Intraoperative neurolysis of the celiac plexus in patients with unresectable pancreatic cancer

BACKGROUND: The analgetic treatment of inoperable pancreatic cancer patients is of paramount importance. The relative ineffectiveness of pharmacological agents has led many investigators to recommend chemical neurolysis of the celiac ganglions for pain control. However, the assessment of the results and the effectiveness of the block carried out during laparotomy have been unclear. PATIENTS AND METHODS: After 41 intraoperative celiac neurolytic blocks pain intensity was retrospectively analysed in 38 patients suffering from unresectable pancreatic carcinoma. The mean age of the patients was 59 years, the observation period after neurolysis ranged to 6 months. All patients underwent definitive neurolysis using 50 % ethanol in 0.5 % prilocaine. Immediate and long-term efficacy, analgetic consumption and mortality were evaluated at follow-up. The calculated parenteral equivalent morphine dosage (mg per day) was evaluated before as well as at different time points after treatment as an objective parameter to describe pain intensity. RESULTS: 7 to 34 days (at discharge from the hospital) after block pain intensity was statistically highly significant reduced (p=0.016). Long-term results were obtained from 17 (10 to 12 weeks after intervention) and 9 (up to 20 weeks after intervention) patients respectively, demonstrating a long-lasting effect of the neurolysis. A statistical analysis was not possible because of the small patient 's number.CONCLUSIONS: Intraoperative celiac neurolytic block is a safe and effective method of pain treatment in patients with unresectable pancreatic carcinoma. However, it alone provides complete pain relief until death only in a few cases. Therefore, it should be considered as an adjuvant treatment in the analgesic strategy. Combined palliative therapy is necessary in most of the cases.     

Combined neurolytic block of celiac, inferior mesenteric, and superior hypogastric plexuses for incapacitating abdominal and/or pelvic cancer pain

Thirty-five patients with extensive abdominal or pelvic cancer who suffered uncontrolled, diffuse, extensive, and incapacitating pain were treated with a combination of neurolytic celiac plexus block (CPB), inferior mesenteric plexus block (IMPB), and superior hypogastric plexus block (SHGPB). The combination of neurolytic CPB, IMPB, and SHGPB was performed with alcohol, mainly using a transintervetebral disc approach. The combination neurolysis produced effective immediate pain relief in all the patients (visual analog scale (VAS), reduced from 8.8 ± 0.2 to 0). This pain relief persisted during the first 3 months (VAS, 2.3 ± 0.5) or until death. Morphine consumption was significantly decreased for the first 1 month (from 96 ± 29 mg to 31 ± 10 mg per day) after the neurolysis and thereafter continued to be lower than before the surgery, though not significantly so. No serious complications were observed to have been caused by the neurolytic procedure on the three sympathetic plexuses. Our preliminary clinical results suggest that the combination of neurolytic CPB, IMPB, and SHGPB improves the quality of life of patients who have incapacitating cancer pain, by reducing both the intensity of the pain and their opioid consumption, without serious complications. This combination procedure may provide a new therapeutic option for pain relief in patients with advanced cancer.     

腹腔神经丛联合上腹下神经丛阻滞对顽固性腹部和（或）盆腔癌痛的作用

目的：评价腹腔神经丛联合上腹下神经丛阻滞对晚期腹部和（或）盆腔恶性肿瘤并发顽固性腹部和（或）盆腔内脏痛患者的镇痛效果。方法：对45例患者,在CT引导下后路经椎间盘旁法穿刺,用90%乙醇作为毁损剂,同时行腹腔丛和上腹下神经丛毁损术。观察毁损前和毁损后24h、1周、1个月和3个月各时段的疼痛VAS评分、吗啡控释片日用量和生活质量（QOL）评分、并发症和副作用。结果：与毁损前比较,毁损后各时段VAS评分和吗啡控释片日用量均明显降低（P〈0.05）,有13例镇痛效果满意直至去世;与术前比较,毁损后24h、1周、1个月QOL评分明显升高（P〈0.05）,第3个月时QOL评分无明显差异（P〉0.05）,未发生严重并发症和副作用。结论：在CT引导下以90%乙醇行腹腔丛联合上腹下神经丛毁损术可有效减轻晚期腹、盆腔癌症患者疼痛,减少吗啡日用量,从而提高患者的生活质量。     

