胰腺癌的疼痛及其治疗的研究进展

 胰腺癌是一种恶性程度较高的消化系统肿瘤,发病率持续上升,预后极差,5年生存率低于5%,死亡率极高,几乎达100%。胰腺癌主要症状之一是疼痛,大部分属于神经源性起源,显著降低患者的生活质量并影响功能活动。胰腺癌最常见的疼痛治疗是药物镇痛治疗,这是基于WHO镇痛阶梯规则。但是它并不总奏效,且许多不良反应降低了患者生活质量。胰腺疼痛的侵入性治疗主要包括腹腔神经丛阻滞和内脏神经切断术,可显著降低疼痛水平,有助于提高生活质量。微创手术不应在最后阶段使用,应考虑在疾病早期阶段(如WHO镇痛阶梯治疗的第一或第二步)。本文综合分析了目前临床上胰腺癌疼痛治疗方法,评估其有效性,希望获取更多对治疗胰腺癌疼痛有帮助的信息。     

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     

A review of the thoracic splanchnic nerves and celiac ganglia

Anatomical variation of the thoracic splanchnic nerves is as diverse as any structure in the body. Thoracic splanchnic nerves are derived from medial branches of the lower seven thoracic sympathetic ganglia, with the greater splanchnic nerve comprising the more cranial contributions, the lesser the middle branches, and the least splanchnic nerve usually T11 and/or T12. Much of the early anatomical research of the thoracic splanchnic nerves revolved around elucidating the nerve root level contributing to each of these nerves. The celiac plexus is a major interchange for autonomic fibers, receiving many of the thoracic splanchnic nerve fibers as they course toward the organs of the abdomen. The location of the celiac ganglia are usually described in relation to surrounding structures, and also show variation in size and general morphology. Clinically, the thoracic splanchnic nerves and celiac ganglia play a major role in pain management for upper abdominal disorders, particularly chronic pancreatitis and pancreatic cancer. Splanchnicectomy has been a treatment option since Mallet‐Guy became a major proponent of the procedure in the 1940s. Splanchnic nerve dissection and thermocoagulation are two common derivatives of splanchnicectomy that are commonly used today. Celiac plexus block is also a treatment option to compliment splanchnicectomy in pain management. Endoscopic ultrasonography (EUS)‐guided celiac injection and percutaneous methods of celiac plexus block have been heavily studied and are two important methods used today. For both splanchnicectomies and celiac plexus block, the innovation of ultrasonographic imaging technology has improved efficacy and accuracy of these procedures and continues to make pain management for these diseases more successful. Clin. Anat. 23:512–522, 2010. © 2010 Wiley‐Liss, Inc.     

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.     

胸腔镜内脏神经切断术治疗肝癌所致的顽固性疼痛

目的探讨胸腔镜内脏神经切断术对肝癌所致的顽固性疼痛的临床疗效。方法对2007年3月~2011年9月共8例失去手术机会的肝癌所致顽固性腹痛患者进行胸腔镜下左侧内脏神经切断术,术后记录手术持续时间、胸腔引流持续时间及住院时间,术中、术后并发症。观察并记录术前、术后第7天和术后1个月疼痛评分(VAS评分)。记录术后患者镇痛剂使用情况。结果手术持续时间25~60 min,平均35 min。7例行胸腔闭式引流患者,术后引流管持续时间为2~4 d,平均2.3 d。住院时间5~7 d,平均5.6 d。术前、术后1周及术后1个月患者VAS评分为(8.92±1.06)∶(1.74±0.89)∶(1.95±1.03)。术后患者住院期间全部无需阿片类镇痛药物,其中6例患者不需要任何止痛药。结论胸腔镜下左侧内脏神经切断术是治疗肝癌性腹痛的一种安全、简单、有效的方法。     

内脏大神经切断术的应用解剖

目的:为内脏大神经切断术提供形态学基础。方法:对144侧内脏大神经进行解剖,观察其起止、行程和分支;测量其长度、直径和分支起点距腹腔神经节的距离以及在主动脉裂孔处内脏大神经距主动脉侧缘的距离。结果:94.4%的内脏大神经由来T5￣10交感神经节的纤维,4.2%的上界纤维起自T4交感神经节,1.4%的下界纤维起自T11交感神经节。内脏大神经长度为(49.3±20.49)mm,直径为(2.47±0.7)mm,在主动脉裂孔处左内脏大神经距主动脉左缘(3.01±2.94)mm,右内脏大神经距主动脉右缘(11.12±5.67)mm,在其行程过程中有35.4%的内脏大神经发出1￣3条分支。结论:在进行左内脏大神经切断术前,应先在CT或MRI下观察腹腔神经节的形状,根据其形状判断是否进行手术切断内脏大神经,术中在主动脉裂孔处腹主动脉左缘能寻找到大部分左内脏大神经,若不能找到,可在腹腔神经节外侧端背面寻找。     

