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Chang VT, Sandifer C, Zhong F. GI Symptoms in Pancreatic Cancer. Clin Colorectal Cancer 2023; 22:24-33. [PMID: 36623952 DOI: 10.1016/j.clcc.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 12/21/2022] [Indexed: 12/31/2022]
Abstract
This review will apply a multidisciplinary approach to GI symptoms with attention to symptom assessment (instruments and qualitative aspects), differential diagnosis, and recent findings relevant to management of symptoms and underlying diseases. We conclude that further development of supportive interventions for GI symptoms for both patient and caregivers has the potential to reduce distress from GI symptoms, and anticipate better symptom control with advances in scientific knowledge and improvement of the evidence base.
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Affiliation(s)
- Victor T Chang
- Section Hematology Oncology (111), VA New Jersey Health Care System, East Orange, NJ; Department of Medicine, Rutgers - New Jersey Medical School, Newark, NJ.
| | | | - Fengming Zhong
- Section Hematology Oncology (111), VA New Jersey Health Care System, East Orange, NJ; Department of Medicine, Rutgers - New Jersey Medical School, Newark, NJ
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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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Burchiel KJ, Raslan AM. Contemporary concepts of pain surgery. J Neurosurg 2020; 130:1039-1049. [PMID: 30933905 DOI: 10.3171/2019.1.jns181620] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 01/03/2019] [Indexed: 11/06/2022]
Abstract
Pain surgery is one of the historic foundations of neurological surgery. The authors present a review of contemporary concepts in surgical pain management, with reference to past successes and failures, what has been learned as a subspecialty over the past 50 years, as well as a vision for current and future practice. This subspecialty confronts problems of cancer pain, nociceptive pain, and neuropathic pain. For noncancer pain, ablative procedures such as dorsal root entry zone lesions and rhizolysis for trigeminal neuralgia (TN) should continue to be practiced. Other procedures, such as medial thalamotomy, have not been proven effective and require continued study. Dorsal rhizotomy, dorsal root ganglionectomy, and neurotomy should probably be abandoned. For cancer pain, cordotomy is an important and underutilized method for pain control. Intrathecal opiate administration via an implantable system remains an important option for cancer pain management. While there are encouraging results in small case series, cingulotomy, hypophysectomy, and mesencephalotomy deserve further detailed analysis. Electrical neuromodulation is a rapidly changing discipline, and new methods such as high-frequency spinal cord stimulation (SCS), burst SCS, and dorsal root ganglion stimulation may or may not prove to be more effective than conventional SCS. Despite a history of failure, deep brain stimulation for pain may yet prove to be an effective therapy for specific pain conditions. Peripheral nerve stimulation for conditions such as occipital neuralgia and trigeminal neuropathic pain remains an option, although the quality of outcomes data is a challenge to these applications. Based on the evidence, motor cortex stimulation should be abandoned. TN is a mainstay of the surgical treatment of pain, particularly as new evidence and insights into TN emerge. Pain surgery will continue to build on this heritage, and restorative procedures will likely find a role in the armamentarium. The challenge for the future will be to acquire higher-level evidence to support the practice of surgical pain management.