Efficacy of Neurolytic Celiac Plexus Block in Varying Locations of Pancreatic Cancer: Influence on Pain Relief

Background: Neurolytic celiac plexus block (NCPB) is an effective way of treating severe pain in some patients with pancreatic malignancy. However, there are no studies to date that evaluate the effectiveness of NCPB related to the site of primary pancreas cancer. The aim of the study was to assess the effectiveness of NCPB in pancreatic cancer pain, depending on the location of the pancreatic tumor.

Methods: The prospective study was conducted in 50 consecutive patients diagnosed with pancreatic cancer. The patients were categorized into two different groups depending on tumor localization: group 1: patients with the cancer of the head of the pancreas and group 2: patients with the cancer of the body and tail of the pancreas. The qualitative and quantitative pain analyses were performed before and after NCPB. The patients underwent prognostic celiac plexus block with bupivacaine, followed by neurolysis during fluoroscopic control within the next 24 h.

Results: After NCPB, 37 patients (74%) had effective pain relief during the first 3 months or until death. Of the 37 patients who had effective pain relief, 33 (92%) were from group 1 and 4 (29%) were from group 2. In the remaining 13 patients (3 patients from group 1 and 10 patients from group 2), pain relief after NCPB was not satisfactory. Those patients were scheduled for repeated retrocrural neurolysis during computed tomography control. Computed tomography showed massive growth of the tumor around the celiac axis with metastases. After repeated neurolysis, pain relief clinically still was not satisfactory, necessitating additional opioid treatment.     

Efficacy of neurolytic celiac plexus block in varying locations of pancreatic cancer: influence on pain relief

BACKGROUND: Neurolytic celiac plexus block (NCPB) is an effective way of treating severe pain in some patients with pancreatic malignancy. However, there are no studies to date that evaluate the effectiveness of NCPB related to the site of primary pancreas cancer. The aim of the study was to assess the effectiveness of NCPB in pancreatic cancer pain, depending on the location of the pancreatic tumor. METHODS: The prospective study was conducted in 50 consecutive patients diagnosed with pancreatic cancer. The patients were categorized into two different groups depending on tumor localization: group 1: patients with the cancer of the head of the pancreas and group 2: patients with the cancer of the body and tail of the pancreas. The qualitative and quantitative pain analyses were performed before and after NCPB. The patients underwent prognostic celiac plexus block with bupivacaine, followed by neurolysis during fluoroscopic control within the next 24 h. RESULTS: After NCPB, 37 patients (74%) had effective pain relief during the first 3 months or until death. Of the 37 patients who had effective pain relief, 33 (92%) were from group 1 and 4 (29%) were from group 2. In the remaining 13 patients (3 patients from group 1 and 10 patients from group 2), pain relief after NCPB was not satisfactory. Those patients were scheduled for repeated retrocrural neurolysis during computed tomography control. Computed tomography showed massive growth of the tumor around the celiac axis with metastases. After repeated neurolysis, pain relief clinically still was not satisfactory, necessitating additional opioid treatment. CONCLUSION: In this study, unilateral transcrural celiac plexus neurolysis has been shown to provide effective pain relief in 74% of patients with pancreatic cancer pain. Neurolysis was more effective in cases with tumor involving the head of the pancreas. In the cases with advanced tumor proliferation, regardless of the technique used, the analgesic effects of NCPB were not satisfactory.     

