内脏与腹腔神经丛阻滞治疗胰腺癌晚期癌性疼痛的比较

[目的]观察CT引导经椎间盘穿刺法行内脏与腹腔神经丛阻滞对胰腺癌晚期癌性疼痛的疗效。[方法]48例晚期胰腺癌伴有上腹部癌性疼痛的患者，随机分为两组，在CT引导下分别行腹腔神经丛（N组）或经椎间盘穿刺行内脏神经（S组）无水乙醇毁损性阻滞。记录术前（Tn）、术后1d（T1）、15d（T15）、30d（T30）、60d（T60）、90d（T90）VAS评分，评估疗效；记录两组并发症和毒副作用。[结果]各组内术后T1-T90时的VAS评分均较R时降低（P〈0．01），S组在k、k时较N组同期降低（P〈0．05）。术后第1d，S组与N组显效率分别为87．5％和83.3％，随时间延长疗效均逐渐降低，至T90时分别为60．O％和42．9％。两组在治疗及随访期间均未发生严重并发症。[结论]内脏神经阻滞应用于晚期胰腺癌癌性疼痛的治疗，其远期疗效优于腹腔神经丛阻滞。CT引导下经椎间盘穿刺法行内脏神经阻滞，操作方便，安全有效。     

腹腔神经丛阻滞术治疗上腹部顽固性癌性疼痛的临床应用研究

目的评价腹腔神经丛阻滞术治疗上腹部顽固性癌性疼痛的止痛效果。方法105例晚期癌症患者,67例伴有后腹膜淋巴结广泛肿大并包绕神经、血管,均有顽固性上腹痛,经CT导引穿入膈脚前及后腹膜肿大淋巴结内行两侧腹腔神经丛乙醇阻滞术。结果经4个月随访观察,在2周,1,2,3,4个月,止痛总有效率分别为100.0%、98.1%、97.1%、93.8%和90.4%。止痛效果显著的患者,可观察到乙醇扩散较完全,能从两侧包绕腹主动脉,肿大的淋巴结有明显坏死。本组无一例严重并发症发生。结论CT导引下腹腔神经丛阻滞术治疗上腹部顽固性癌性疼痛是一种安全、有效的方法,值得推广应用。     

腹腔神经丛阻滞术的应用进展

腹腔神经丛阻滞术（neurolytic celiac plexus block，NCPB）是缓解胰腺癌或其他恶性肿瘤所致上腹部及背部疼痛的有效方法。腹腔神经丛松解术是治疗上腹部癌痛的常规和有效方法，在缓解疼痛的同时减少了镇痛药物导致的不良反应，提高了患者的生存质量。本文对临床常用的腹腔神经丛阻滞术的方法学研究和进展进行综述。      

不同分割三维适形放疗胰腺癌的疗效比较

胰腺癌的首选治疗方法为手术切除，但因多数不能早期发现而切除率低(5％～15％)。胰腺癌容易侵及腹腔神经丛和胰头神经丛，从而引起难以忍受的疼痛，尤以胰体部癌更为明显。对于局部晚期无法手术切除的胰腺癌患者，放疗可缓解疼痛，提高生活质量。对2000年2月至2003年3月治疗的伴有腹背疼痛的52例局部晚期胰腺癌患者进行分析，其中采用低分割三维适形放疗28例，常规分割适形放疗24例，治疗效果报道如下。     

