Has the analgesic efficacy of neurolytic celiac plexus block been demonstrated in pancreatic cancer pain?

Cancer of the pancreas is rising in incidence and will strike 27,000 Americans this year. There is no curative therapy for most patients, so palliation of symptoms should be the prime concern. Severe pain is very common, and often difficult to treat. Neurolytic celiac plexus block (NCPB) is claimed by some to be the most effective way to treat pancreatic cancer pain (PCP), yet only a minority of patients undergo this procedure. We have reviewed the literature on NCPB to determine if it has been adequately evaluated in the management of PCP. There have been 15 published series since 1964 on NCPB for PCP. A total of 480 patients with cancer of the pancreas were reported; at least a satisfactory response to NCPB was reported in 418 (87%). We found major deficiencies in these reports. None described the pre-NCPB analgesic history. Post-NCPB data were also limited. No information was given concerning post-NCPB analgesic dosages, and only 4 series stated that most patients did not require opiates. Information on whether NCPB was effective until death was lacking or incomplete in 12 series. Many claimed additional benefits of NCPB such as decreased nausea, decreased constipation, and increased appetite, but none provided any data to support these claims. We conclude that the data available on NCPB for PCP are insufficient to judge for efficacy, long-term morbidity, or cost effectiveness, and rigorous evaluation of the technique is required.     

CT引导下腹腔神经丛毁损术治疗胰腺癌疼痛的护理配合

本文结合32例CT引导下腹腔神经毁损治疗胰腺癌疼痛患者的护理经验,总结神经毁损治疗中的护理配合流程。32例患者在CT引导下行腹腔神经丛毁损术效果显著,治疗过程顺利,未出现并发症,治疗后患者平均疼痛视觉模拟评分(VAS)由治疗前的(9.54±2.38)分下降到(1.26±0.36)分,治疗后1周随访患者平均VAS评分为(3.35±0.72)分。护理配合主要包括治疗前协助麻醉医生评估,仪器设备、药品及物品的准备,治疗空间的合理布局和优化;治疗中协助体位的摆放,对患者的监测、阻滞效果的评估;治疗后对患者的宣教、心理护理以及并发症的观察等,良好的护理配合能够确保神经毁损治疗的安全性和高效性。     

Improving palliation in pancreatic cancer: intraoperative celiac plexus block for pain relief.

Most patients with pancreatic carcinoma are not curable. Surgical palliation of obstructive jaundice and gastric outlet obstruction leaves many patients with severe pain from pancreatic carcinoma. Anesthesiologists have drawn increasing attention to the successful use of postoperative percutaneous celiac plexus block for the treatment of pancreatic pain. Ironically, little attention has been paid to celiac plexus block during laparotomy. We reviewed the cases of 12 patients with pancreatic carcinoma and severe abdominal pain who were treated surgically. All patients had operative celiac plexus block with absolute alcohol at the time of exploratory laparotomy for biliary bypass, gastroenterostomy, or tumor biopsy. Complete postoperative pain relief was obtained in 10 of the 12 patients; two had only partial relief. No operative complications were related to celiac plexus block; one patient died postoperatively of pneumonia. Average postoperative hospital stay was 13 days and average postoperative survival was 3 1/2 months. Most patients had excellent pain relief for at least 2 months or until death. Because most patients treated surgically for pancreatic carcinoma are receiving only palliation with biliary bypass or gastroenterostomy, surgeons should pay increased attention to pain relief. Operative celiac plexus block is easy, safe, and highly effective in relieving the agonizing pain of pancreatic carcinoma.     

