The role of neurolytic celiac plexus block in the treatment of pancreatic cancer pain.

Pancreatic carcinoma, an important leading cause of cancer death, has increased steadily in incidence and still has a poor prognosis. Pain is one of the most frequent symptoms, affecting more than 75% of patients. It is often present in the early stages of disease and may be severe and difficult to treat. Abdominal viscera, including pancreas, liver, gallbladder, adrenal, kidney, and the gastrointestinal tract from the level of the gastroesophageal junction to the splenic flexure of the colon are innervated, at least in part, via the celiac plexus. Thus, painful tumors in these viscera may have pain relieved through the use of a neurolytic celiac plexus block (NCPB). Although some investigators questioned the role and the efficacy of NCPB in the treatment of upper abdominal cancer pain, most of them have suggested that it may represent the optimal treatment, especially for pancreatic cancer pain. In this report we have reviewed the techniques, results, and complications of NCPB for the treatment of pancreatic cancer pain.

Both right and left cervical cordotomies depress sympathetic indexes derived from heart rate variability in humans.

Unilateral percutaneous cervical cordotomy, performed in humans to relieve intractable cancer pain, elicits signs of ipsilateral sympathetic block. In patients undergoing right or left percutaneous cervical cordotomy (9 per group), changes in sympathovagal balance were evaluated by spectral analysis of heart rate to confirm the sympatholytic effect of this surgical procedure and to investigate the lateralization of sympathetic cardiac control. For these purposes, heart rate variability was recorded 1 hour before cordotomy and 24 hours later. Cordotomy significantly depressed the low frequency peak (LF) of heart rate variability and increased the high frequency component (HF), when measured as a percentage of total power. As a consequence, the LF/HF ratio decreased significantly (P =.001), particularly during standing. The effects of right or left cordotomies were not significantly different. In conclusion, in humans unilateral percutaneous cervical cordotomy depresses some sympathetic indexes (LF/total power ratio and LF/HF ratio) derived from heart rate variability, irrespective of side.

Celiac block for the treatment of pancreatic pain.

Neurolytic celiac plexus block (NCPB) is commonly performed to relieve pancreatic cancer pain. Since Kappis described the percutaneous NCPB, a number of variations of this technique have been proposed to improve analgesic results and minimize complications. In this article, we review and discuss techniques, results, and complications of NCPB.

A double-blinded evaluation of propacetamol versus ketorolac in combination with patient-controlled analgesia morphine: analgesic efficacy and tolerability after gynecologic surgery.

UNLABELLED: We assessed the relative morphine consumption in a combined analgesic regimen (on-demand morphine plus the nonopioids propacetamol or ketorolac) after gynecologic surgery. Two hundred women randomly received two i.v. doses of propacetamol 2 g or ketorolac 30 mg in a double-blinded, double-dummy trial. Patients were monitored for 12 h, and the following efficacy variables were assessed: total dose of morphine, pain intensity, and global efficacy. Safety and tolerability were evaluated by the occurrence of adverse events, especially the presence and intensity of gastrointestinal symptoms. Hemostatic variables were measured 30 and 60 min after the first infusion; arterial blood pressure, heart and respiratory rates, sedation scores, and renal and hepatic function were also assessed. Total morphine requirements were not significantly different between the propacetamol (10.6 +/- 4.8 mg) and ketorolac (10.2 +/- 4.4 mg) groups. The evolution of pain intensity and the global efficacy also showed similar patterns in the two groups: 70.2% of patients in the propacetamol group rated the efficacy as "good/ excellent" compared with 68.2% in the ketorolac group. There were no clinically significant changes in vital signs or laboratory values and no observed differences between the two groups, although ketorolac slightly, but not significantly, prolonged the bleeding time. Epigastric pain was present in 9% and 15% of patients receiving propacetamol and ketorolac, respectively. There were two adverse events in the propacetamol group and four in the ketorolac group. Propacetamol demonstrates an efficacy similar to that of ketorolac and has an excellent tolerability after gynecologic surgery. IMPLICATIONS: Propacetamol and ketorolac, combined with patient-controlled analgesia morphine, show similar analgesic efficacy after gynecologic surgery. Morphine consumption and pain scores were comparable in the two studied groups. Propacetamol is as effective as ketorolac and has an excellent tolerability after gynecologic surgery.

[Management of postoperative pain in stomatology with ibuprofen L-arginine and naproxen]. / Trattamento del dolore postoperatorio in odontostomatologia con ibuprofene L-arginina e naprossene.

