiving many of the thoracic splanchnic nerve fibers as they course toward the organs of the abdomen. The location of the celiac ganglia are usually described in relation to surrounding structures, and also show variation in size and general morphology. Clinically, the thoracic splanchnic nerves and celiac ganglia play a major role in pain management for upper abdominal disorders, particularly chronic pancreatitis and pancreatic cancer. Splanchnicectomy has been a treatment option since Mallet-Guy became a major proponent of the procedure in the 1940s. Splanchnic nerve dissection and thermocoagulation are two common derivatives of splanchnicectomy that are commonly used today. Celiac plexus block is also a treatment option to compliment splanchnicectomy in pain management. Endoscopic ultrasonography (EUS)-guided celiac injection and percutaneous methods of celiac plexus block have been heavily studied and are two important methods used today. For both splanchnicectomies and celiac plexus block, the innovation of ultrasonographic imaging technology has improved efficacy and accuracy of these procedures and continues to make pain management for these diseases more successful.
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Affiliation(s)
- Marios Loukas
- Department of Anatomical Sciences, School of Medicine, St. George's University, Grenada, West Indies.
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8
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Raphael J, Hester J, Ahmedzai S, Barrie J, Farqhuar-Smith P, Williams J, Urch C, Bennett MI, Robb K, Simpson B, Pittler M, Wider B, Ewer-Smith C, DeCourcy J, Young A, Liossi C, McCullough R, Rajapakse D, Johnson M, Duarte R, Sparkes E. Cancer pain: part 2: physical, interventional and complimentary therapies; management in the community; acute, treatment-related and complex cancer pain: a perspective from the British Pain Society endorsed by the UK Association of Palliative Medicine and the Royal College of General Practitioners. PAIN MEDICINE 2010; 11:872-96. [PMID: 20456069 DOI: 10.1111/j.1526-4637.2010.00841.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE This discussion document about the management of cancer pain is written from the pain specialists' perspective in order to provoke thought and interest in a multimodal approach to the management of cancer pain, not just towards the end of life, but pain at diagnosis, as a consequence of cancer therapies, and in cancer survivors. It relates the science of pain to the clinical setting and explains the role of psychological, physical, interventional and complementary therapies in cancer pain. METHODS This document has been produced by a consensus group of relevant healthcare professionals in the United Kingdom and patients' representatives making reference to the current body of evidence relating to cancer pain. In the second of two parts, physical, invasive and complementary cancer pain therapies; treatment in the community; acute, treatment-related and complex cancer pain are considered. CONCLUSIONS It is recognized that the World Health Organization (WHO) analgesic ladder, whilst providing relief of cancer pain towards the end of life for many sufferers world-wide, may have limitations in the context of longer survival and increasing disease complexity. To complement this, it is suggested that a more comprehensive model of managing cancer pain is needed that is mechanism-based and multimodal, using combination therapies including interventions where appropriate, tailored to the needs of an individual, with the aim to optimize pain relief with minimization of adverse effects.
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Affiliation(s)
- Jon Raphael
- Faculty of Health, Birmingham City University, Birmingham, UK.
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9
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Celiac Plexus Blockade in Children Using a Three-Dimensional Fluoroscopic Reconstruction Technique. Reg Anesth Pain Med 2007. [DOI: 10.1097/00115550-200711000-00010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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EUS-Guided Celiac Plexus Block and Celiac Plexus Neurolysis. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2007. [DOI: 10.1016/j.tgie.2006.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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11
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Akinci D, Akhan O. Celiac ganglia block. Eur J Radiol 2005; 55:355-61. [PMID: 16129244 DOI: 10.1016/j.ejrad.2005.03.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2005] [Revised: 03/07/2005] [Accepted: 03/10/2005] [Indexed: 11/16/2022]
Abstract
Pain occurs frequently in patients with advanced cancers. Tumors originating from upper abdominal viscera such as pancreas, stomach, duodenum, proximal small bowel, liver and biliary tract and from compressing enlarged lymph nodes can cause severe abdominal pain, which do not respond satisfactorily to medical treatment or radiotherapy. Percutaneous celiac ganglia block (CGB) can be performed with high success and low complication rates under imaging guidance to obtain pain relief in patients with upper abdominal malignancies. A significant relationship between pain relief and degree of tumoral celiac ganglia invasion according to CT features was described in the literature. Performing the procedure in the early grades of celiac ganglia invasion on CT can increase the effectiveness of the CGB, which is contrary to World Health Organization criteria stating that CGB must be performed in patients with advanced stage cancer. CGB may also be effectively performed in patients with chronic pancreatitis for pain palliation.
