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。     

未能切除胰腺癌患者术中NCPB的临床意义

目的 研究术中腹腔神经丛阻滞对无法切除胰腺癌患者的镇痛疗效及并发症。方法 41例患者经腹行直视下的腹腔神经丛阻滞，每人次注射无水酒精20－50ml，同时行胆肠转流或／和胃肠转流，部分患者行区域动脉化疗。结果 腹腔神经丛阻滞后6个月内或已死亡者中有32例患者疼痛完全缓解，4例明显减轻，5例无明显效果。38例术中出现血压下降，15例术后腹泻，结论 术中直视下经腹行无水酒精腹腔神经丛阻滞对缓解未能切除胰腺癌患者的疼痛具有明显的镇痛效果。     

影像引导下腹腔神经丛毁损术的研究进展

腹腔神经丛毁损术(NCPB)常用于治疗上腹部癌症患者的疼痛，其原理是对腹腔神经丛注射神经破坏药以破坏神经，进而达到缓解疼痛的目的。由于腹腔神经丛解剖位置的特殊性，如何精准地注射神经破坏药以提高毁损的成功率及降低并发症的发生率是该领域的研究热点。随着影像技术的不断发展，NCPB的治疗方式及疗效不断提高。本文旨在探讨影像引导下NCPB治疗上腹部顽固性癌痛的研究进展。     

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。     

腹腔神经丛阻滞治疗晚期上腹部癌痛的临床观察

近年来，应用腹腔神经丛阻滞(neurlytiec eliac plexus block，NCPB)治疗晚期上腹部癌痛国外已有报道，我院对40例晚期上腹部癌症病人进行了腹腔神经丛阻滞(NCPB)治疗，取得了较好疗效，现报告如下：     

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.     

腹部恶性肿瘤腹腔神经丛封闭术的改进

腹部恶性肿瘤患者,在常规止痛效果不佳时,常行腹腔神经丛封闭以止痛。古典腹腔神经丛封闭术(CPN)是在 X 线透视和触摸指引下,在腹主动脉两侧分别进行注射麻醉剂。近     

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。     

不同入路CT导引下腹腔神经丛毁损术治疗上腹部癌性疼痛的疗效观察

目的探讨不同入路CT导引下腹腔神经丛毁损术治疗上腹部癌性疼痛的临床疗效。方法选取2013年4月至2015年7月间宝鸡市中医医院收治的90例上腹部癌性疼痛患者,采用随机数表法分为前入路组和后入路组,每组45例。所有患者均行CT导引下腹腔神经丛毁损术,前入路组患者采用前入路法,后入路组患者采用后入路法,观察两组患者术后临床表现、手术成功率、治疗效果及并发症状况。结果前入路法与后入路法手术成功率均为100.0%,两组患者术后均有并发症表现,经适当治疗后痊愈,无严重并发症发生。前入路组患者临床短期(<1个月)显效率为70.1%,总有效率为96.3%,后入路组患者短期显效率为63.4%,总有效率为92.5%;前入路组长期(>3个月)显效率为50.3%,总有效率为90.1%,后入路组长期显效率为44.7%,总有效率为81.6%,前入路组患者临床短期与长期显效率和总有效率均较高,差异均有统计学意义(均P<0.05)。结论经前入路法CT导引下穿刺腹腔神经丛毁损术治疗癌性疼痛临床疗效较理想,值得推广。     

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.     

Ensuring quality cancer care: a follow-up review of the Institute of Medicine's 10 recommendations for improving the quality of cancer care in America

Responding to growing concerns regarding the safety, quality, and efficacy of cancer care in the United States, the Institute of Medicine (IOM) of the National Academy of Sciences commissioned a comprehensive review of cancer care delivery in the US health care system in the late 1990s. The National Cancer Policy Board (NCPB), a 20-member board with broad representation, performed this review. In its review, the NCPB focused on the state of cancer care delivery at that time, its shortcomings, and ways to measure and improve the quality of cancer care. The NCPB described an ideal cancer care system in which patients would have equitable access to coordinated, guideline-based care and novel therapies throughout the course of their disease. In 1999, the IOM published the results of this review in its influential report, Ensuring Quality Cancer Care. The report outlined 10 recommendations, which, when implemented, would: 1) improve the quality of cancer care, 2) increase the current understanding of quality cancer care, and 3) reduce or eliminate access barriers to quality cancer care. Despite the fervor generated by this report, there are lingering doubts regarding the safety and quality of cancer care in the United States today. Increased awareness of medical errors and barriers to quality care, coupled with escalating health care costs, has prompted national efforts to reform the health care system. These efforts by health care providers and policymakers should bridge the gap between the ideal state described in Ensuring Quality Cancer Care and the current state of cancer care in the United States.     