Laparoscopic Douglasectomy in the treatment of painful uterine retroversion

Background: One of the etiologies of pelvic pain in women, often unrecognized, is the Masters-Allen syndrome, which was described in 1955 as the ``universal joint cervix' syndrome. It has the following three elements: (1) etiology: obstetrics-related trauma; (2) clinical findings: uterine retroversion with hypermobile cervix following elongation or desinsertion of the uterosacral ligaments; (3) anatomy: visualization of a tearing of the posterior serosa and subperitoneal fascia of the ligamentum latum. Methods: Forty-one laparoscopic Douglasectomies with uterosacral ligamentopexy were performed in the department of Gynecology at the University Hospital of Caen during the period between 1990 and 1995 in patients with painful retroverted uterus. The patient selection was made thanks to the ``pessary test.' The surgical endoscopic procedure, identical to the operation first promoted by Jamain and Letessier in 1976 by laparotomy, is described. Results: Total pain relief was experienced by 31 patients (75%) and partial relief by five patients (5%). Two main complications occurred, requiring one laparotomy (bleeding from a pelvic varicose vein with a concomitantly occurring breakdown of the washing-aspiration system) and one second laparoscopy at day 15 (one case of hematoma below the peritonization revealed by pain). Twenty-three women became pregnant again, and had normal deliveries except for two cesareans, with no recurrence of pain. Douglasectomy is compared to alternative techniques in the literature. Other indications for Douglasectomy are discussed. Conclusion: Douglasectomy is the only definitive procedure for restoring normal anatomy of the pelvic floor in case of painful uterine retroversion occurring in a setting of Masters-Allen syndrome. Additionally, it provides for pathological analysis of the excised peritoneum. The results of this procedure are excellent when the indication is correctly set, particularly as concerns positive pessary testing. Received: 22 April 1996/Accepted: 15 July 1996     

Thoracoscopic splanchnicectomy for pain control in patients with unresectable carcinoma of the pancreas

Background: Intractable pain is the most distressing symptom in patients suffering from unresectable pancreatic carcinoma. Palliative interventions are justified to relieve the clinical symptoms with as little interference as possible in the quality of life. The purpose of this study was to examine the efficacy and safety of thoracoscopic splanchnicectomy for pain control in patients with unresectable carcinoma of the pancreas. Methods: Between May 1995 and April 1998, 24 patients (14 men and 10 women) with a mean age of 65 years (range, 30–85) suffering from intractable pain due to unresectable carcinoma of the pancreas underwent 35 thoracoscopic splanchnicectomies. All patients were opiate-dependent and unable to perform normal daily activities. Subjective evaluation of pain was measured before and after the procedure by a visual analogue score. The following parameters were also evaluated: procedure-related morbidity and mortality, operative time, and length of hospital stay. Results: All procedures were completed thoracoscopically, and no intraoperative complications occurred. The mean operative time was 58 ± 22 min for unilateral left splanchnicectomy and 93.5 ± 15.6 min for bilateral splanchnicectomies. The median value of preoperative pain intensity reported by patients on a visual analogue score was 8.5 (range, 8–10). Postoperatively, pain was totally relieved in all patients, as measured by reduced analgesic use. However, four patients experienced intercostal pain after bilateral procedures, even though their abdominal pain had disappeared. Complete pain relief until death was achieved in 20 patients (84%). Morbidity consisted of persistent pleural effusion in one patient and residual pneumothorax in another. The mean hospital stay was 3 days (range, 2–5). Conclusions: We found thoracoscopic splanchnicectomy to be a safe and effective procedure of treating malignant intractable pancreatic pain. It eliminates the need for progressive doses of analgesics, with their side effects, and allows recovery of daily activity. The efficacy of this procedure is of major importance since life expectancy in these patients is very short. Received: 23 December 1999/Accepted: 6 January 2000/Online publication: 12 July 2000     