Pain in pancreatic cancer: review of medical and surgical remedies

Pancreatic cancer is a malignant tumour with very poor prognosis and a chance for 5‐year survival is approximately 6%. One of the main symptoms of this neoplasm is pain, mostly of neuropathic origin, which significantly decreases the quality of life and impairs the functional activity of patients. The most common treatment of pain in pancreatic cancer is conservative therapy which is based on analgesic ladder rules established by the World Health Organization. Unfortunately, it is not always effective and it has many side effects that also can diminish patients’ quality of life. Invasive treatment of pain in pancreatic cancer includes mainly coeliac plexus block and sympathectomy, and both of them significantly reduce levels of pain and help to improve the quality of life. It is postulated that the place of those two invasive methods should not be at the final stage of treatment, but they can provide significantly better improvement of pain once instituted earlier (such as the first or second step of analgesic World Health Organization's ladder). The aim of this article is to review and assess the conservative as well as the invasive therapy in the management of pain in pancreatic cancer. It also presents brief insight into non‐medical methods of pain reduction, which can be supplementary to conservative and/or invasive treatment.     

Effect of NCPB and VSPL on pain and quality of life in chronic pancreatitis patients

AIM: To compare the effects of neurolytic celiac plexus block (NCPB) and videothoracoscopic splanchnicectomy (VSPL) on pain and quality of life of chronic pancreatitis (CP) patients. METHODS: Forty-eight small duct CP patients were treated invasively with NCPB (n = 30) or VSPL (n = 18) in two non-randomized, prospective, case-controlled protocols due to chronic pain syndrome, and compared to a control group who were treated conservatively (n = 32). Visual analog scales were used to assess pain and opioid consumption rate was evaluated. In addition, the quality of life was measured using QLQ C-30 for NCPB and FACIT for VSPL. Although both questionnaires covered similar problems, they could not be compared directly one with another. Therefore, the studies were compared by meta-analysis methodology. RESULTS: Both procedures resulted in a significant positive effect on pain of CP patients. Opioids were withdrawn totally in 47.0% of NCPB and 36.4% of VSPL patients, and reduced in 53.0% and 45.4% of the respective patient groups. No reduction in opioid usage was observed in the control group. In addition, fatigue and emotional well-being showed improvements. Finally, NCPB demonstrated stronger positive effects on social support, which might possibly be attributed to earlier presentation of patients treated with NCPB. CONCLUSION: Both invasive pain treatment methods are effective in CP patients with chronic pain.     

Quality of life after bilateral thoracoscopic splanchnicectomy: Long-term evaluation in patients with chronic pancreatitis

We prospectively evaluated quality of life and visual analogue scale pain scores after bilateral thoracoscopic splanchnicectomy in 55 patients with small-duct chronic pancreatitis and abdominal pain. The perioperative morbidity rate was 11% and there were no perioperative deaths. Four late deaths occurred (7%), and three patients were lost to follow-up. Patients were divided into those who had prior operative or endoscopic interventions (N=38) and those who did not (N=17). Preoperatively there were no significant differences between the two groups with regard to age, sex, etiology, pain score, or narcotic use. Pain score, narcotic use, and symptoms scales improved significantly in both groups at 3 and 6 months postoperatively (P<0.0001). The group with no prior surgical or endoscopic intervention did significantlybetter initially (P< 0.007), and the improvements in their quality-of-life and pain scores continued for the remainder of the study. In contrast, quality-of-life and pain scores in patients who had undergone prior surgical or endoscopic intervention returned to baseline by 12 months postoperatively and remained poor throughout the remainder of the study. Bilateral thoracoscopic splanchnicectomy appears to work best in patients who have had no prior operative or endoscopic interventions. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (oral presentation).     

Opioid use determines success of videothoracoscopic splanchnicectomy in chronic pancreatic pain patients

Objective Videoscopic splanchnicectomy (VSPL) is a method of pain relief in chronic pancreatitis patients. Because this method is not equally effective in all patients, this study was designed to identify the factors determining the unfavorable results of VSPL. Materials and methods This is a non-randomized prospective case-controlled study designed to compare a group of patients suffering from chronic pancreatitis treated with VSPL (N = 48) versus a group of patients treated symptomatically (N = 42). The outcome was measured as the intensity of pain ailments [visual analog scale (VAS)-pain scale] and subjective satisfaction of the patients from the surgical treatment [Functional Assessment of Chronic Illness Therapy-Treatment Satisfaction (FACIT-TS)]. The predictive variables considered in this study were: age, sex, emotional status, social support (the two last variables were measured by subscales of quality-of-life questionnaire from the group of FACIT), history of previous surgical treatment, and opioid use for at least 3 months before VSPL. The follow-up was 18 months. Logistic regression was performed using dichotomized pain as outcome variable: high score more than 66.7 on VAS scale and low under 50 points on VAS scale 18 months after VSPL. Results VSPL significantly reduced the pain ailments at all points of the study when compared to the control. However, the pain intensity at the end of the study was higher than directly after the surgery. In the patients treated with opioids before the surgery, the pain intensity was significantly higher than in the patients not using this group of drugs. Logistic regression revealed that opioid administration before VSPL was the most important predictor of high pain scores 18 months after the surgery. Conclusion When planning the VSPL in the treatment of pain in patients suffering from chronic pancreatitis, it is necessary to take into consideration the previous chronic use of opioids, as this variable can significantly influence poorer results of this surgical pain management.