CT引导下腹腔神经丛毁损性阻滞治疗顽固性胰腺癌痛的临床观察

目的：观察CT引导下腹腔神经丛毁损性阻滞对顽固性胰腺癌痛的镇痛效果、并发症及对患者生活质量的影响。方法：46例顽固性胰腺癌症疼痛患者，在CT引导监视下经背侧入路经皮穿刺，行腹腔神经丛无水酒精阻滞治疗。结果：治疗后1周内全部患者疼痛减轻或消失。在治疗后第7、14、30、60、90天，患者的疼痛评分、疼痛缓解率、生活质量均明显改善，大多数患者临终前无痛或仅轻度疼痛。治疗过程中和治疗后未发生严重并发症。结论：CT引导下腹腔神经丛阻滞治疗顽固性胰腺癌痛的疗效确切，安全性高。     

Comparison of epidural butamben to celiac plexus neurolytic block for the treatment of the pain of pancreatic cancer

OBJECTIVE: To compare pain relief in metastatic pancreatic cancer patients between neurolytic celiac plexus block (NCPB) and epidural 5% butamben suspension (EBS), a material-based delivery system of a local anesthetic that produces a long-lasting differential nerve block. DESIGN: Open-label patient-selected parallel groups. SETTING: Urban tertiary care medical center. PATIENTS: Twenty-four adult patients with metastatic pancreatic cancer experiencing pain uncontrolled by systemic opioids who were referred to a multidisciplinary pain clinic for interventional therapy. INTERVENTIONS: Antecrural NCPB-block with ethanol and epidural 5% butamben suspension injections. MEASURES: Subjective global pain relief assessments on a 0-100% scale were made weekly for 4 weeks and then monthly. Change in opioid use postintervention. RESULTS: Eight patients had a single NCPB and three patients had two NCPB. Four of the former and two of the latter had successful pain relief defined to be a more than 75% reduction in pain when compared with pretreatment maintained for more than 4 weeks or until death (if less than 4 weeks). Thirteen patients received EBS in divided doses. Eleven patients received a cumulative EBS dose of 5 grams, one patient received a cumulative EBS dose of 2.5 grams, and one patient received a cumulative EBS dose of 8.75 grams. Nine of the eleven patients and each of the other two patients had successful pain relief. The overall incidence (85% EBS vs. 55% NCPB), the duration of successful pain relief, and the percent reduction in opioid use did not differ between the two groups. There were no serious complications. CONCLUSION: EBS appears to be a safe and effective alternative to NCPB in the treatment of pancreatic cancer pain.     

CT引导内脏与腹腔神经丛阻滞治疗上腹癌痛的比较

目的：观察CT引导下内脏与腹腔神经丛毁损性阻滞对上腹癌痛的镇痛效果比较。方法：48例顽固性上腹部癌症重度疼痛患者，随机分两组，在CT引导下分别行腹腔神经丛（Ｆ组）或内脏神经丛（Ｎ组）无水乙醇毁损阻滞治疗。观察两组镇痛效果、疼痛缓解程度及不良反应。结果：治疗后即刻全部患者疼痛减轻或消失。在治疗后第3、7、15、30、60、90天，患者的疼痛评分、疼痛程度均明显改善，两组间无显著差异，治疗过程中和治疗后未发生严重并发症。结论：内脏神经丛阻滞可取得与腹腔神经丛阻滞一致的效应，操作方便、疗效确切、安全性高，可供临床选择。     

内镜超声引导下腹腔神经丛阻滞联合局部化疗在胰腺癌长期镇痛治疗中的研究

目的评价内镜超声引导下腹腔神经丛阻滞联合局部注射化疗对进展期胰腺癌患者的长期镇痛作用。方法选择无手术指征进展期胰腺癌患者23例，在内镜超声引导下行腹腔神经丛阻滞联合局部注射化疗，治疗后随访20周，通过视觉疼痛类比量表（VAS）评分、每周镇痛药注射次数、肿瘤最大径等指标评价治疗效果。结果23例胰腺癌患者均成功进行了腹腔神经丛阻滞和局部化疗，未出现严重并发症。治疗后患者疼痛明显缓解，第4周视觉疼痛类比量表评分下降69．1％（P〈0．05），而治疗后第20周仍下降52．9％。疼痛的缓解与肿瘤的部位及大小无关。镇痛药物的应用次数在治疗前后差异无显著性意义。局部化疗后肿瘤最大径无明显变化。结论内镜超声引导下腹腔神经丛阻滞联合局部化疗控制进展期胰腺癌疼痛长期疗效确切，安全性好。     