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Kongsgaard UE. Letter to the Editor regarding "CT guided neurolytic blockade of the coeliac plexus in patients with advanced and intractably painful pancreatic cancer". Scand J Pain 2019; 18:759. [PMID: 30048239 DOI: 10.1515/sjpain-2018-0110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 07/09/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Ulf E Kongsgaard
- Department of Anaesthesia, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway, Phone: (+47) 95 75 31 76
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Molnár I, Hegyi G, Zsom L, Saahs C, Vagedes J, Kapócs G, Kovács Z, Sterner MG, Szőke H. Celiac plexus block increases quality of life in patients with pancreatic cancer. J Pain Res 2019; 12:307-315. [PMID: 30679920 PMCID: PMC6338112 DOI: 10.2147/jpr.s186659] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background Pancreatic cancer is a malignant disease with a high mortality rate and severe pain that is challenging to manage. To reduce the excruciating abdominal pain, opioids and adjuvant agents are conventionally used. Objectives PRNCPB is a treatment of neural therapy. The number of studies assessing the effect on patients' QoL is limited and inconsistent. With this study, we intended to address this issue. Study design A prospective nonrandomized study with a series of cases of unresectable pancreatic cancer was conducted. Setting The study was performed at our pain clinic under real life conditions. Materials and methods A total number of 16 patients with severe abdominal pain were enrolled in the study all of whom had responded to combined systemic analgesic therapy inadequately and had intolerable side effects contraindicating further increase in dose. The efficacy of this invasive, palliative analgesic procedure was evaluated 35 days after PRNCPB was performed. Primary outcomes were changed in pain intensity using the VAS questionnaire. Secondary outcomes were improved in QoL using the SF-36 questionnaire. Changes in pain medications and adverse reactions were monitored. Results After PRNCPB patients experienced a significant decrease (P=0.002) in pain intensity as shown by the VAS score, and a decreased opiate demand. Their QoL scores considering effect sizes also improved (P<0.001). No complications attributable to PRNCPB were observed during the study period. Additionally, no adverse drug reactions were observed. Limitations Detection, observation, and reporting bias can be estimated as moderate. Selection bias was not detected. Conclusion Our results give preliminary evidence that PRNCPB might be helpful as an additional treatment to conventional pain management in end-stage pancreatic cancer patients. PRNCPB seems to improve QoL in these patients in a time frame of at least 5 weeks after intervention.
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Affiliation(s)
- István Molnár
- Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary,
| | - Gabriella Hegyi
- Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary, .,Department of CAM, Faculty of Health Sciences, University of Pécs, Pécs, Hungary,
| | - Lajos Zsom
- Department of Nephrology, Fresenius Medical Care, Cegléd, Hungary
| | - Christine Saahs
- Department of Pediatrics, University of Vienna, Vienna, Austria.,Pediatric Outpatient Department, Krems, Austria
| | - Jan Vagedes
- University Children's Hospital, University of Tuebingen, Tuebingen, Germany.,Department of Complementary and Integrative Medicine, ARCIM Institute (Academic Research in Complementary and Integrative Medicine), Filderstadt, Germany
| | - Gábor Kapócs
- Department of Psychiatry and Psychiatric Rehabilitation, Saint John Hospital, Budapest, Hungary
| | - Zoltán Kovács
- Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary,
| | | | - Henrik Szőke
- Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary, .,Department of CAM, Faculty of Health Sciences, University of Pécs, Pécs, Hungary,
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Han L, Ma J, Duan W, Zhang L, Yu S, Xu Q, Lei J, Li X, Wang Z, Wu Z, Huang JH, Wu E, Ma Q, Ma Z. Pancreatic stellate cells contribute pancreatic cancer pain via activation of sHH signaling pathway. Oncotarget 2017; 7:18146-58. [PMID: 26934446 PMCID: PMC4951278 DOI: 10.18632/oncotarget.7776] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 01/05/2016] [Indexed: 12/29/2022] Open
Abstract
Abdominal pain is a critical clinical symptom in pancreatic cancer (PC) that affects the quality of life for PC patients. However, the pathogenesis of PC pain is largely unknown. In this study, we show that PC pain is initiated by the sonic hedgehog (sHH) signaling pathway in pancreatic stellate cells (PSCs), which is activated by sHH secreted from PC cells, and then, neurotrophic factors derived from PSCs mediate the pain. The different culture systems were established in vitro, and the expression of sHH pathway molecules, neurotrophic factors, TRPV1, and pain factors were examined. Capsaicin-evoked TRPV1 currents in dorsal root ganglion (DRG) neurons were examined by the patch-clamp technique. Pain-related behavior was observed in an orthotopic tumor model. sHH and PSCs increased the expression and secretion of TRPV1, SP, and CGRP by inducing NGF and BDNF in a co-culture system, also increasing TRPV1 current. But, suppressing sHH pathway or NGF reduced the expression of TRPV1, SP, and CGRP. In vivo, PSCs and PC cells that expressed high levels of sHH could enhance pain behavior. Furthermore, the blockade of NGF or TRPV1 significantly attenuated the pain response to mechanical stimulation compared with the control. Our results demonstrate that sHH signaling pathway is involved in PC pain, and PSCs play an essential role in the process greatly by inducing NGF.
