Coeliac plexus block for control of pain in chronic pancreatitis

Management of pain in small duct chronic pancreatitis

Small duct chronic pancreatitis (CP) is defined by a nondilated main pancreatic duct, and the morphological and clinical features of chronic pancreatitis with pain are the most prominent symptoms. Current treatment strategies are based on pain history and the location and extent of disease. Traditionally, radical pancreatic resectional procedures have been carried out for small duct CP, especially with an associated head mass of uncertain aetiology. Based on the information from five randomized trials, the duodenum-preserving pancreatic head resection and its modifications have proven to provide excellent long-term pain relief and to be superior to more radical operations. Therefore, these procedures can be considered the standard for small duct CP with head dominant disease. The longitudinal V-shaped excision of the ventral pancreas combines extensive drainage and a limited resection and offers good pain relief in diffuse small duct CP. However, long-term results and larger series are awaited for definite conclusions. Thoracoscopic splanchnicectomy and endosonography-guided celiac plexus blocks require controlled trials before their routine use. This article provides an overview about the current and evidence-based pain management in small duct CP.

Surgical management of chronic pancreatitis and the role of islet cell autotransplantation

Chronic pancreatitis is a disease characterized by disabling pain, inability to eat, steatorrhea, and eventual malnutrition. This often results in repeated hospitalizations and attempts to control symptoms with various analgesic regimens. As a result, the medical treatment of chronic pancreatitis is one of symptomatic management. Eventually, in some, nutritional supplementation becomes a necessity. For a fortunate few, the disease apparently burns itself out in time, lessening pain and improving appetite. In many patients, frustration over pain management and repeated hospitalizations leads to surgical treatment. Various procedures have been devised but, generally, fall into 2 categories: operations to decompress dilated ducts and operations to resect diseased pancreas. Results with either approach are unpredictable and often unsuccessful. For those without dilated ducts or with recurrent pain after surgery, total pancreatectomy has been suggested to remove all inflammatory tissue. This can be coupled with islet cell autotransplantation to avoid the dangers of pancreatogenic diabetes. Appropriate care of the removed pancreas and islet cell separation and purification are critical to this procedure to produce viable cells. Dispersed islets have been shown to successfully engraft and function for indefinite periods of time. Although insulin independence may not be achieved, easier maintenance of blood glucose can usually be realized.

Nerve blocks and neuroablative surgery for chronic pancreatitis

Surgical decompressive procedures for "large-duct" chronic pancreatitis have been notably successful in relieving pain. However, management of patients with intractable pain from "small-duct" chronic pancreatitis has been difficult, often resulting in narcotic addiction and/or malnutrition from major pancreatic resection. In view of the disappointing results from extensive pancreatic resections in these cases, denervation of pancreatic sympathetic pain afferents has been suggested as an alternative. Although denervation procedures have been attempted at multiple anatomical levels, results have unfortunately been mixed. The observed variability in results has been attributed to poor patient selection, incomplete understanding of neurophysiology of pancreatic pain, and perhaps inadequate knowledge of pancreatic neuroanatomy. At present, the preferred form of neural ablation is splanchnicectomy. However, a consistent and reliable method for identifying candidates for splanchnicectomy is critical, as it is clinically difficult to distinguish true pancreatic pain from other nociceptive conditions masquerading as pancreatic pain. Differential epidural anesthesia (DEA) is a promising, safe test for initial evaluation and patient selection, although it is not as precise as sometimes claimed. Patients responding to sympathetic block during DEA seem to be the best candidates for operative sympathetic ablation. At the moment, the optimal surgical approach to splanchnic ablation, which offers the least morbid technique, most favorable results, and an attractive risk-benefit ratio, is bilateral thoracoscopic splanchnicectomy. More experience and longer follow-up will be necessary to evaluate this approach.

Neurolytic Approaches for the Treatment of Pain in Patients with Chronic Pancreatitis

In large part, treatment options for patients with painful chronic pancreatitis remain empirical because of our limited understanding of the pathobiology of pancreatic pain. The procedures of neural block/ablation exemplify these limitations, which include the lack of a clear biologic rationale for various approaches, as well as unequivocal data on long-term outcomes and efficacy. Although the techniques themselves appear to be well established, controlled trials of various medical, endoscopic, radiologic, and surgical options to define the best treatment are clearly needed. In addition, the lack of uniform improvement with any technique underscores the need for applying a multidisciplinary approach to these patients, as should be the case for any chronic pain disorder.