CT引导下无水乙醇阻滞双侧腹腔神经丛治疗腹部癌性疼痛的价值

目的探讨CT引导下腹腔神经丛无水乙醇阻滞治疗腹部癌性疼痛的临床价值。方法对无法切除和无法有效止痛的12例晚期上腹部癌症患者，CT引导下应用无水乙醇10～15ml实施双侧腹腔神经丛阻滞，评价其止痛效果、不良反应及生存质量等。结果7例疼痛完全消失，3例仅口服或肌肉注射曲马朵即能止痛，有效率83．3％；6例无或轻微疼痛维持3个月，1例维持4．3个月。患者精神状态、饮食和睡眠均明显好转。结论CT引导下无水乙醇阻滞双侧腹腔神经丛可较有效地解除上腹部顽固性癌性疼痛。     

双针会师法腹腔神经丛阻滞的程序化护理

目的 总结对双针会师法腹腔神经丛阻滞治疗癌性腹痛的护理配合经验.方法 结合CT引导下双针会师法腹腔神经丛阻滞治疗癌性腹痛的临床护理,分析该技术需护理配合的关键环节,初步制订相应的护理配合常规.结果 除1例患者不能耐受俯卧位放弃治疗外,其余38例均成功实施了双针会师法腹腔神经丛阻滞治疗,术后31例完全停服止痛药.早期有3例漏做碘过敏试验,4例输液硬针头"跑针";术后23例低血压,11例有"醉酒"表现,12例出现腹泻,其中6例弄脏了衣、被.结论 CT引导下双针会师法腹腔神经丛阻滞治疗癌性腹痛效果确切,充分的术前护理准备可使阻滞操作更流畅,良好的术中、术后护理配合减少、减轻术后低血压、醉酒、腹泻等并发症.     

Endoscopic ultrasound-guided injection: a close look at celiac plexus block and celiac plexus neurolysis.

This article describes the use of interventional endoscopic ultrasonography, namely, endoscopic ultrasound-guided injection therapy for the treatment of pain. With the assistance of endoscopic ultrasonography, it is now possible to safely inject the celiac plexus with pharmacological agents to provide analgesia in painful pancreatic conditions such as cancer and chronic pancreatitis. The indications for celiac plexus injection, the procedure, required accessories, complications, and nursing care are discussed.     

Celiac plexus block in cancer pain management

The neurolytic celiac plexus block (NCPB) has been recommended for pain relief in patients with upper abdominal cancer by the WHO Cancer Pain Relief Program. In this article, we review the indications, techniques, and adverse effects of NCPB based on the previous findings in the literature and our own experience of 142 NCPBs during the past 11 years. No well-validated indication criteria for the NCPB have been available from invasive trials or non-invasive pain evaluations. Thus, the procedure has been employed using comprehensive pain assessment. Several modified approaches have been described for NCPB with differences in the target space where the alcohol is injected (precrural and retrocrural) and the insertion route of the needle (posterolateral and transdiscal). We have used the retrocrural transdiscal approach because of its simplicity and safety. The efficacy of the resultant pain relief does not differ among these techniques. Therefore, whether a distinction exists between blocks of the celiac plexus and those of the splanchnic nerves is controversial. The term "peri-aortic nerve block" may better describe the feature of this neurolytic intervention. The noteworthy adverse effects of alcoholic neurolysis include regional pain, hypotension, diarrhea, hypoxemia, and acute alcoholic intoxication. Most of them are transient and controllable. The diarrhea may counteract the morphine-induced constipation. NCPB relieves visceral pain in upper abdominal cancer with no serious adverse effects. We recommend this procedure to improve the quality of life of the patients suffering from abdominal cancer pain.     