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Affiliation(s)
- Devrim Akinci
- Department of Radiology, Hacettepe University School of Medicine, Sihhiye, 06100 Ankara, Turkey
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12
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de Oliveira R, dos Reis MP, Prado WA. The effects of early or late neurolytic sympathetic plexus block on the management of abdominal or pelvic cancer pain. Pain 2004; 110:400-8. [PMID: 15275792 DOI: 10.1016/j.pain.2004.04.023] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2004] [Revised: 04/06/2004] [Accepted: 04/12/2004] [Indexed: 12/19/2022]
Abstract
Neurolytic sympathetic plexus block (NSPB) has been proposed to prevent the development of pain and improve the quality of life of patients with cancer, thus questioning the WHO protocol that proposes the use of invasive methods only as a final resort. This study evaluates the pain relief, opioid consumption and quality of life provided by the use of NSPB in two different phases of cancer pain and compares them with that provided by pharmacological therapy only. Sixty patients with abdominal or pelvic cancer pain were divided into three groups and observed for 8 weeks. In group I, neurolytic celiac (NCPB) or superior hypogastric plexus block (SHPB), or lumbar sympathetic ganglion chain block (LSGCB) was performed with alcohol in patients using NSAID and a weak oral opioid or morphine (dose</=90 mg/day) and reporting VAS>/=4. In group II, NCPB, SHPB or LSGCB were performed on patients using NSAID and morphine (dose>/=90 mg/day) and reporting VAS>/=4. The patients of group III received pharmacological therapy only. The patients of groups I and II had a significant reduction of pain (P < 0.004), opioid consumption (P < 0.02) and a better quality of life (P < 0.006) than those of group III, but no significant differences between groups I and II were seen in these aspects. Opioid-related adverse effects were significantly greater in group III (P < 0.05). The occasional neurolysis-related complications were transitory. The results suggest NSPB for the management of cancer pain should be considered earlier in the disease.
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Affiliation(s)
- Raquel de Oliveira
- Department of Biomechanic, Medicine and Rehabilitation of the Locomotor Apparatus, Faculty of Medicine of Ribeirão Preto, Av. Bandeirantes 3900, 14049-900, Ribeirão Preto, SP, Brazil
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13
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Retroperitoneal abscess after neurolytic celiac plexus block from the anterior approach. Reg Anesth Pain Med 2004. [PMID: 14634943 DOI: 10.1097/00115550-200311000-00009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES The anterior approach for celiac plexus block has the potential risks of infection, hemorrhage, and fistula formation. We report a case of a patient who developed a retroperitoneal abscess with the formation of a vascular-enteric fistula after a neurolytic celiac plexus block from the anterior approach. CASE REPORT A 60-year-old female with a history of pain secondary to chronic idiopathic calcifying pancreatitis (VAS 7-8) underwent a subtotal resection of the head of the pancreas with an end-to-side pancreatojejunostomy using a Roux-en-Y loop. Pain continued secondary to chronic pancreatitis. Because of intolerance (vomiting and constipation) of morphine and transdermal fentanyl over a 2-month period, it was decided to perform a neurolytic celiac plexus block using the anterior approach with ultrasound guidance. The patient's pain was completely relieved, enabling withdrawal of oral analgesics. Pain reappeared after 2 years, and the same technique was repeated. Ten days later, she was admitted with diabetic ketoacidosis and lower gastrointestinal bleeding. Computed tomography showed a left paravertebral retroperitoneal abscess; arteriography suggested a fistula between the mesenteric vein and the jejunum. Urgent surgery was undertaken, revealing a leak of the pancreatojejunostomy and a large abscess around the celiac plexus. A distal pancreatectomy and partial resection of the Roux-en-Y loop was performed. The patient was discharged 1 month later in good clinical condition. Because of recurrent pain, she has required repeated neurolytic celiac plexus blocks via a posterior approach without complications. CONCLUSION The posterior approach for neurolytic celiac plexus block should be considered in particular in patients with previous pancreatic surgery.