腰方肌与腹横肌平面阻滞在卵巢癌根治术后#br# 镇痛效果比较#br#

目的比较超声引导下腰方肌阻滞(QLB) 与腹横肌平面阻滞（TAPB）用于开腹卵巢癌根治术后镇痛的临床效果。方法采用随机数字表法将72例全身麻醉下行开腹卵巢癌根治术患者分为QLB组(n=36）和TAPB组(n=36）。术毕患者进入麻醉恢复室（PACU）分别行超声引导下双侧腰方肌阻滞和腹横肌平面阻滞。每组行患者自控静脉镇痛（PCIA）。记录患者一般情况、手术和麻醉时间、切口长度; 观察神经阻滞操作时间、PACU停留时间、阻滞平面、并发症发生情况;记录术后首次需额外镇痛时间及24 h镇痛泵按压次数,分别于出PACU时、神经阻滞后2、6、12、24 h行静态和动态疼痛视觉模拟评分(VAS)。结果两组患者一般情况、手术和麻醉时间、切口长度差异均无统计学意义。QLB组感觉阻滞平面在T7～L1,TAPB组在T10～L1;与TAPB组比较,QLB组术后24 h镇痛泵按压次数减少,术后首次需额外镇痛时间延长; QLB组术后12 h、24 h静态和动态 VAS 评分均较TAPB组低。结论与TAPB相比,超声引导下QLB提供更广泛的阻滞范围,为开腹卵巢癌根治术患者减少术后镇痛泵药物用量,延长首次需要额外镇痛时间,降低术后疼痛评分。     

腹腔神经丛毁损阻滞癌痛患者血浆胃动素及β-内啡肽的变化

目的:观察腹腔神经丛毁损性治疗前后镇痛效果、患者生存质量及血浆胃动素、β-内啡肽的变化.方法:选取2009年2月至2010年9月间中国医科大学附属盛京医院收治的62例顽固性上腹部癌性疼痛患者,其中男37例,女25例,平均年龄57.6岁.应用多种强阿片类镇痛药效果不佳或不良反应严重,疼痛评分大于5,生存质量低下,无严重凝血功能障碍,无腹腔内感染、脓毒血症及肠梗阻.在CT引导下行腹腔神经丛毁损性阻滞治疗.观察镇痛疗效、生存质量、不良反应及并发症,在治疗前及治疗后第1、3、7天检测血浆胃动素及β-内啡肽水平.结果:治疗后患者疼痛明显缓解,疼痛评分降低,治疗前11点数字疼痛评分(NRS)为7.6±1.2,治疗后第7天为1.1±0.3,疼痛缓解50%(中度)以上的患者占96.8%.治疗后不良反应轻微,均在3天内缓解,无严重并发症发生,生存质量评分在治疗后明显改善,QOL各指标评分均明显降低.血浆胃动素水平在治疗后1天开始明显升高,治疗后3天达高峰,治疗后7天略有回落,但仍明显高于治疗前水平;β-EP水平在治疗后1天未见明显变化,但在治疗后3天明显升高,治疗后7天高达(336.9±29.4)pg/mL.结论:腹腔神经丛毁损阻滞治疗可以明显缓解上腹部癌痛,提高胃动素及β-内啡肽水平,改善胃肠动力,提高患者的生存质量,疗效确切,安全易行.     

CT引导下腹腔神经丛射频热凝术治疗晚期胰腺癌顽固性疼痛的临床分析

目的:探讨CT引导下腹腔神经丛射频热凝术治疗晚期胰腺癌顽固性疼痛的临床镇痛效果。方法:选取2016年6月至2018年6月70例晚期胰腺癌顽固性疼痛患者为研究对象,按随机数字表法分为对照组和观察组各35例。对照组:采用芬太尼透皮贴剂4.125 mg/贴×2/72 h 外用+加巴喷丁胶囊 200 mg po 3/d;观察组:采用CT引导下腹腔神经丛射频热凝术,射频治疗参数设置为:3 min,70 ℃。评价两组晚期胰腺癌顽固性疼痛患者镇痛效果。结果:治疗后3 d、6 d、21 d、60 d两组患者VAS评分均呈下降趋势（P<0.05),且观察组治疗后各时间点VAS评分均低于对照组,疼痛缓解率均高于对照组,差异有统计学意义（P<0.05）。两组患者治疗前躯体功能评分、情绪功能评分、社会功能评分、总健康状况评分差异均无统计学意义（P>0.05）。治疗后3 d、6 d、21 d、60 d观察组较对照组躯体功能评分、情绪功能评分、社会功能评分呈下降趋势,总健康状况评分呈上升改变,两组差异有统计学意义（P<0.05)。治疗前1 d两组患者血清炎性因子TNF-α、IL-6、CRP含量比较差异无统计学意义（P>0.05）。治疗后1 d、3 d,观察组血清TNF-α、IL-6、CRP含量均明显低于对照组,两组差异有统计学意义（P<0.05)。结论:CT引导下腹腔神经丛射频热凝术治疗晚期胰腺癌顽固性疼痛镇痛效果确切,具有操作简单、创伤小、见效快、安全有效等优势。     