Early experience with laparoscopic abdominoperineal resection

Background: Laparoscopic abdominoperineal resection (LAPR) has not been fully evaluated as a technique in the treatment of rectal and anal cancer or inflammatory bowel disease. The purpose of our study was to evaluate the early experience with laparoscopic abdominoperineal resection at Washington University Medical Center. Methods: A prospective analysis was performed on the first 21 patients undergoing the procedure at Washington University Medical Center. Indications for surgery included rectal cancer (14 patients), anal squamous cell cancer (four patients), inflammatory bowel disease (two patients), and anal melanoma (one patient). Results: The procedure was converted to open procedure in four patients (19%). The mean (±SEM) operative time and blood loss for completed and converted LAPR were 239 ± 11 min and 424 ± 43 ml, respectively. Postoperative hematocrit dropped a mean of 8.3% ± 1.2% SEM; five patients required blood transfusion (24%). Wound complication occurred in four patients (19%; three perineal, one trocar site). Bowel function returned after a mean of 3 days, and mean postoperative hospital stay for the completed LAPR group was 5 days. Mild pain was experienced by 81% of patients (17/21) while 19% (4/21) noted moderate pain, usually of the perineal wound. The mean duration of patient-controlled analgesia use was 2 days. During the 1–44-month follow-up, six patients (29%) died from cancer (stage III or IV at operation) and only one patient developed local recurrence in the pelvis (5%). There were no trocar-site implants of cancer. Furthermore, there was no relationship between prior abdominal operations, the amount of blood loss, postoperative drop of hematocrit, or blood transfusion requirement and the length of hospitalization or complication rates. Conclusion: Laparoscopic abdominoperineal resection is a feasible alternative to the conventional open technique in both cancer and colitis patients. Received: 23 April 1996/Accepted: 8 July 1996     

Development of a laparoscopic approach to neurolytic celiac plexus block in a porcine model

Background: Neurolytic celiac plexus block (NCPB) is an effective method of palliative pain control in cases of inoperable pancreatic cancer. This study was undertaken to evaluate the feasibility of a laparoscopic approach to NCPB in an experimental animal model. Methods: The laparoscopic technique for NCPB was developed in an acute study of six domestic swine followed by a chronic study of nine domestic swine that were monitored 3–21 days after surgery for adverse neurologic, gastrointestinal, or other sequelae. Using a four-port laparoscopic technique, the esophageal hiatus was dissected to expose the aorta at the level of the diaphragmatic crura. Under combined endoscopic and laparoscopic ultrasound (LUS) guidance, 5 ml of sclerosant dye (95% ethanol mixed with India ink) was injected into either side of the para-aortic soft tissue via a percutaneously placed 18-gauge spinal needle. After the animals were killed, the aorta and periaortic tissue were harvested from each animal for gross and histologic analysis. Results: Under LUS guidance, sclerosant was injected successfully into the para-aortic soft tissue in all animals. There were no intraoperative complications in the acute animal group. Placement of sclerosant injection was successful in all nine chronic cases. Two pigs in the chronic study group died in the immediate postoperative period secondary to pneumothorax. No adverse neurologic, gastrointestinal, or other sequelae were observed in the remaining seven animals at 3–21 days postoperatively. After the animals were killed, we found no injuries to the aorta or esophagus, and histologic analysis demonstrated good placement of dye-labeled sclerosant with no compromise of aortic structural integrity. Conclusion: A laparoscopic approach to the aortic hiatus and NCPB is feasible. Further studies are warranted to evaluate this approach in patients who undergo staging laparoscopy for pancreatic cancer and are found to have unresectable disease. Received: 19 March 1999 /Accepted: 18 November 1999 /Online publication: 26 July 2000     