Palliation of pain in chronic pancreatitis. Use of neural blocks and neurotomy

Effective management of the pain of chronic pancreatitis may require a multidisciplinary approach involving gastroenterologists, anesthesiologists, psychologists or counselors for chemical addiction (alcohol, narcotics), and surgeons. Viable approaches use pharmacologic analgesics with selected psychotropic medications, celiac plexus blocks, and possibly thoracoscopic splanchnic nerve transections. If these management techniques that preserve pancreatic parenchyma and function, fail, resective surgical therapy may be indicated. For most of these patients, all attempts at nonresective therapy should be exhausted before operative intervention.

Coeliac plexus block and cephalic spread of injectate

Extensive cephalic spread of solution occurred in three out of seven cases studied during coeliac plexus blockade. Spread on to cardiac nerves and plexus may be a factor in hypotension following this procedure. Incremental dosage and careful screening is recommended.

Steroid celiac plexus block for chronic pancreatitis: results in 16 cases

Sixteen cases in which celiac plexus block with depot steroid was used to treat chronic pancreatitis pain were reviewed. Only 4 of 16 patients reported pain relief with the procedure. Of the 12 patients who did not obtain relief, narcotic dependence was present in 11 of 12. No patients in the "relief" group were narcotic dependent. Prior pancreatic surgery was present in 9 of the 12 patients without relief and in 1 of 4 patients with relief. It is postulated that refractory chronic pancreatitis pain may be an extreme form of what has been termed "abnormal illness behavior." Furthermore, these results underscore the poor results experienced using neural blockade for the relief of chronic pain when narcotic dependence is present.

Coeliac plexus block versus pancreaticogastrostomy for pain in chronic pancreatitis. A controlled randomized trial

Seventeen patients with chronic pancreatitis and dilated pancreatic ducts were randomly allocated to coeliac plexus block or pancreaticogastrostomy. The number of patients with pain relief after coeliac plexus block and pancreaticogastrostomy did not differ at discharge. Pain score and use of analgesics before coeliac plexus block and 6 months later were unaffected but were significantly less after pancreaticogastrostomy. Operation decreased pancreatic tissue pressure significantly. This pressure decrease is believed to explain pain relief.

Coeliac plexus block for pain in pancreatic cancer and chronic pancreatitis

We have performed coeliac plexus block by standard percutaneous technique for disabling pain in 36 patients (13 with cancer and 23 with chronic pancreatitis). Eleven of the 13 cancer patients had complete pain relief initially and 7 remained pain free at the time of death. By contrast, only 12 of the 23 patients with pancreatitis had complete pain relief, 6 had partial relief and there was no effect in 5. The mean pain-free period in the chronic pancreatitis patients was only 2 months, and the longest 4 months. Benefit was least in patients with previous pancreatic surgery and repeat blocks were unhelpful. Transient postural hypotension occurred in most patients; two had nerve root pain and one developed persistent weakness and anaesthesia of the left leg, with bladder disturbance. These results warrant the continuing use of coeliac plexus block in pancreatic cancer, but rarely in chronic pancreatitis.

Chronic pancreatitis: results of a protocol of management

Thirty-five patients with chronic pancreatitis of varying cause have been treated according to a protocol first introduced in 1979. At the end of a mean follow up time of 2.1 years, only 54% of patients were found to have derived benefit defined by pain relief and improved quality of life. Patients with alcoholic pancreatitis did particularly poorly, and alcoholics who continued to drink almost never benefited. Patients with dilated pancreatic ducts were more likely to do well than those with small ducts, and pancreaticojejunostomy had a satisfactory record of pain relief. Patients with biliary pancreatitis generally did well with cholecystectomy and clearance of the common bile duct. The 40-80% pancreatectomy had a poor record for pain relief, and produced diabetes in the majority of patients in whom it was used. Nothing will reverse the established pathology of chronic pancreatitis, which remains an unsatisfactory condition to treat.