BACKGROUND: The aim of this prospective, randomized study is to compare the efficacy and safety of ibuprofen L-arginine and naproxen in the treatment of postoperative dental pain. METHODS: Seventy patients undergoing removal of impacted third molars were randomly allocated to receive 4 hours after surgery a single oral dose of either ibuprofen L-arginine 400 mg or naproxen 550 mg. Ten patients dropped out from the study because they took the study drug before the allowed time. Using a self-rating record, patients rated their pain and its relief for 1 hour after the drug administration. Remedication, if needed, and mean time of remedication were also recorded. RESULTS: A statistically significant reduction in pain scores with respect to the baseline values was recorded 5 minutes and 15 minutes after the drug administration in the ibuprofen L-arginine and in the naproxen-treated group, respectively. The summed pain intensity difference (SPID) over 60 minutes resulted significantly higher in the ibuprofen L-arginine than in the naproxen-treated group. A complete abolition of pain 60 minutes after medication was obtained in 12/28 patients (42.9%) in the ibuprofen L-arginine and in 5/32 patients (15.6%) in the naproxen-treated group, respectively (p = 0.04). Number of patients requiring remedication, mean time of remedication and drug related adverse effects did not significantly differ in the two treatment group. CONCLUSIONS: Global evaluation of the drugs by the patients showed ibuprofen more effective drug than naproxen.

Prospective randomized double-blind trial of neurolytic coeliac plexus block in patients with pancreatic cancer.

BACKGROUND: In a randomized double-blind study the efficacy of neurolytic coeliac plexus block (NCPB) was compared with pharmacological therapy in the treatment of pain from pancreatic cancer. METHODS: Twenty-four patients were divided into two groups: 12 patients underwent NCPB (group 1) and 12 were treated with pharmacological therapy (group 2). Immediate and long-term efficacy, mean analgesic consumption, mortality and morbidity were evaluated at follow-up. Statistical analysis was performed with the unpaired t test, Mann-Whitney U test and Fisher's exact test. RESULTS: Immediately after the block, patients in group 1 reported significant pain relief compared with those in group 2 (P < 0.05), but long-term results did not differ between the groups. Mean analgesic consumption was lower in group 1. There were no deaths. Complications related to NCPB were transient diarrhoea and hypotension (P not significant between groups). Drug-related adverse effects were constipation (five of 12 patients in group 1 versus 12 of 12 in group 2), nausea and/or vomiting (four of 12 patients in group 1 versus 12 of 12 in group 2) (P < 0.05), one gastric ulcer and one gluteal abscess in group 2. CONCLUSION: NCPB was associated with a reduction in analgesic drug administration and drug-related adverse effects, representing an effective tool in the treatment of pancreatic cancer pain.

Ondansetron versus metoclopramide in the treatment of postoperative nausea and vomiting.

In this prospective, randomized, double-blind study, we compared the efficacy and safety of ondansetron and metoclopramide in the treatment of postoperative nausea and vomiting (PONV). One hundred seventy-five patients with PONV during recovery from anesthesia for gynecological laparoscopy were treated intravenously with either ondansetron 4 mg (58 patients), metoclopramide 10 mg (57 patients), or placebo (60 patients). Early antiemetic efficacy (abolition of vomiting within 10 min and of nausea within 30 min from the administration of the study drugs with no further vomiting or nausea episodes during the first hour) was obtained in 54 of 58 patients (93.1%) in the ondansetron group, in 38 of 57 patients (66.7%) in the metoclopramide group, and in 21 of 60 patients (35%) in the placebo group (P < 0.001). This difference was still significant when controlling for age, body weight, history of motion sickness, previous PONV episodes, duration of anesthesia, and intraoperative fentanyl consumption using a logistic model. Early antiemetic efficacy was inversely related to the amount of fentanyl administered during anesthesia, regardless of treatment. According to the Kaplan-Meier method, the probability of remaining PONV-free for 48 h after a successful treatment was 0.59 (95% confidence interval 0.45-0.71) in the ondansetron group, 0.45 (0.29-0.60) in the metoclopramide group, and 0.33 (0.15-0.53) in the placebo group (P = 0.003). In conclusion, ondansetron 4 mg is more effective than metoclopramide 10 mg and placebo in the treatment of established PONV.

[Balanced spinal analgesia in the treatment of oncologic pain. Review of the literature]. / Analgesia spinale bilanciata nel trattamento del dolore oncologico. Rassegna della letteratura.