Endoscopic photodynamic therapy for obstructing esophageal cancer: 77 cases over a 2-year period

rid="id="<e5>Correspondence to:</e5> J. D. Luketich, 200 Lothrop Street, C-800, Presbyterian Hospital, Pittsburgh, PA 15213, USA Background: Photodynamic therapy (PDT) is an alternative treatment option for the palliation of obstructive esophageal cancer. We report our experience with PDT for patients presenting with inoperable, obstructing, or bleeding esophageal cancer. Methods: Seventy-seven patients with inoperable, obstructing esophageal cancer were treated with PDT from November 1996 to July 1998. Photofrin (1.5–2.0 mg/kg) was administered, followed by endoscopic light treatment (630 nm red dye laser) at 48 h. Dysphagia score (1 for no dysphagia to 5 for complete obstruction), dysphagia-free interval, and patient survival were assessed. Results: Seventy-seven patients underwent 125 PDT courses. The mean dysphagia score at 4 weeks after PDT in 90.8% of the patients improved from 3.2 ± 0.7 to 1.9 ± 0.8 (p < 0.05). PDT adequately controlled bleeding in all six patients who had bleeding. The most common complications after the 125 PDT courses were esophageal stricture (4.8%), Candida esophagitis (3.2%), symptomatic pleural effusion (3.2%), and sunburn (10.0%). Twenty-nine patients (38%) required more than one PDT course, and seven patients required placement of an expandable metal stent for recurrent dysphagia. The mean dysphagia-free interval was 80.3 ± 58.2 days. The median survival was 5.9 months. Conclusions: Photodynamic therapy is a safe and effective treatment for the palliation of obstructing and bleeding esophagus cancer. Received: 8 May 1999/Accepted: 24 September 1999/Online publication: 15 May 2000     

Celiac plexus block: A reappraisal

Background and Objectives. The neurolytic celiac plexus block is an established, well-developed procedure and the most widely applicable of all the neurolytic pain blocks. It optimizes palliative treatment for cancer of the upper abdominal viscera. Several techniques have been proposed in an attempt to increase success rates, reduce morbidity, and enhance technical accuracy. However, the assessment of the results and effectiveness of the block have been controversial. Methods. A survey was made of pertinent English language literature on the anatomic and technical problems, indications, advantages, complications, and outcomes related to the neurolytic celiac plexus block as well as the neurolytic solutions and radiologic guidance used. Results. The successful relief of the pain of pancreatic cancer and other abdominal malignancies can be expected in 85% and 73% of patients, respectively. Following the block, many patients can be weaned from opioids or at least have their dose reduced. The half-life of the celiac plexus block seems to be more than 4 weeks. The probability of patients remaining completely pain-free diminishes with increases survival time. The technique selected should be appropriate to the available and the extent of malignancy, since the analgesic results seem to be independent of the principal techniques used. Serious complications are extremely rare. However, critical analysis revealed major deficiencies in all of the reports reviewed. Conclusion. Neurolytic celiac plexus block alone is capable of providing complete pain relief until death in a few cases and, therefore, should be considered as an adjuvant treatment in the analgesic strategy. Combination palliative therapy is necessary in most cases. Failure of the block may be attributed to tumor metastatizing beyond the nerves that conduct pain via the celiac plexus and the component nerves that form it. Concomitant pain of somatic origin (frequently observed in upper gastrointestinal cancer because of significant peritoneal involvement) requires other therapeutic measures.     

Selective role for endoscopic retrograde cholangiopancreatography in abdominal trauma