超声引导下腹腔神经丛毁损治疗上腹部癌痛的安全性和有效性

目的 评估超声引导下腹腔神经丛毁损（CPN）治疗上腹部癌痛的安全性和有效性。方法 对15例进展性上腹部癌痛患者行超声引导下CPN,利用视觉模拟量表（VAS）评分进行评估,记录CPN治疗前和治疗后即刻、1天、1周、1个月、3个月患者疼痛程度,并进行统计学分析。结果 2例因治疗前评估无安全穿刺路径而被剔除。成功实施超声引导下CPN治疗13例。治疗后13例患者VAS评分明显低于治疗前（P<0.05）。治疗过程中无严重并发症发生。3例发生穿刺部位疼痛,24 h后缓解;2例肠蠕动增快而出现腹泻;1例出现恶心、呕吐;1例术后出现低血压。结论 超声引导下CPN安全有效,可作为微创治疗上腹部癌痛的方法之一。     

不同剂量无水乙醇腹腔神经丛阻滞治疗上腹癌痛的疗效观察

目的 观察不同剂量无水乙醇腹腔神经丛阻滞术治疗晚期上腹部癌痛患者的疗效。方法 选取45例保守治疗无效的晚期上腹部癌痛患者,并随机分为15 ml无水乙醇组（A组）、20 ml无水乙醇组（B组）和25 ml无水乙醇组（C组）,每组15例,在CT引导下经前腹壁或背侧入路行经皮腹腔神经丛阻滞术,止痛效果分为0~Ⅲ级,分别于术后1个月、3个月时评价止痛效果。结果 随访观察3个月,1个月、3个月时20 ml和25 ml无水乙醇组有效率显著均高于15 ml无水乙醇组（P均<0.01）;而20 ml无水乙醇组与25 ml无水乙醇组有效率差异无统计学意义（P>0.05）,但25 ml无水乙醇组术后疼痛的患者数明显高于20 ml组。20 ml无水乙醇组术后1个月的有效率为93.33%（14/15）,3个月有效率为73.33%（11/15）,均未发生严重并发症。3组患者术后1个月与术后3个月疗效差异无统计学意义（P均>0.05）。结论 用20 ml无水乙醇腹腔神经丛阻滞治疗晚期上腹部癌痛是一种安全、有效的方法。     

Celiac plexus block for pancreatic cancer pain: factors influencing pain, symptoms and quality of life

Neurolytic celiac plexus block (NCPB) is claimed to be an effective method of pain control for pancreatic cancer pain. However, the factors that may influence long-term analgesia, adverse effects, and quality of life after performing NCPB have never been determined. In a prospective multicenter study, 22 patients who underwent NCPB were followed until death. Numerous parameters other than pain and symptom intensity were evaluated, including age, gender, initial site of cancer, sites of pain, possible peritoneal involvement, technique, and oncologic interventions. Indices were calculated to determine the opioid consumption ratio (EAS) and the trend of opioid escalation (OEI). NCPB was effective in reducing opioid consumption and gastrointestinal adverse effects for at least 4 weeks. In the last four weeks prior to death, there was the typical trend of increasing symptom intensity common to the terminal cancer population. None of the factors studied influenced the analgesic effectiveness of NPCB. NPCB, performed by skilled clinicians, regardless of the technique chosen, is a safe and useful means that should be considered as an adjuvant to common analgesic regimens at any stage, as it may allow the reduction of the visceral component of pancreatic pain that may prevail in certain phases of the illness. The analgesic and symptomatic effect of NCPB is presumably advantageous for about four weeks. A possible factor interfering with long-term outcome includes the capacity of cancer to involve the celiac axis, which can distort the anatomy and prevent neurolytic spread, or modify the pain mechanisms. Outcomes are strongly based on individual variation.     

