Increasing the efficacy of a celiac plexus block in patients with severe pancreatic cancer pain.

The purpose of this study was to evaluate the technical possibilities of placing a catheter near the celiac plexus for performance of a celiac plexus block, and to study the efficacy of repeated neurolytic celiac plexus blocks with alcohol in patients with advanced pancreatic cancer pain resistant to opioid treatment. In 12 patients, a neurolytic celiac plexus block with alcohol, administered via an indwelling celiac catheter, was performed. To evaluate the efficacy, visual analog scale scores were recorded every day. Quality of life scores were registered before and 4 weeks following the procedure. Alterations in opioid consumption, and the time between the diagnosis of pancreatic cancer and the performance of the block, were registered. All patients were followed until they died. Two patients remained without pain after the first neurolytic celiac plexus block. In all other patients a second block was administered which provided only temporary relief. Additional intermittent administration of bupivacaine through the catheter was necessary to provide adequate pain relief in these patients. Quality of life increased significantly during the treatment. Opioid consumption decreased significantly in all patients. Our study indicates that a neurolytic celiac plexus blockade with alcohol results in a significant but short-lasting analgesic effect. The use of a celiac catheter improves the long-term management of pancreatic cancer pain.     

Neurolytic celiac plexus block: a better alternative to opioid treatment in upper abdominal malignancies: an Indian experience

The majority of patients with advanced upper abdominal malignancies suffer from moderate to severe pain due to unavailability of morphine in developing world. This study was undertaken to evaluate the role of neurolytic celiac plexus block on pain and quality of life in this patient subpopulation. One hundred consecutive patients receiving opioids for their pain relief were divided in two groups. Group I (control) patients received oral morphine & NSAIDS and group II (study) patients underwent neurolytic celiac plexus block (NCPB) to compare their effects on pain relief, morphine consumption, quality of life (QOL), Karnofsky and performance scores up to one month. NCPB provided statistically significant better pain relief and reduced morphine consumption at one month (P = 0.000). Superior Karnofsky and performance scores also favored NCPB group (P = 0.000); however the difference in overall QOL was not statistically significant (P = 0.24). Patients in oral morphine group had more side effects (94% vs. 58%) as compared to NCPB (P = 0.000). NCPB is an effective tool to reduce opioid requirement and the drug-related adverse effects. It is a rewarding technique, especially when morphine availability and its easy accessibility to the deserving patient is poor.     

Celiac plexus block for visceral pain

Celiac plexus block has long been used to provide analgesia for upper abdominal pain. In particular, neurolytic celiac plexus block has been advocated for pancreatic cancer pain. In this article, recent advances clarifying the role and limitations of neurolytic celiac plexus block are reviewed. Neurolytic celiac plexus block provides persistent augmented analgesia when used as an adjunct to systemic opiates, but does not reliably decrease opiate requirements. In addition, neurolytic celiac plexus block may prolong survival, but the data supporting this remain controversial. The optimal technique for accomplishing neurolytic celiac plexus block remains undetermined.     

The effects of early or late neurolytic sympathetic plexus block on the management of abdominal or pelvic cancer pain

Neurolytic sympathetic plexus block (NSPB) has been proposed to prevent the development of pain and improve the quality of life of patients with cancer, thus questioning the WHO protocol that proposes the use of invasive methods only as a final resort. This study evaluates the pain relief, opioid consumption and quality of life provided by the use of NSPB in two different phases of cancer pain and compares them with that provided by pharmacological therapy only. Sixty patients with abdominal or pelvic cancer pain were divided into three groups and observed for 8 weeks. In group I, neurolytic celiac (NCPB) or superior hypogastric plexus block (SHPB), or lumbar sympathetic ganglion chain block (LSGCB) was performed with alcohol in patients using NSAID and a weak oral opioid or morphine (dose/=4. In group II, NCPB, SHPB or LSGCB were performed on patients using NSAID and morphine (dose>/=90 mg/day) and reporting VAS>/=4. The patients of group III received pharmacological therapy only. The patients of groups I and II had a significant reduction of pain (P < 0.004), opioid consumption (P < 0.02) and a better quality of life (P < 0.006) than those of group III, but no significant differences between groups I and II were seen in these aspects. Opioid-related adverse effects were significantly greater in group III (P < 0.05). The occasional neurolysis-related complications were transitory. The results suggest NSPB for the management of cancer pain should be considered earlier in the disease.     