Background: Emergency endsocopic retrograde cholangiopancreatography (ERCP) is rarely indicated in trauma patients; however, in cases of suspected pancreatic or bile duct injury or bile leak, it may be useful. The purpose of this paper is to review our ERCP experience in trauma patients. Our Level I Trauma Center admits 1800 patients annually. Methods: Since January 1991, we have performed ERCP in 12 trauma patients, nine after blunt injury and three after penetrating injury. Results: ERCP was used as a diagnostic tool to evaluate the pancreatic duct in six stable patients with equivocal CT scans and unexplained abdominal pain, fever, and an elevated amylase or a peripancreatic pseudocyst. Based on their ERCP findings—one intact pancreatic duct, one transected duct, and four pseudocysts—five of the six patients had operations. We performed ERCP in six patients for persistent bile leaks (five cases) or jaundice (one case). The findings were one case of bilemia (intrahepatic biliovenous fistula), one case of common bile duct disruption, and four cases of persistent bile leaks from the liver after liver injuries. Endobiliary stents placed in five patients successfully stopped the four bile leaks and closed the biliovenous fistula. The one case of ductal disruption required an open choledochojejunostomy. The only ERCP complication was an episode of cholangitis treated with antibiotics. The earliest ERCP was 3 days after injury, and most were performed within 2 months. Conclusions: ERCP is a helpful procedure for diagnosing biliary and pancreatic duct injury in a select group of trauma patients who do not have obvious indications for exploration. In addition, ERCP techniques are also effective for treating most bile leaks. Received: 21 April 1997/Accepted: 22 September 1997     

Celiac plexus block: injectate spread and pain relief in patients with regional anatomic distortions

BACKGROUND: The success of the neurolytic celiac plexus block, despite different approaches and methods used, depends on adequate spread of the injectate in the celiac area. This retrospective study was conducted to evaluate the patterns of alcohol spread and pain relief in patients with cancer or therapy-related anatomic distortion of the celiac area. METHODS: From 177 cancer patients who underwent computed tomography (CT)-guided single-needle neurolytic celiac plexus block via an anterior approach, a radiologist, blind to the aim of the study, retrospectively selected 105 patients with abnormal anatomy of the celiac area as judged by CT images obtained before the block. To evaluate CT patterns of neurolytic (mixed with contrast) spread, the celiac area was divided on the frontal plane into four quadrants: upper right and left and lower right and left, as related to the celiac artery. Results were expressed as the number of quadrants into which contrast spread, ie., four, three, two, or one quadrants with contrast. The patterns of contrast spread according to the number of quadrants with anatomic distortion were analyzed. Patient assessment by visual analog scale was reviewed to evaluate the degree of pain relief. Pain relief 30 days after block was considered long-lasting. Pain relief at 30 days after block was analyzed according to the number of quadrants with contrast. RESULTS: Overall, four, three, two, and one quadrants with contrast were observed in 9 (8%), 21 (20%), 49 (47%), and 26 (25%) patients, respectively. An inverse correlation was observed between the number of quadrants with anatomic distortion and the number of quadrants with contrast (P < 0.001). Long-lasting pain relief was noticed in nine of nine patients (100%; 95% confidence interval, 66-100) with contrast in four-quadrants, and in 10 of 21 patients (48%; 95% confidence interval, 26-70) with contrast in 3 quadrants (P < 0.01). None of the 75 patients with contrast in two quadrants or one quadrant experienced long-lasting pain relief. CONCLUSIONS: These findings suggest that, using the single-needle anterior approach, the neurolytic spread in the celiac area is highly hampered by the regional anatomic alterations. It also appears that only a complete (four quadrants) neurolytic spread in the celiac area can guarantee long-lasting analgesia, and that this picture may be obtained in a very limited fraction of patients with regional anatomic alterations.     

Neurohistopathologic findings after a neurolytic celiac plexus block with alcohol in patients with pancreatic cancer pain

Pancreatic cancer has a very poor prognosis resulting in the death of 98% of patients. Pain may be severe and difficult to treat. Management of pain includes chemotherapy, radiotherapy, pharmacologic treatment, and neurolytic celiac plexus block. Recent reviews of the efficacy of neurolytic celiac plexus block however, have reached conflicting conclusions. In this paper, we present two patients with severe pancreatic cancer pain resistant to pharmacologic treatment. Analgesic effect following repeated neurolytic celiac plexus blocks with alcohol was limited in time. Post-mortem neurohistopathologic examination of the celiac plexus revealed an abnormal celiac architecture with a combination of abnormal neurons with vacuolization and normal looking neuronal structures (ganglionic structures and nerve fibers) embedded in fibrotic hyalinized tissue. Our results show that a neurolytic celiac plexus block with alcohol is capable of partially destroying the celiac plexus. These findings may explain the significant but short-lasting analgesic effect following neurolytic celiac plexus block with alcohol.     