Certain types of cancer pain fail to respond well either to systemic drug therapy or to spinal opioids because of the occurrence of intolerable adverse effects. In addition to spinal opioids other drugs may produce an antinociceptive effect when administered by the spinal route, such as local anesthetics, NSAID, alpha 2-agonists, calcium-channel blockers, NMDA antagonists, cholinergic drugs, peptides such as somatostatin, octreotide or calcitonin, adenosine agonists, benzodiazepines, neurokinin and cholecystokinin antagonists, nitric oxide synthase inhibitors, corticosteroids, and enkephalinase inhibitors. All these drugs may be administered in combination between them, realising the so called balanced spinal analgesia. The aim of this study is to analyse: the available methods for the evaluation of pharmacological interactions, the types of interaction between different spinal antinociceptive drugs and the role of balanced spinal analgesia in the treatment of cancer pain. Analysis of the presented data shows that the spinal synergism between opioids-local anesthetics and opioids-alpha 2-agonists can be useful in the treatment of opioid refractory cancer pain. Furthermore, the use of cholinergic drugs combined with opioids and alpha 2-agonists may be promising. Finally, even if the synergism between NSAID or NMDA antagonists with opioids or alpha 2-agonists have been proved, at the moment their use in man by the spinal route is not advisable because of the absence of adequate studies on their neurotoxicity and adverse effects.

Gastric Peristalsis Control by Mono Situ Electrical Stimulation: a Preliminary Study.

BACKGROUND: This study was initiated 3 years ago when antral gastric stimulation was first used successfully to reduce free feeding in swine. METHODS: Three swine weighing 45 kg each were implanted with one subserosal bipolar electrode, positioned in the antrum, close to the pylorus, at the anterior side of the lesser gastric curvature. RESULTS: During 4 hours of kethamine anesthesia we paced the stomach by various patterns of electrical stimulation and obtained both forward and backward peristalsis, as well as gastric peresis. CONCLUSION: Variations in antral electrical stimulation produce characteristic patterns of forward and reverse peristalsis.

[Hemodynamic and metabolic impairment during hepatectomy: effect of continuous dobutamine infusion]. / Alterazioni emodinamiche e metaboliche in corso di intervento di emiepatectomia: effetto dell'infusione continua di dobutamina.

Following surgical liver resection haemodynamic and metabolic impairment, potentially responsible for post-operative hepatic failure may occur. In this prospective, randomized study such impairments and the effect on them of continuous peri-operative infusion of dobutamine were examined. Twelve patients, scheduled for hepatectomy, were divided in two groups: Group I was treated with an infusion of dobutamine 6 micrograms/kg/min from 10 minutes before the induction of anaesthesia till the fifth postoperative hour; Group II was considered as the control group. The main haemodynamic parameters, gastric pHi and serum lactate level were examined. No significant differences were detected in heart rate, parameters of pressure and SvO2. In both groups, during portal clamp, SVR increased while Cl and DO2 decreased with respect to basal and the other intra- and postoperative values. Gastric pHi decreased in both groups after portal clamp. These alterations were significantly lower in the group treated with dobutamine when compared with the control group. Serum lactate level increased in both groups. This increase was lower in Group I. Differences between groups were not statistically significant. In conclusion, during hepatectomy important haemodynamic and metabolic impairments occur. Dobutamine, by reducing such impairments, can be usefully employed in this kind of surgery.

[Hepatobiliopancreatic surgery in patients over 70 years old: which anesthesia?]. / Chirurgia epatobiliopancreatica nei pazienti oltre i 70 anni: quale anestesia?

In the last years the criteria of operability have been extended to elderly patients with hepato-pancreatic-biliary diseases. We selected 46 patients (in the seventies or older, class 3 or 4 of ASA score, affected by hepato-pancreatic-biliary neoplasms) in order to evaluate the behavior of these patients undergoing to different anaesthesiological techniques. Randomly, we treated 24 patients (group A) in general anaesthesia, and 22 patients (group B) in peridural anaesthesia. We considered mortality rate, morbidity rate, as sepsis, wound infection, pleuritis, and pneumonias. The data were analyzed by chi2-test and Fisher's exact test (p < 0.05). Mortality rate was similar in the two groups (A = 4.1, B = 4.5) (p = ns), and no complications were determined by the different anesthesiologic procedures. Pleuritis was present in 44% of group A vs 45% of group B (p = ns). Atelectasis areas were present in 58% of group A vs 27% of group B (p = ns), pneumonia was present in 33% of group A vs 9% of group B: this value was significant (p = 0.049). There were no differences between the two groups regarding wound infection rate (only one case in group B). We think that pulmonary diseases can be determined by intubation and mechanical ventilation. We show a significant reduction of pneumonia in the patients that underwent peridural anaesthesia. For this reason, peridural technique can be safely extended to elderly patients with hepato-pancreatic-biliary diseases.