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Neurolytic Celiac Plexus Block for Benign Pain. Reg Anesth Pain Med 2003. [DOI: 10.1097/00115550-200311000-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Affiliation(s)
- Michael J Levy
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota 55905, USA
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16
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Solomon SB, Banks SM, Gerstenberger E, Csako G, Bacher JD, Thomas ML, Costello R, Eichacker PQ, Danner RL, Natanson C. Sympathetic blockade in a canine model of gram-negative bacterial peritonitis. Shock 2003; 19:215-22. [PMID: 12630520 DOI: 10.1097/00024382-200303000-00004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We investigated, in a well-established canine model of human sepsis, the effects of two different techniques of sympathetic blockade during bacterial peritonitis on pain relief, hemodynamics, and survival rate. Twenty-two purpose-bred beagles (12-28 months old, weighing 10-12 kg) were studied. Fourteen animals received an epidural infusion of bupivicaine and morphine, and the other eight received either a celiac plexus block (n = 4) or a sham block (n = 4). Eighteen of the 22 animals received an intraperitoneal challenge of Escherichia coli (1-10 x 10(9) CFU kg(-1) body weight). At comparable doses of intraperitoneal-implanted E. coli (2.5-5 x 10(9) CFU kg(-1) body weight), the addition of sympathetic blockade produced a synergistic decrease in survival times (P = 0.002) and mean left ventricular ejection fraction (P = 0.008), and increase in creatinine levels (P = 0.02). There was also a significant increase in tumor necrosis factor (TNF) levels (P = 0.004) and decrease in blood endotoxin clearance (P = 0.006) associated with sympathetic blockade during sepsis. The celiac plexus-blocked animals had no improvement in pain scores, and subjectively looked clinically worse than animals with sepsis without a celiac plexus block. In contrast, the epidural block was effective in blocking the pain and discomfort associated with low lethality doses of intraperitoneal bacteria reflected by no increase in pain scores compared with animals not receiving bacterial challenge. This study shows that during severe bacterial peritonitis, maintenance of sympathetic tone irrespective of pain relief provided is necessary for clearance of bacterial toxins, control of proinflammatory mediator release, hemodynamic stability, and survival.
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Titton RL, Lucey BC, Gervais DA, Boland GW, Mueller PR. Celiac plexus block: a palliative tool underused by radiologists. AJR Am J Roentgenol 2002; 179:633-6. [PMID: 12185033 DOI: 10.2214/ajr.179.3.1790633] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Ross L Titton
- Department of Radiology, Division of Abdominal Imaging and Intervention, Massachusetts General Hospital, White 270, 55 Fruit St., Boston, MA 02114, USA
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18
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Teitelbaum JE, Berde CB, Nurko S, Buonomo C, Perez-Atayde AR, Fox VL. Diagnosis and management of MNGIE syndrome in children: case report and review of the literature. J Pediatr Gastroenterol Nutr 2002; 35:377-83. [PMID: 12352533 DOI: 10.1097/00005176-200209000-00029] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) syndrome is a rare disorder that presents in childhood; however, marked delay in diagnosis is common. We report a case and review the literature describing the typical features that should alert pediatricians to the diagnosis. We also describe a novel management strategy for providing symptomatic relief.
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Affiliation(s)
- J E Teitelbaum
- Department of Pediatrics, Divison of Gastroenteroloy and Nustrition, Monmouth Mediacal Center, MCP Hahnemann Medical School, Long Branch, New Jersey 07740, USA.
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Abstract
Pain is a common complaint in patients with autosomal-dominant polycystic kidney disease, and a systematic approach is needed to differentiate the etiology of the pain and define an approach to management. A thorough history is the best clue to the multifactorial causes of the pain, superimposed upon an understanding of the complex innervation network that supplies the kidneys. The appropriate use of diagnostic radiology (especially MRI) will assist in differentiating the mechanical low back pain caused by cyst enlargement, cyst rupture and cyst infection. Also, the increased incidence of uric acid nephrolithiasis as a factor in producing renal colic must be considered when evaluating acute pain in the population at risk. MRI is not a good technique to detect renal calculi, a frequent cause of pain in polycystic kidney disease. If stone disease is a possibility, then abdominal CT scan and/or ultrasound should be the method of radiologic investigation. Pain management is generally not approached in a systematic way in clinical practice because most physicians lack training in the principles of pain management. The first impulse to give narcotics for pain relief must be avoided. Since chronic pain cannot be "cured," an approach must include techniques that allow the patient to adapt to chronic pain so as to limit interference with their life style. A detailed stepwise approach for acute and chronic pain strategies for the patient with autosomal dominant polycystic kidney disease is outlined.