Celiac Plexus Block: Injectate Spread and Pain Relief in Patients with Regional Anatomic Distortions

Background: The success of the neurolytic celiac plexus block, despite different approaches and methods used, depends on adequate spread of the injectate in the celiac area. This retrospective study was conducted to evaluate the patterns of alcohol spread and pain relief in patients with cancer or therapy-related anatomic distortion of the celiac area.

Methods: From 177 cancer patients who underwent computed tomography (CT)-guided single-needle neurolytic celiac plexus block via an anterior approach, a radiologist, blind to the aim of the study, retrospectively selected 105 patients with abnormal anatomy of the celiac area as judged by CT images obtained before the block. To evaluate CT patterns of neurolytic (mixed with contrast) spread, the celiac area was divided on the frontal plane into four quadrants: upper right and left and lower right and left, as related to the celiac artery. Results were expressed as the number of quadrants into which contrast spread, i.e., four, three, two, or one quadrants with contrast. The patterns of contrast spread according to the number of quadrants with anatomic distortion were analyzed. Patient assessment by visual analog scale was reviewed to evaluate the degree of pain relief. Pain relief 30 days after block was considered long-lasting. Pain relief at 30 days after block was analyzed according to the number of quadrants with contrast.

Results: Overall, four, three, two, and one quadrants with contrast were observed in 9 (8%), 21 (20%), 49 (47%), and 26 (25%) patients, respectively. An inverse correlation was observed between the number of quadrants with anatomic distortion and the number of quadrants with contrast (P < 0.001). Long-lasting pain relief was noticed in nine of nine patients (100%; 95% confidence interval, 66-100) with contrast in fourquadrants, and in 10 of 21 patients (48%; 95% confidence interval, 26-70) with contrast in 3 quadrants (P < 0.01). None of the 75 patients with contrast in two quadrants or one quadrant experienced long-lasting pain relief.     

CT引导下腹腔神经丛阻滞术治疗癌性腹痛(附132例报道)

目的:评价CT引导下腹腔神经丛阻滞(NCPB)术治疗癌性腹痛的疗效,比较不同肿瘤和不同进针途径对疗效的影响。方法:分析经CT引导下注射无水乙醇进行NCPB术治疗胰腺癌、肝(胆)癌和胃癌等晚期肿瘤导致的顽固性腹痛共132例。对于术后止痛效果进行1周～3个月的评价,评价方法采用4分制法,判断NCPB术的治疗效果。结果:经腹前壁途径NCPB术治疗胰腺癌43例、肝(胆)癌32例、胃癌22例,其术后1周和3个月有效率分别为95.4%、90.7%;84.4%、75.0%和100.0%、77.3%。经脊柱旁途径治疗胰腺癌19例、肝(胆)癌13例、胃癌3例,其术后1周和3个月有效率分别为89.5%、89.5%;76.9%、61.5%和100.0%、66.7%。NCPB治疗不同肿瘤的长期总有效率是81.1%,胰腺癌、肝(胆)癌和胃癌分别是:90.3%、71.1%、76.0%。不同肿瘤之间有效率有显著差异。两种不同途径NCPB之间长期疗效分别为82.5%、77.1%,无显著差异。结论:对不同肿瘤的NCPB治疗效果相比,胰腺癌的长期疗效最佳。前路进针的NCPB术定位准确,无水乙醇弥散程度好,但长期治疗效果和后路进针无显著差异。     

Conversions and complications in 185 laparoscopic adjustable silicone gastric banding cases