[Is pain therapy just an ethical-behavioral problem?]. / La terapia del dolore è solo un problema etico-compartamentale?

Pain is a subjective sensation caused not only by pathological events which trigger signals perceived as algogenic (sensory component), but also by emotional mechanisms and critical assessments which modify its perception, both quantitatively and qualitatively. Therefore pain is an unique and unrepeatable experience resulting from the interaction of these three components. When faced with a patient suffering pain, it is fundamental to establish the respective quantitative incidences of these three components, in order to define the correct therapy of the pain in its totality. Whereas there are numerous therapies for dealing with the sensory component, the same cannot be said of the emotional and critical elements. We therefore suggest a number of guidelines for tackling the problem and for developing therapeutic strategies. In the literature there are few perspective and randomized studies that may evaluate the real effectiveness of the different treatments; it follows that the tested and accepted by scientific community therapeutical protocols are very few. Only recently some studies that intend to evaluate the different therapeutical strategies in connection with the different algesic syndromes are being published in the most important scientific journals.

[Peridural administration of low-dose morphine on demand following major abdominal surgery]. / Somministrazione peridurale di morfina in basse dosi a domanda nel postoperatorio della chirurgia addominale maggiore.

The present report deals with 20 patients undergoing major abdominal surgery, in whom a postoperative antalgic regimen has been administered on demand by means of morphine via lumbar peridural catheter. We injected 3 mg as the first dose after surgery and subsequent 2 mg doses when required. In each patient we controlled regularly for 72 hours the following: respiratory function, antalgic effects and side effects. We concluded that this technique is fit to obtain good analgesia with rare and mild side-effects.

[Psychologic implications in loco-regional anesthesia]. / Implicazioni psicologiche in anestesia loco-regionale.

A patients, who undergoes surgery, bears so stressful an emotional charge that his personality layout and life conflicts may emerge. When a patient is scheduled for loco-regional anaesthesia, the above mentioned issues should be taken into account to get a proper relation between the patient and the anaesthetist both in the pre- and intraoperative period. The following survey deals with psychological dynamics which compel the patient to ask for or reject a loco-regional anaesthetic procedure. Suggestions are also provided in order to manage adequately the anxiety and the hidden fears of the patient.

[Treatment of pain in advanced-stage intra-abdominal neoplasms]. / Il trattamento del dolore nelle neoplasie endoaddominali in fase avanzata.

Different types of pain are present in far advanced intra-abdominal cancer, sometimes in the same site too. An accurate semeiological analysis of pain is important because different types of pain often differently respond to the available therapeutical tools. In this paper the results and the complications of the most important methods of pain management in far advanced intra-abdominal cancer are examined. Analysis of the data reveals that the association of more methods, pharmacological and non, should be a rule rather than the exception.

Three posterior percutaneous celiac plexus block techniques. A prospective, randomized study in 61 patients with pancreatic cancer pain.

Variations and refinements of the classic retrocrural technique of neurolytic celiac plexus block (NCPB) for pancreatic cancer pain (PCP) have been proposed over the last 30 yr to improve success rates, avoid complications and enhance diagnostic accuracy. The aim of this prospective, randomized study was to assess the efficacy and morbidity of three posterior percutaneous NCPB techniques in 61 patients with PCP. The 61 patients were randomly allocated to three NCPB treatment groups: group 1 (20 patients, transaortic plexus block); group 2 (20 patients, classic retrocrural block); and group 3 (21 patients, bilateral chemical splanchnicectomy). The quality and quantity of pain were analyzed before and after NCPB. No statistically significant differences (P greater than 0.05) were found among the three techniques in terms of either immediate or up-to-death results. Operative mortality was nil with the three techniques and morbidity negligible. NCPB abolished celiac PCP in 70-80% of patients immediately after the block and in 60-75% until death. Because celiac pain was only a component of PCP in all patients, especially in those with a longer time course until death: 1) abolition of such pain did not ensure high percentages of complete pain relief (immediate pain relief in 40-52%; pain relief until death in 10-24%); 2) NCPB was effective in controlling PCP in a higher percentage of cases if performed early after pain onset, when the pain was still only or mainly of celiac type and responded well to nonsteroidal antiinflammatory drug therapy; and 3) the probability of patients remaining completely pain-free diminished with increased survival time.(ABSTRACT TRUNCATED AT 250 WORDS)