CT引导下腹腔神经丛毁损术治疗慢性顽固性腹部癌痛

目的：观察CT引导下腹腔神经丛毁损性阻滞对顽固性腹部癌痛的镇痛效果及患者生活质量的影响。方法：74例顽固性腹部癌症疼痛患者，在CT引导监视下经背侧入路经皮穿刺腹腔神经丛无水乙醇阻滞治疗。结果：治疗后一周内全部患者疼痛减轻或消失。在治疗后第7、14、30、60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腹部癌痛的疗效确切，安全性高．     

Early Ultrasound‐Guided Neurolysis for Pain Management in Gastrointestinal and Pelvic Malignancies: An Observational Study in a Tertiary Care Center of Urban India

Abstract: Patients with advanced gastrointestinal and pelvic malignancies commonly present with pain of varying severity. In a majority of these patients, pain can be effectively managed using an integrated systemic pharmacological approach with oral morphine being the cornerstone of treatment. However, with escalating doses, intolerable side effects of oral morphine may lead to patient dissatisfaction. When oral pharmacotherapy fails to adequately address the issue of pain or leads to insufferable side effects, neurolytic blocks of the sympathetic axis are usually used for pain alleviation. As these blocks may reduce oral analgesic requirement, a reevaluation of their timing is merited. This article presents our hospital‐based in‐patient palliative care unit experience with early ultrasonography‐guided neurolysis of celiac plexus, superior hypogastric plexus and ganglion impar. Of the 44 patients we studied, 20 underwent celiac plexus neurolysis, 18 superior hypogastric plexus neurolysis, and 6 ganglion impar neurolysis. Their pain was being managed with oral morphine before neurolysis, but only 11.4% patients required oral morphine for satisfactory pain control, 2 months after neurolysis. The mean Visual Analog Scale score before block placement was 5.64 ± 0.69 and fell to 2.25 ± 1.33 at 2 months post neurolysis (P < 0.001). We suggest that bedside ultrasonography‐guided sympathetic axis neurolysis may be employed early in patients with incurable abdominal or pelvic cancer. Its use as a first‐line intervention for achieving pain control with minimal complications warrants further consideration and investigation. ?     

Celiac plexus block: a new technique using the left lateral approach

We describe a new celiac plexus block approach in a patient with cholangiocarcinoma who was referred to the Pain Clinic due to uncontrollable abdominal pain. The patient was initially programmed for a neurolytic celiac plexus block using the anterior approach with helical computerized tomography (CT) guidance. The CT scan revealed interposition of the transverse colon in the anterior approach territory, which made the anterior approach technique difficult, and also difficulty to practice the posterior approach without injuring the kidneys. We decided to attempt a left lateral atypical approach because the CT revealed the possibility of using a left lateral window to arrive to the celiac area. The left lateral access allowed us to carry out the neurolytic block using 50% alcohol without injuring any viscera. The patient tolerated the technique and was discharged without pain. No complications regarding either the punction or the block were observed.     

Computed tomography-guided neurolytic celiac plexus block with alcohol complicated by superior mesenteric venous thrombosis

Neurolytic celiac plexus block (CPB) under radiological guidance is often performed to manage pain associated with pancreatic cancer. Serious complications related to the block are rare. Computed Tomography (CT)-guided neurolytic CPB is advocated to improve the efficacy of the block and to reduce the incidence of associated complications. We describe a case of superior mesenteric vein thrombosis associated with neurolytic CPB performed under CT guidance.     

Acupuncture for chronic low back pain: diagnosis and treatment patterns among acupuncturists evaluating the same patient. (Washington University School of Medicine, St. Louis, MO) Southern Med J. 2001;94:486–492.

This case report discussed a 62-year-old woman who suffered from intractable, tumor-associated pain. Neurolytic celiac plexus block (CPB) under radiological guidance is often performed to manage pain associated with pancreatic cancer. Serious complications related to the block are rare. Computed tomography (CT)-guided neurolytic CPB is advocated to improve the efficacy of the block and to reduce the incidence of associated complications.     

The percutaneous anterior approach to the celiac plexus using CT guidance

This paper describes a new approach to the neurolytic block of the celiac plexus through the anterior abdominal wall using CT guidance. In 5 patients, CT guidance was used for needle placement and visualization of the spread of the injection. Once the pain has been relieved on completion of the neurolytic block, the radiologist proceeds with the biopsy. Pain relief was obtained in 80% of the cases after 2 weeks and in 60% after 6 months. No serious complications were observed. The anterior approach is simple and is useful in those patients with upper chronic abdominal pain scheduled for biopsy of the pancreas, and in those terminally ill patients who cannot tolerate the prone position.     