Background: Kuzmak's gastric silicone banding technique is the least invasive operation for morbid obesity. The purpose of this study was to analyze the complications of this approach. Methods: Between September 1992 and March 1996, 185 patients underwent laparoscopic gastroplasty by the adjustable silicone band technique. A minimally invasive procedure using five trocars was performed. Results: In 11 patients exposure of the hiatus was impeded because of hypertrophy of the left liver lobe which led to conversion in eight patients and abortion of the procedure in three other patients. Anatomical complications: We observed two gastric perforations and one band slippage at the early stage, one infection and three rotations of the access port. Functional complications: There were eight (4%) cases of irreversible total food intolerance resulting in pouch dilation and eight cases (4%) of esophagitis. One fatality on the 45th day in a patient with a Prader-Willi syndrome. Conclusion: The most disturbing complications of gastric banding technique are gastric perforation and pouch dilation. Their incidence may be reduced by improving the technique and by considering pitfalls of the procedure. Received: 28 May 1996/Accepted: 25 July 1996     

Paraplegia following intraoperative celiac plexus injection

The technique for percutaneous and open neurolytic celiac plexus injection, using ethanol or phenol, for relief of intractable pancreatic cancer pain has been well described. Prospective randomized studies, demonstrating safety and efficacy with few complications, have led to widespread acceptance and use of this palliative procedure. The complications of neurolytic celiac plexus injection are rare, and are usually minor. However, transient or permanent paraplegia has been reported previously in 10 cases. The case described herein represents the third reported case of permanent paraplegia following open intraoperative neurolytic celiac plexus injection using 50% ethanol. The literature surveying the indications for this procedure, routes of administration, known complications, and their pathophysiology are reviewed.     

Laparoscopy for chronic abdominal pain

Background: This purpose of this investigation was to evaluate the utility of laparoscopy in patients with chronic abdominal pain. Methods: A retrospective review was performed of 34 patients who underwent laparoscopy for chronic abdominal pain. Average patient age was 39 years. The majority were women. Most had undergone abdominal surgery in the past. Results: All procedures were performed laparoscopically. A positive finding was made in 65% of patients. Fifty-six percent of patients underwent adhesiolysis, but 26% required no operative intervention other than laparoscopic exploration. Notably, 73% of patients reported improvement in pain postoperatively, whether or not a positive finding had been made on laparoscopy. Conclusions: This retrospective study suggests laparoscopy can identify abnormal findings and improve outcome in a majority of selected cases. Recommendations are provided for patient selection. Prior abdominal surgery is not an absolute contraindication to laparoscopic exploration for chronic abdominal pain. Received: 16 April 1996/Accepted: 30 May 1996     

Lobectomy with extended lymph node dissection by video-assisted thoracic surgery for lung cancer

Background: Between September 1992 and September 1996, we performed 88 VATS (video-assisted thoracic surgery) lobectomies and two VATS pneumonectomies. Methods: The indications for surgery were 68 cases of lung cancer, nine cases of bronchiectasis, six cases of tuberculosis, and seven cases of benign lesions. Of the 68 cases of lung cancer, 36 were treated by VATS lobectomy with extended lymph node dissection for clinical stage I lung cancer, making full use of recently developed devices for thoracoscopic surgery, such as roticulating endoscissors, miniretractors, endoclips, and harmonic scalpels. Results: Twenty-four lymph nodes were resected on average (range, 10 to 51) by VATS. This number was comparable to lymph nodes resected in open thoracotomy during the same period. Among the 36 patients who underwent extended lymph node dissection, 20 showed no lymph node metastasis postoperatively (stage I), while 16 had N1 or N2 cancer. All patients with stage I cancer have survived 4 to 36 months (median: 17 months) with no signs of recurrence. Conclusions: This survival of stage I lung cancer after VATS is comparable to that of open thoracotomy. We thus believe that VATS lobectomy with extended lymph node dissection can be an alternative to standard posterolateral thoracotomy for stage I lung cancer. Received: 10 May 1996/Accepted: 19 November 1996