扩大根治性手术治疗胰腺癌

有学者认为胰腺切除无助于胰腺癌的治疗,但很多报告推荐全胰及淋巴管、淋巴结的切除可用作根治胰腺癌的方法,对于肿瘤的区域性浸润甚至可切除门静脉及肠系膜上静脉,作者采用经侧后腹膜途径的扩大根治性手术治疗胰腺癌,并对其中53例胰头癌病例资料进行统计处理,初步评价本术式的疗效。 本术式的关键在于经侧后腹膜途径彻底切除腹腔干及肠系膜上动脉周围的淋巴结和神经丛,充分的淋巴管道切除包括自胰周和肾上腺到腹主动脉分叉处全部腹膜后淋巴结     

胰周神经离断术对晚期胰腺癌的治疗

目的探讨胰周神经离断术在晚期胰腺癌病人的应用价值。方法收集自1992年10月～1998年8月间共42例不能切除的胰腺癌病例,行剖腹探查或内引流术24例,剖腹探查或内引流术加胰周神经离断术18例,分别观察这些病例术后腹疼变化、饮食情况和术后存活时间。结果前者无一例外地在术后短期内出现腹疼,且愈益加重,后期均需要强效镇疼药止疼,也因疼痛影响了进食,术后存活2～11个月,平均5±2.32个月;后者有7例病人出现腹疼,4例病人需要强效镇疼药止疼,术后短期内饮食状况明显改善,术后存活3～18个月,平均7±4.06个月。结论胰周神经离断术作为晚期胰腺癌的一种辅助治疗措施,方法简便、效果确实,不但能够有效地缓解疼痛,而且可以改善症状、延长存活时间。     

颈浅丛神经阻滞用于甲状腺手术的临床观察

目的 观察双侧颈浅丛神经阻滞麻醉用于甲状腺手术的麻醉效果。方法对甲状腺手术113例患者行双侧颈浅丛神经阻滞麻醉，术前、术中静脉辅助一定量氟芬合剂。结果113例双侧颈浅丛神经阻滞麻醉总的麻醉有效率为95．6％，其中阻滞效果优者75例，良者23例，可者10例，差者5例，5例阻滞效果差者术中改用其它麻醉方法完成手术。副作用：本组所有病例中有1例发生局麻药中毒反应，1例出现膈神经阻滞，2例出现喉返神经麻痹。结论双侧颈浅丛神经阻滞麻醉用于甲状腺手术是安全可靠的麻醉方法。     

A comparison of two invasive techniques in the management of intractable pain due to inoperable pancreatic cancer: neurolytic celiac plexus block and videothoracoscopic splanchnicectomy

Background and aimsPancreatic cancer is characterized by a constant deterioration in quality of life, excruciating pain and progressive cachexia. The aim of this study was to compare the effectiveness of two invasive methods of pain treatment in these patients: neurolytic coeliac plexus block (NCPB) and videothoracoscopic splanchnicectomy (VSPL) to a conservatively treated control group concerning pain, quality of life and opiates' consumption.Patients and methodsFifty nine patients suffering from pain due to inoperable pancreatic cancer were treated invasively with NCPB (N=35) or VSPL (N=24) in two non-randomised, prospective, case-controlled protocols. Intensity of pain (VAS-pain), quality of life (FACIT and QLQ C30) and opioid intake were compared between the groups and to a control group of patients treated conservatively before the procedure and after 2 and 8 weeks of follow-up. The analysis was performed retrospectively using meta-analysis statistics.ResultsBoth methods of invasive pain treatment resulted in significant reduction of pain (VSPL effect size=11.27, NCPB effect size=7.29) and fatigue (effect sizes, respectively, 1.23 and 3.37). NCPB improved also significantly physical, emotional and social well-being (effect sizes, respectively, 2.37, 4.13 and 7.51) which was not observed after VSPL. No influence on ailments characteristic for the disease was demonstrated. Mean daily opioid consumption was significantly decreased after both procedures. There was no perioperative mortality and no major morbidity.ConclusionBoth NCPB and VSPL provide significant reduction of pain and improvement of quality of life in inoperable pancreatic cancer patients. They present rather similar efficacy, but lower invasiveness of NCPB, in combination with its more positive effect on quality of life, pre-disposes it as being the preferred method.     

