The endoscopic management of pain in chronic pancreatitis

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

The impact of bacterial colonization on graft success after total pancreatectomy with autologous islet transplantation: considerations for early definitive surgical intervention

OBJECTIVE

The purpose of this study was to determine whether bacterial contamination of islets affects graft success after total pancreatectomy with islet autotransplantation (TPIAT).

BACKGROUND

Factors associated with insulin independence after TPIAT are inconclusive. Although bacterial contamination does not preclude transplantation, the impact of bacterial contamination on graft success is unknown.

METHODS

Patients who received TPIAT at the University of Virginia between January 2007 and January 2016 were reviewed. Patient charts were reviewed for bacterial contamination and patients were prospectively contacted to assess rates of insulin independence.

RESULTS

There was no significant difference in demographic or perioperative data between patients who achieved insulin independence and those who did not. However, six of 27 patients analyzed (22.2%) grew bacterial contaminants from culture of the final islet preparations. These patients had significantly lower islet yield and C-peptide at most recent follow-up (P<.05), and none of these patients achieved insulin independence.

CONCLUSIONS

Islet transplant solutions are often culture positive, likely secondary to preprocurement pancreatic manipulation and introduction of enteric flora. Although autotransplantation of culture-positive islets is safe, it is associated with higher rates of graft failure and poor islet yield. Consideration should be given to identify patients who may develop refractory chronic pancreatitis and offer early operative management to prevent bacterial colonization.

Matrix metalloproteinase-9, transforming growth factor-β1, and tumor necrosis factor-α plasma levels in chronic pancreatitis

OBJECTIVE

The aim of the study was to investigate the plasma levels of matrix metalloproteinase-9 (MMP-9), transforming growth factor-β 1 (TGF-β1), and tumor necrosis factor-α (TNF-α) in chronic pancreatitis (CP).

METHODS

Blood samples were obtained from 71 patients with CP and 100 control subjects, and plasma levels of MMP-9, TGF-β1, and TNF-α were determined by enzyme-linked immunosorbent assay.

RESULTS

The plasma levels of MMP-9 (18.3 ± 3.0 ng/mL, p < 0.0001), TGF-β1 (215.4 ± 178.1 ng/mL, p = 0.0301), and TNF-α (111.2 ± 69.3 ng/mL, p < 0.001) were significantly elevated in CP compared to the control group.

CONCLUSION

The role of elevated plasma MMP-9, TGF-β1, and TNF-α in CP requires further evaluation.