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。     

Celiac plexus block: evaluation of injectate spread by three-dimensional computed tomography

We describe a case of pancreatic cancer in which the spread pattern of injectate during neurolytic celiac plexus block was evaluated by three-dimensional helical computed tomography. Three-dimensional images provide excellent visualization of the spread patterns of injectate in a target site, which appears to provide patients with effective relief from intractable pain.     

Abstracts of selected papers from the current literature

We describe a case of pancreatic cancer in which the spread pattern of injectate during neurolytic celiac plexus block was evaluated by three-dimensional helical computed tomography. Three-dimensional images provide excellent visualization of the spread patterns of injectate in a target site, which appears to provide patients with effective relief from intractable pain.     

Discriminative effects of morphine in the squirrel monkey.

Squirrel monkeys were trained in a two-choice discrete trial avoidance task to discriminate between intramuscular injections of saline and 3.0 mg/kg of morphine. Morphine (0.1-10 mg/kg) produced a dose-related increase in the number of trials completed on the morphine-appropriate lever. The stimulus control produced by the discriminative effects of morphine met the following criteria for classification as a specific narcotic effect: 1) morphine-like stimulus control was produced by all other narcotic analgesics tested (fentanyl, oxymorphone, levorphanol, methadone and meperidine); 2) in so doing, these drugs spanned a 900-fold potency range relative to morphine; 3) stimulus control was blocked by the specific narcotic antagonist naloxone; and 4) stereospecificity was a requirement for stimulus control--levorphanol produced stimulus control equivalent to 3.0 mg/kg of mrophine but its optical isomer dextrorphan did not. The time course of the stimulus control produced by 3.0 mg/kg of morphine showed that the animals continued to respond on the morphine-appropriate lever up to 14 hours after morphine administration. In contrast, monkeys administered 0.01 mg/kg of fentanyl responded on the morphine lever for only as lone as 1/2 hour after fentanyl administration. Naloxone, d-amphetamine and pentobarbital all failed to substitute for morphine, Thus, this study has extended previous observations of the discriminative properties of morphine in rats by demonstrating that qualitatively similar data are produced in a second species, the squirrel monkey.     

Sympathetic blockade in a canine model of gram-negative bacterial peritonitis

We investigated, in a well-established canine model of human sepsis, the effects of two different techniques of sympathetic blockade during bacterial peritonitis on pain relief, hemodynamics, and survival rate. Twenty-two purpose-bred beagles (12-28 months old, weighing 10-12 kg) were studied. Fourteen animals received an epidural infusion of bupivicaine and morphine, and the other eight received either a celiac plexus block (n = 4) or a sham block (n = 4). Eighteen of the 22 animals received an intraperitoneal challenge of Escherichia coli (1-10 x 10(9) CFU kg(-1) body weight). At comparable doses of intraperitoneal-implanted E. coli (2.5-5 x 10(9) CFU kg(-1) body weight), the addition of sympathetic blockade produced a synergistic decrease in survival times (P = 0.002) and mean left ventricular ejection fraction (P = 0.008), and increase in creatinine levels (P = 0.02). There was also a significant increase in tumor necrosis factor (TNF) levels (P = 0.004) and decrease in blood endotoxin clearance (P = 0.006) associated with sympathetic blockade during sepsis. The celiac plexus-blocked animals had no improvement in pain scores, and subjectively looked clinically worse than animals with sepsis without a celiac plexus block. In contrast, the epidural block was effective in blocking the pain and discomfort associated with low lethality doses of intraperitoneal bacteria reflected by no increase in pain scores compared with animals not receiving bacterial challenge. This study shows that during severe bacterial peritonitis, maintenance of sympathetic tone irrespective of pain relief provided is necessary for clearance of bacterial toxins, control of proinflammatory mediator release, hemodynamic stability, and survival.     

Current Indications of Neurolytic Blocks in Cancer Pain

The concept of palliative care for cancer pain treatment is being accepted throughout several countries. As a consequence, invasive procedures available to provide acceptable pain relief in cancer patients have been rediscussed in terms of less invasiveness, lower technology, and more care. Very few neurolytic blocks survive in the common clinical practice, among them the neurolytic celiac plexus block and the percutaneous cervical cordotomy are considered the most effective. The former has recently been reconsidered [1•] after years of debate in the literature; the later is a specific neurosurgical procedure that may provide regional anesthesia by destroying specific pathways with heat. In this article we’ll try to define which role both procedures may currently have in the management of cancer pain.     

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.     

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.     