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Affiliation(s)
- Z H Bajwa
- Department of Anesthesia and Neurology, Renal Division, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215-5491, USA
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Gress F, Schmitt C, Sherman S, Ciaccia D, Ikenberry S, Lehman G. Endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience. Am J Gastroenterol 2001; 96:409-16. [PMID: 11232683 DOI: 10.1111/j.1572-0241.2001.03551.x] [Citation(s) in RCA: 251] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE In our previous randomized trial, we suggested a possible role for endoscopic ultrasound (EUS) guided celiac plexus block in the treatment of abdominal pain associated with chronic pancreatitis. The purpose of this study was to evaluate our prospective experience with EUS-guided celiac plexus block for controlling pain attributed to chronic pancreatitis, including follow-up on response rates and complications. METHODS All subjects enrolled had documented chronic pancreatitis by ERCP and EUS criteria and presented with chronic abdominal pain unresponsive to current treatment options. All were treated with EUS-guided celiac plexus block under the guidance of linear array endosonography using a 22-gauge FNA needle (GIP, Mediglobe Inc., Tempe, AZ) inserted on each side of the celiac area, followed by injection of 10 cc bupivacaine (0.25%) and 3 cc (40 mg) triamcinolone on each side of the celiac plexus. Individual pain scores, based on a visual analog scale (0-10), were determined preblock and postblock by a nurse at 2, 7, 14 days and monthly thereafter. Subjects also rated their overall comfort level during the EUS procedure. RESULTS EUS-guided celiac plexus block was performed in 90 subjects (40 males, 50 females) having a mean age of 45 yr (range 17-76 yr) between July 1, 1995 and December 30, 1996. A significant improvement in overall pain scores occurred in 55% (50/90) of patients. The mean pain score decreased from 8 to 2 post EUS celiac block at both 4 and 8 wk follow-up (p < 0.05). In 26% of patients there was persistent benefit beyond 12 wk, and 10% still had persistent benefit at 24 wk, including three patients who were pain-free between 35 and 48 wk. Younger patients (<45 yr of age) and those having previous pancreatic surgery for chronic pancreatitis were unlikely to respond to the EUS-guided celiac block. Three patients experienced diarrhea post EUS celiac block, which resolved in 7-10 days; however, it is unclear whether this diarrhea was due to the block or to refractory disease. A cost comparison between the EUS ($1200) and CT ($1400) techniques shows the EUS celiac block to be less costly and perhaps more cost efficient in a subset of subjects. CONCLUSIONS EUS-guided celiac plexus block appears to be safe, effective, and economical for controlling pain in some patients with chronic pancreatitis. Younger patients (<45 yr) and those having prior pancreatic surgery for chronic pancreatitis do not appear to benefit from this technique. Prophylactic antibiotics should be considered if acid suppressing agents are being taken.
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Affiliation(s)
- F Gress
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, USA
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Miguel R. Interventional treatment of cancer pain: the fourth step in the World Health Organization analgesic ladder? Cancer Control 2000; 7:149-56. [PMID: 10783819 DOI: 10.1177/107327480000700205] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND For most patients with cancer pain, the World Health Organization's three-step analgesic ladder provides adequate management with oral or transdermal options. However, some cancer patients are not well palliated with these approaches. METHODS The author reviews interventional options that include nerve blocks, spinal administration of local anesthetics, opioids, alpha-2 agonists, spinal cord stimulation, and surgical interventions. RESULTS Numerous interventional options are readily accessible and most can be performed on an outpatient basis. They can be used as sole agents for the control of cancer pain or as useful adjuncts to supplement analgesia provided by opioids, thus decreasing opioid dose requirements and side effects. CONCLUSIONS Cancer-related pain can be controlled with several interventions when oral or transdermal opioids are inadequate. A risk:benefit ratio should be considered before implementing invasive analgesic methods.
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Affiliation(s)
- R Miguel
- Anesthesiology Service, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
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Abstract
Coeliac plexus blocks have been used successfully in the treatment of abdominal pain in advanced cancer and in benign chronic abdominal pain. However, concern remains about occasional potentially serious complications. One possible way to reduce the risks of this procedure may be to improve imaging during the procedure. We report a series of 38 coeliac plexus blocks carried out under computer tomographic (CT) guidance, mostly using the anterior approach. The technique is described. Effectiveness and side-effect rates were similar to other reported series. There were no major complications. Analysis of contrast spread would indicate that anterior preaortic or bilateral contrast spread is necessary to obtain pain relief. Our experience would indicate that routine CT guidance can be a simple aid to coeliac plexus block, and can be achieved easily in a district general hospital. Improved imaging allows accurate needle placement, while avoiding vital structures such as the aorta and pleura. Accurate placement may also allow the use of reduced volumes of neurolytic drugs.