Pain mechanisms involved and outcome in advanced cancer patients with possible indications for celiac plexus block and superior hypogastric plexus block

AIMS AND BACKGROUND: There is controversy about the role of neurolytic sympathetic blocks in advanced cancer, when pain syndromes may assume other characteristics, with a possible involvement of structures other than visceral. The aim of the present study was to assess the pain characteristics and the analgesic response of a consecutive sample of home care patients with pancreatic and pelvic pain, which would have possible indications for a celiac plexus block and a superior hypogastric block, respectively. METHODS: From January 1999 to December 1999, 400 consecutive advanced cancer patients were surveyed for a prospective longitudinal survey. We considered only patients who had pancreatic cancer or pelvic cancer with pain. RESULTS: Thirty-six patients were surveyed: 22 patients had pelvic cancers and 14 had pancreatic cancer. Patients with pelvic cancers showed a longer survival than those with pancreatic cancer (P = 0.019). Patients with pelvic cancers more frequently showed a neuropathic component associated with a visceral or somatic mechanism than patients with pain due to pancreatic cancer (P = 0.019). When the pain mechanism was taken into consideration, patients with pelvic cancers with a neuropathic component showed worse pain relief than patients with pain due to pancreatic cancer (P = 0.040). CONCLUSIONS: Sympathetic procedures for pain conditions due to pancreatic and pelvic cancers should be intended as adjuvant techniques to reduce the analgesic consumption, and not as a panacea, given that multiple pain mechanisms are often involved because progression of disease is able to change the underlying pain mechanisms. Pancreatic pain seems to maintain visceral characteristics amenable to sympathetic block more than pain due to pelvic cancer.     

The evolving role of interventional pain management in oncology

Patients with cancer frequently experience chronic pain, especially in the terminal phases of illness. Fortunately, most patients (90%) can achieve good pain relief using standard and adjuvant analgesics. For those patients who experience severe pain resistant to traditional analgesic therapies, interventional pain management techniques often provide welcome pain relief. The use of neurolytic substances has been used for many decades but has found a niche in the treatment of pain related to abdominal and pelvic cancers. Simple, percutaneous injections of alcohol or phenol can provide much needed pain relief for patients with pancreatic, colon, or gynecologic cancers. The percutaneous placement of catheters for the chronic infusion of spinal analgesics can provide pain relief for virtually any part of the body. Internal or external infusion pumps can be well managed at home, improving quality of life. The physician treating the pain should be aware of these and other interventional pain management techniques to provide alternative therapies to patients with refractory cancer pain.     

Pain management of the oncologic patient

After the first 5 years of life, cancer is one of the three most common causes of death. Most investigations of cancer pain have shown that 50-70% of patients suffer needlessly. Pain may be due to the tumor or a co-existant benign pain syndrome. Methods of pain management include: 1) neurolytic blockade: stellate ganglion block, celiac plexus block, lumbar sympathetic block, epidural phenol, subarachnoid neurolysis; and 2) non-pharmacologic methods: radiofrequency thermocoagulation lumbar sympathectomy, transcutaneous nerve stimulation (TENS), dorsal column stimulation (DCS). In summary, we utilize every possible combination of therapeutic modalities for cancer pain management. With so many safe procedures available, we encourage the primary physician to refer patients early in their disease process. Neurolytic procedures should be performed prior to initiation of high dose narcotic therapy, radiation, chemotherapy, and surgery when possible.     