超声引导腹腔神经节阻滞治疗胰腺癌疼痛

目的 探讨超声介入腹腔神经节阻滞对胰腺癌患者的止痛作用。方法 超声引导细针穿刺于腹腔动脉干旁注入１％普鲁卡因或乙醇行腹腔神经节阻滞；采用视觉模拟评分法（ＶＡＳ）对治疗前后的疼痛强度进行动态随访。结果 穿刺成功率９６％，无严重并发症。单纯普鲁卡因阻滞疼痛缓解时间只能维持５ｄ，无水乙醇阻滞在术后３ｄＶＡＳ评分与术前有非常显著性差异（Ｐ〈０．０１），并能维持较长时间。结论 超声能为腹腔神经节阻滞提供准确     

Monitoring of celiac plexus block in chronic pancreatitis

Pharmacological, percutaneous celiac plexus blockade is often inefficient in the treatment of pain in chronic pancreatitis. Lack of efficiency could be due to incomplete denervation of the plexus; however, a method for measuring the completeness of celiac plexus blockade is not yet available. We have, therefore, monitored the physiological completeness of pharmacological percutaneous celiac blockade with 40 ml 25% ethanol by measuring the effect of posture on heart rate, blood pressure, hepato-splanchnic vascular resistance, and pancreatic hormone concentrations before and after celiac plexus block in 6 patients with chronic pancreatitis. Blood pressure decreased and heart rate increased after the block (P less than 0.025), whereas no significant change was found in hepato-splanchnic vascular resistance nor in the change of these parameters during transition from the supine to standing position. Pancreatic hormones (C-peptide, free insulin, glucagon, pancreatic polypeptide and somatostatin) did not change in response to standing, either before or after the block. The cardiovascular variables were normalized the day after the block, and all the patients were in their habitual state regarding pain after 1 week. In conclusion, pancreatic hormone concentrations in response to standing are not useful for monitoring celiac plexus block, whereas heart rate, blood pressure and hepato-splanchnic blood flow may yield useful information. From such measurements it was concluded that permanent denervation of the celiac plexus was not achieved in our patients after injection of 40 ml 25% ethanol.     

Coeliac plexus block for upper abdominal cancer pain

The use of coeliac plexus block (CPB) to relieve intractable pain owing to upper abdominal malignancy is well established. Significant relief of pain is reported in 70-90% of patients, allowing a reduction in opioid use and in the occurrence of opioid-related side effects (Eisenberg et al, 1995; Prasanna, 1996). Duration of relief varies, but the majority of patients experience relatively pain-free deaths (Patt, 1993). CPB is a relatively safe procedure, and although it is associated with common adverse effects such as diarrhoea, hypotension and local pain, these are mostly transient. However, severe complications, including paraplegia, have been reported. When CPB is performed, nurses should be aware of these potential complications and their management.     

Arteriovenous differences of blood alcohol concentrations after celiac plexus block.

After a celiac plexus block with ethyl alcohol, patients sometimes complain of symptoms of alcohol intoxication. We studied the consecutive changes of arterial and venous blood alcohol concentrations in 11 patients and investigated whether an arteriovenous difference exists. We performed a celiac plexus block with 10 ml absolute ethyl alcohol. The sampling sites were radial artery and internal jugular vein. Blood samples were collected at 0, 5, 10, 15, 30, 60, 120, 240 and 480 minutes after the block. The maximum level was reached 15 minutes after injection in both arterial and venous blood, 29.9 +/- 19.4 and 27.7 +/- 21.8 mg/dl (means +/- SD), respectively. Arteriovenous differences were observed 5 and 10 minutes after ethyl alcohol injection (p less than 0.01). There was a significant negative correlation between the ratio of arteriovenous differences to venous sampling and the time elapsed after the block (r = 0.41, p less than 0.01).     

Celiac plexus block in pancreatic neuroendocrine tumors

Pancreatic neuroendocrine tumors (pNETs), an uncommon finding, are distinct from pancreatic carcinomas. When pNETs are unresectable and progressive, visceral pain often presents and is challenging to treat. Opioids commonly used for pain control are difficult to implement in this setting because of adverse side effects such as constipation. Neurolytic celiac plexus blocks are indicated in the treatment of visceral pain related to upper abdominal malignancies when opioid analgesia does not provide adequate relief or is contraindicated because of side effects. As a result, this article presents a brief review of pNETs, celiac plexus blocks, associated side effects, and contraindications along with related literature in the context of a case study.