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Affiliation(s)
- A Perello
- King Edward VII Hospital, Midhurst, UK
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Gress F, Schmitt C, Sherman S, Ikenberry S, Lehman G. A prospective randomized comparison of endoscopic ultrasound- and computed tomography-guided celiac plexus block for managing chronic pancreatitis pain. Am J Gastroenterol 1999; 94:900-5. [PMID: 10201454 DOI: 10.1111/j.1572-0241.1999.01042.x] [Citation(s) in RCA: 287] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Computed tomography (CT)-guided celiac plexus neurolysis has been used for controlling the chronic abdominal pain associated with intra-abdominal malignancy and chronic pancreatitis. Endoscopic ultrasound (EUS)-guided celiac plexus neurolysis has been reported to have some success in controlling pain from pancreatic cancer. The aim of this study is to assess the efficacy of EUS-guided celiac plexus block versus CT-guided celiac plexus block for controlling the chronic abdominal pain associated with chronic pancreatitis. METHODS Patients enrolled were randomly assigned to EUS-guided or CT-guided celiac plexus block. Pain scores were determined pre- and postceliac block for both techniques. Follow-up was obtained by a nurse at 1 day post-block, then weekly thereafter for 24 wk. Patients also rated overall experience with these procedures. The EUS celiac block was performed with a 22-gauge sterile needle inserted into the celiac region with guidance of real-time linear array endosonography followed by injection of 10 ml of bupivacaine (0.75%) and 3 ml (40 mg) of triamcinolone on both sides of the celiac area. RESULTS Twenty-two consecutive patients (10 men, 12 women), were ultimately enrolled in this study between 7/1/95 and 12/30/95; four patients were excluded for protocol violations. We performed EUS-guided celiac block in 10 patients and CT-guided celiac block in eight. A significant improvement in pain scores with reduction in pain medication usage occurred in 50% (five of 10) of patients having the EUS block. The mean postprocedure follow-up was 15 weeks (range: 8-24 wk). Persistent benefit was experienced by 40% of patients at 8 wk and by 30% at 24 wk. In the patients with CT block, however, only 25% (two of eight) had relief. The mean follow-up was 4 wk (range: 2-6 wk). Only 12% (one of eight) had some relief at 12 wk of follow-up. There were no complications. EUS-guided celiac block was the preferred technique among patients who experienced both techniques. A cost comparison between both celiac block techniques shows EUS to be less costly than CT. CONCLUSIONS EUS-guided celiac block provided more persistent pain relief than CT-guided block and was the preferred technique among the subjects studied. EUS-guided celiac block appears to be a safe, effective, and less costly method for controlling the abdominal pain that can accompany chronic pancreatitis in some patients.
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Affiliation(s)
- F Gress
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, USA
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Naveira FA, Speight KL, Rauck RL. Atheromatous aortic plaque as a cause of resistance to needle passage during transaortic celiac plexus block. Anesth Analg 1996; 83:1327-9. [PMID: 8942608 DOI: 10.1097/00000539-199612000-00034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- F A Naveira
- Department of Anesthesia (Pain Control Center), Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, North Carolina 27157-1009, USA
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Naveira FA, Speight KL, Rauck RL. Atheromatous Aortic Plaque as a Cause of Resistance to Needle Passage During Transaortic Celiac Plexus Block. Anesth Analg 1996. [DOI: 10.1213/00000539-199612000-00034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Affiliation(s)
- V W Chan
- Department of Anesthesia, University of California, San Francisco 94143-0648, USA
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Abstract
The purpose of this article is to familiarize the anaesthetist with the basic anatomy of the coeliac plexus; the techniques used to perform the procedure, its indications, complications and results in the management of chronic abdominal pain syndromes. Radiological, surgical and anaesthetic literature from the beginning of the century were reviewed. The main indication for neurolytic coeliac plexus block is intractable pain secondary to carcinoma of the pancreas or stomach. There appear to be theoretical advantages to techniques that result in spread of solution anterior to the aorta, such as the trans-aortic approach. These have not yet been demonstrated in any studies with large numbers of patients.
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Affiliation(s)
- F Fugère
- Department of Anaesthesia, Ottawa Civic Hospital, Ottawa University, Ontario
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