200例癌症患者自身因素对癌痛治疗影响的调查分析

目的：了解癌症患者对疼痛本身及疼痛治疗的认识,探讨癌症患者自身相关因素对癌痛治疗的影响。方法：应用疼痛量表对患者疼痛程度进行分类,采用自行设计的癌症患者疼痛情况认识调查问卷进行问卷调查。结果：共完成200例癌症患者的调查,重度疼痛者49例,中度疼痛者38例,轻度疼痛者12例,无疼痛者101例,疼痛患者中有94例患者正在进行止痛药物治疗。对疼痛的错误认识,没有如实汇报疼痛,对阿片类药物的成瘾顾虑,担心阿片类药物的不良反应,不正确的服药方法,以及经济压力是影响癌症患者疼痛治疗的障碍因素。结论：癌症患者自身的障碍因素影响癌性疼痛的治疗的依从性。     

165例癌痛患者癌症相关神经病理性疼痛的诊疗现状调查

目的 通过调查癌症疼痛的患者中神经病理性疼痛的发生比例及其诊疗现状,了解临床医生对于神经病理性疼痛的认知情况,从而进一步规范难治性癌痛的临床诊疗。方法 本研究为非干预性、开放性、观察性的临床研究。调查对象为2010年10月—2012年3月华中科技大学同济医学院附属同济医院肿瘤科住院及门诊病人,主诉有疼痛者。共发放调查问卷206份,回收问卷206份,按照事先设定的入选和剔除标准,共收集符合标准的癌症疼痛患者165例(80.10%)。使用NRS、LANSS和IDPain量表评估165名患者的疼痛程度和疼痛性质。记录患者临床相关镇痛药物的用药情况和用药不良反应。结果 癌痛患者中癌症相关神经病理性疼痛为103例,发生比例为62.42%。癌症相关神经病理性疼痛的发生比例与性别、年龄因素无关。疼痛程度严重者,发生神经病理性疼痛的比例更高。54例(52.43%)患者在使用常规镇痛药物的同时合并使用了针对神经病理性疼痛的辅助用药,不良反应发生率低。结论 癌症相关神经病理性疼痛已经引起了一部分临床医生的重视。针对神经病理性疼痛的辅助镇痛药物对神经病理性疼痛疗效肯定,副作用小,可以大大提高疼痛的控制率和缓解率。     

310例中重度癌痛患者临床特征分析

  目的   通过对伴有中重度癌痛患者的临床特征进行前瞻、开放性横断面评估,旨在了解癌痛发病的总体特征、提高诊治水平。   方法   选取2012年12月至2013年12月因中重度癌痛首次收治入院的恶性肿瘤患者,于入院当天评估疼痛强度、部位、性质、诱发缓解因素,并进行病理生理学分类。   结果   310例患者完成疼痛评估,包括中度痛101例（32.58%）,重度痛209例（67.42%）。肿瘤来源前5位依次为:肺癌102例（32.90%）、结直肠癌30例（9.68%）、胰腺癌27例（8.71%）、乳腺癌24例（7.74%）和胃癌20例（6.54%）。310例患者共报告533处疼痛,常见为腰部132例、上腹125例、胸部88例、下肢71例,其次颈肩上肢47例、盆腔33例、会阴区23例、头面部14例,胰腺癌疼痛部位中90.63%与原发肿瘤部位一致。病理生理学分类中骨痛145例（27.20%）、内脏痛138例（25.89%）、软组织痛126例（23.64%）和神经病理性疼痛124例（23.27%）,胰腺癌患者内脏痛的发生率为92.59%。   结论   中重度癌痛发生于各种常见恶性肿瘤,以肺癌来源最为多见,胰腺癌痛主要表现为与原发肿瘤部位一致的内脏痛,其他肿瘤疼痛特征没有明显特异性。      

癌痛管理相关进展及全球差异性

在全球范围内,癌痛仍然是一个重要的临床问题。癌症引发疼痛的机制复杂、多种多样。伴随癌痛的生物学进展,越来越多的人认为癌痛是肿瘤细胞与宿主免疫、周围神经系统与中枢神经系统之间的交叉效应所致的结果。癌痛管理是控制疼痛、提高病人生活质量的不可或缺的治疗手段,癌痛治疗的选择也应根据不同个体量身定制。阿片类药物仍然是治疗癌痛最有效的药物,而神经调节作为治疗神经性癌痛的新兴技术也发展迅速。当前,全球范围内镇痛药物的可用性存在差异,中低收入国家明显低于高收入国家。在未来的几十年,全球癌症负担将逐年加重,因此提高全社会的癌痛管理意识迫在眉睫。     

Cancer pain management among underserved minority outpatients: perceived needs and barriers to optimal control

BACKGROUND: Minority patients with cancer are at risk for undertreatment of cancer-related pain. Most studies of patient-related barriers to pain control have surveyed primarily non-Hispanic Caucasian patients. The purpose of the current study was to explore barriers to optimal pain management among African-American and Hispanic patients with cancer through the use of structured patient interviews. Structured interviews allowed the authors to probe for previously unidentified barriers to pain management in these populations. METHODS: Thirty-one socioeconomically disadvantaged minority patients with cancer (14 African-American patients and 17 Hispanic patients) who had cancer-related pain completed structured interviews that assessed three main content areas: information and communication regarding cancer pain, treatment of cancer pain, and the meaning of cancer pain. RESULTS: The African-American and Hispanic patients reported severe pain and many concerns about pain management. The majority of patients in both ethnic groups expressed a belief in stoicism and concerns about possible addiction to opioid medications and the development of tolerance. The patients described their physicians as the most frequent and trusted source of information about cancer pain. However, patients also reported difficulties with communication and a reluctance to complain of pain. CONCLUSIONS: The reported barriers to pain management indicate that socioeconomically disadvantaged African-American and Hispanic patients can benefit from educational interventions on cancer pain that dispel myths about opioids and teach patients to communicate assertively about their pain with their physicians and nurses.