基于循证医学的临床常用癌痛微创介入技术

癌痛严重影响肿瘤患者的生命质量,临床上仍有一部分患者药物治疗后未能获得满意的疼痛缓解。微创介入在其中发挥了重要意义。根据循证医学证据,建议使用腹腔神经丛或内脏神经阻滞治疗上腹部癌痛、上腹下丛阻滞治疗骨盆肿瘤所致内脏痛、经皮椎体成形或椎体后凸成形术治疗肿瘤所致椎体疼痛。肋间神经阻滞治疗胸壁癌痛、奇神经节及鞍区阻滞治疗骨盆肿瘤所致会阴部癌痛只有在临床研究中或是无有效缓解手段时作为一种体恤性治疗使用。     

Percutaneous computed tomography guided cryoablation of the celiac plexus as an alternative treatment for intractable pain caused by pancreatic cancer

Computed Tomography (CT)-guided percutaneous cryoablation was performed in a 43-year-old patient with intractable epigastric abdominal pain caused by advanced adenocarcinoma of the pancreas and extensive celiac trunk involvement. Initial treatment with celiac plexus nerve neurolysis using local ethanol injection was unsuccessful. A 17-gauge 17-cm cryoablation probe (Galil Medical Inc. Plymouth Meeting, PA) was placed into the expected location of the celiac plexus through a left paraspinal approach under CT guidance and two cycles of freeze-thaw were performed. Patient's pain decreased from 10 of 10 (subjective pain scoring using a visual analog scale; VAS; 0-10) to 3. No post-procedure complication was observed. His pain has remained stable after 6 months of follow up. Percutaneous cryoablation appears to be an effective alternative to neurolytic celiac plexus block for palliative treatment of celiac plexus involvement. Further study with larger number of patients is needed to evaluate the safety and efficacy.     

Evidence report on the treatment of pain in cancer patients

Pain associated with cancer is of widespread concern. We conducted a systematic review to evaluate the best available evidence on the efficacy of treatments of cancer-related pain. The sources used were MEDLINE, CancerLit, and the Cochrane Library from 1966 through April 2001, as well as bibliographies of meta-analyses and review articles. We selected randomized controlled trials (RCTs) reporting on cancer pain treatment. We recorded the study characteristics, patient and disease characteristics, treatment comparisons, outcome measures, and results. The methodological quality, applicability, and magnitude of treatment effect for each study were graded. We screened 24 822 titles and selected 213 RCTs to address specific questions. RCTs of cancer pain control often enroll few subjects, have low methodological quality, offer little detail about pain characteristics and mechanisms, and involve heterogeneous interventions and outcomes. Nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, selected adjuvant medications, bisphosphonates, radionuclides, external radiation, palliative chemotherapy, and neurolytic celiac plexus block are each efficacious in relieving cancer pain. However, the retrieved RCTs indicate no difference in the analgesic efficacies of NSAIDs versus other NSAIDs, NSAIDs plus opioids versus NSAIDs alone, or NSAIDs versus opioids. Studies of adjuvant medications and behavioral therapies are too few and varied to synthesize. RCTs of the analgesic effects of corticosteroids were not retrieved in our review, although we did conduct supplemental evidence reviews concerning pain control in oral mucositis, acute herpes zoster, or postherpetic neuralgia. RCTs confirm the efficacy of diverse interventions in relieving cancer pain. The optimal initial and subsequent sequence of choices among analgesic drug types cannot be inferred from the retrieved RCTs. Patient preferences, the relative efficacy of different routes of drug administration, the side effects of analgesics, and the relation of pain control to quality of life have not been studied comprehensively. The quantity and quality of scientific evidence on cancer pain relief compare unfavorably with evidence related to treatment of other high-impact conditions, including cancer itself. One contributor to this gap is the heterogeneity of outcomes instruments employed: of 218 retrieved trials, there were 125 distinct pain outcomes assessed. In the current era of patient-centered care, improving the quality and combinability of trials on cancer pain relief should be a high research priority.