CT-guided percutaneous neurolytic celiac plexus block technique

Up to now, the studies in the world have demonstrated that CT-guided percutaneous neurolytic celiac plexus block (PNCPB) is an invaluable therapeutic modality in the treatment of refractory abdominal pain caused by cancer. Its efficacy of pain relief varied in reported studies. The main technical considerations which would affect the analgesic effects on abdominal pain included the patients’ cooperation, needle entry approaches, combined use of blocking approaches, localization of the target area, dosage of the blocker, and so on. A success of PNCPB depends greatly on close cooperation with patients. The patient should be educated about the purpose and steps of the procedure, and trained of breathing in and breathing hold. The needle entry can be divided into the posterior approach and the anterior approach. The former one is the most commonly used in clinical practice, but the latter one is rarely used except in the cases that the posterior approach becomes technically difficult. Bilateral multiple blocking of celiac plexus and splanchnic nerves is often required to achieve optimal analgesia. The needle entry site, insertion course, and depth should be preselected and simulated on CT monitor prior to the procedure in order to ensure an accurate and safe celiac plexus block. The magnitude of analgesic effect is closely related to the degree of degeneration and necrosis of the celiac plexus. Maximally filling with blocker in the retropancreatic space is an indication of sufficient blocking. We also provided an overview of indications and contraindications, preoperative preparations, complications and its treatment of PNCPB.     

Anesthesia (9)

Lumbar plexus clock reduces pain and blood loss associated with total hip arthroplasty. (Hôpitaux Universitaires de Genéve, Geneva, Switzerland) Anesthesiology 2000;93:115–121. In this study, 60 patients undergoing total hip arthroplasty were randomized to receive general anesthesia with (plexus group, n = 30) or without (control group, n = 30) a posterior lumbar plexus block. The block was performed after induction using a nerve stimulator, and 0.4 mL/kg bupivacaine, 0.5%, with epinephrine was injected. General anesthesia was standardized, and supplemental fentanyl was administered per hemodynamic guidelines. Postoperative pain and patient‐controlled intravenous morphine use were serially assessed for 48 h. The proportion of patients receiving supplemental fentanyl intraoperatively was more than 3 times greater in the control group (20 of 30 vs. 6 of 29, P = 0.001). In the postanesthesia care unit, a greater than fourfold reduction in pain scores was observed in the plexus group and “rescue” morphine boluses were administered 10 times less frequently. Pain scores and morphine consumption remained significantly lower in the plexus group until 6 h after randomization. Operative and postoperative (48 h) blood loss was decreased modestly in the treated group. Epidural‐like distribution of anesthesia occurred in 3 of 28 plexus group patients, but no other side effects were noted. Conclude that posterior lumbar plexus block provides effective analgesia for total hip arthroplasty, reducing intraoperative and postoperative opioid requirements. Blood loss during and after the procedure is diminished. Epidural anesthetic distribution should be anticipated in a minority of cases. Comment by Alan David Kaye, MD, PhD. The benefits of regional anesthetic techniques are well established for patients undergoing total hip arthroplasty. For example, it is common knowledge to the clinical anesthesiologist that regional anesthesia results in reduced blood loss as well as a reduction in thromboembolic events postoperatively. This interesting study considered a posterior lumbar plexus block since a significant portion of the hip is innervated via branches of the lumbar plexus. A randomized, double‐blinded trial of 60 consecutive patients undergoing total hip arthroplasty under general anesthesia was performed. Thirty patients had general anesthesia alone and 30 patients had general anesthesia with the lumbar plexus block. Pain scores and morphine consumption postoperatively were evaluated over a 48‐h period. Patients in the control group required supplemental narcotic (20/30) versus those in the lumbar plexus block group (6/30). No BIS monitor was employed simply with the end point of additional analgesic being an increase in blood pressure or heart rate greater than 130% of the baseline. Epidural‐like distribution of anesthesia occurred in 3 of 28 patients receiving the block. Incidence of nausea and vomiting was similar in both groups and pain scores were significantly lower until the 6‐h period postoperatively. There was a block‐associated reduction in hemorrhage. These results are not surprising; however, it would be unlikely that this block would be done in a repeated series and the authors describe a continuous catheter‐based technique, which they have presented in abstract form for longer‐term postoperative pain relief. The associated complications with this block must be weighed with these positive and predictable findings. The complexity of proper placement of this block compared with other regional techniques and its potential side effects would make this block difficult to implement in the operating room. The authors should be complemented for this study and great consideration for its potential benefits in clinical practice should be considered.