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Affiliation(s)
- Liang Han
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Jiguang Ma
- Department of Anesthesiology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Wanxing Duan
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Lun Zhang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Shuo Yu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Qinhong Xu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Jianjun Lei
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Xuqi Li
- Department of General Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Zheng Wang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Jason H Huang
- Department of Neurosurgery, Baylor Scott and White Health Care, Temple, TX, 76508, USA.,Department of Surgery, Texas A & M College of Medicine, Temple, TX, 76504, USA
| | - Erxi Wu
- Department of Neurosurgery, Baylor Scott and White Health Care, Temple, TX, 76508, USA.,Department of Pharmaceutical Sciences, Texas A & M Health Science Center, College Station, TX, 77843, USA
| | - Qingyong Ma
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Zhenhua Ma
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
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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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Lahoud MJ, Kourie HR, Antoun J, El Osta L, Ghosn M. Road map for pain management in pancreatic cancer: A review. World J Gastrointest Oncol 2016; 8:599-606. [PMID: 27574552 PMCID: PMC4980650 DOI: 10.4251/wjgo.v8.i8.599] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 03/25/2016] [Accepted: 05/13/2016] [Indexed: 02/05/2023] Open
Abstract
Beside its poor prognosis and its late diagnosis, pancreatic cancer remains one of the most painful malignancies. Optimal management of pain in this cancer represents a real challenge for the oncologist whose objective is to ensure a better quality of life to his patients. We aimed in this paper to review all the treatment modalities incriminated in the management of pain in pancreatic cancer going from painkillers, chemotherapy, radiation therapy and interventional techniques to agents under investigation and alternative medicine. Although specific guidelines and recommendations for pain management in pancreatic cancer are still absent, we present all the possible pain treatments, with a progression from medical multimodal treatment to radiotherapy and chemotherapy then interventional techniques in case of resistance. In addition, alternative methods such as acupuncture and hypnosis can be added at any stage and seems to contribute to pain relief.
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Bosanquet DC, Wilcox CRM, Rasheed A. Bilateral Thoracoscopic Splanchnotomy to Alleviate Pain in Chronic Pancreatic Disease. Ann Thorac Surg 2016; 101:e91-3. [PMID: 26897240 DOI: 10.1016/j.athoracsur.2015.10.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 09/03/2015] [Accepted: 10/09/2015] [Indexed: 11/18/2022]
Abstract
Chronic intractable pain is a common problem in severe pancreatic disease. Bilateral thoracoscopic splanchnotomy, a thoracoscopic neurotomy of the splanchnic nerves, is rarely performed but may provide significant pain relief in these patients. We present a safe strategy that uses prone positioning and two thoracoscopic ports for either hemithorax, permitting easy exposure and simple dissection of the greater and lesser splanchnic nerves. In our experience, this technique provides excellent pain relief with a minimal postoperative stay and few postoperative adverse events. This intervention has the potential to reduce dependency on opioid agents and improve quality of life in carefully selected patients.
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Affiliation(s)
- David C Bosanquet
- Department of Surgery, Royal Gwent Hospital, Newport, United Kingdom.
| | | | - Ashraf Rasheed
- Department of Surgery, Royal Gwent Hospital, Newport, United Kingdom; University of South Wales, Newport, United Kingdom
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