Value of Adding Dexmedetomidine in Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis for Treatment of Pancreatic Cancer-Associated Pain.

BACKGROUND: Abdominal and back pain is present in up to 80% of patients with pancreatic cancer and represents a significant cause of morbidity. Celiac plexus neurolysis (CPN) demonstrated good results in relief of pain of upper abdominal malignancy. Dexmedetomidine is alpha-2 adrenoceptor highly selective agonist approved for procedural sedation use. PATIENTS AND METHODS: Fifty patients divided in two groups with locally advanced pancreatic cancer-associated abdominal pain underwent endoscopic ultrasound (EUS)-guided CPN using bupivacaine 0.5% alone with alcohol for the first group and bupivacaine 0.5% plus dexmedetomidine in the second. Patients scored their pain according to the Numeric Rating Scale (NRS-11) before, 2, 4, 6, 8, 12, 16, and 24 week after the procedure. RESULTS: The study has included 50 patient in two groups. There was no significant difference between the two groups as regards medical, laboratory, or tumor characters. The median pain score decreases from 8.32 ± 0.75 before the procedure to 3.75 ± 3.72 24 week after the procedure in group 1 and from 8.08 ± 0.86 before to 1.67 ± 2.3 24 week after the procedure in group 2. However, there was no significant difference between the two groups in the median pain score during the first 4 weeks. There was no statistically significant difference between the two groups as regards the median survival time. CONCLUSION: The addition of dexmedetomidine to bupivacaine 0.5% in EUS-CPN demonstrated beneficial effects as regards the degree and duration of pain relieve with negligible effect on the patient survival.

A retrospective case series of patients who have undergone coeliac plexus blocks for the purpose of alleviating pain due to intra-abdominal malignancy.

BACKGROUND: Coeliac plexus block (CPB) is an interventional pain management option for patients with pancreatic or other upper abdominal malignancy. AIMS: To assess the safety, utilization, and outcomes of CPBs in the local context. METHODS AND RESULTS: We conducted a retrospective case series of all patients with cancer who underwent CPB at 4 Sydney teaching hospitals from March 2010 to February 2016. We recorded baseline demographic data, details of the injectate, procedural approach and survival, as well as pain scores and analgesic use at 4 time points of interest. Thirty-nine procedures were performed during the study period. Twenty-four were performed endoscopically, 14 were performed via a bilateral percutaneous posterior approach by Pain Specialists or Radiologists and 1 was performed intraoperatively by a Surgeon. Patients had experienced pain for a mean of 17 weeks prior to CPB. Prior to CPB, the mean pain score was 8.8 out of 10. The mean pain score was reduced at 48 hours, 2 weeks, and 4 weeks following CPB (P < .01). The mean oral morphine equivalent daily dose prior to CPB was 362 mg which was reduced at 48 hours and 2 weeks but increased at the 4 weeks following CPB. One patient developed a bacteremia but otherwise no complications were observed. CONCLUSION: CPB is performed by a number of approaches and is well tolerated. The approach selected appears to depend on patient anatomy, preference, and availability of local expertise. Local clinicians could consider CPB earlier in the management of malignant epigastric pain.

Contrast-enhanced ultrasound-guided celiac plexus neurolysis in patients with upper abdominal cancer pain: initial experience.

OBJECTIVES: The purpose of this study was to determine the efficacy and safety of contrast-enhanced ultrasound (CEUS)-guided celiac plexus neurolysis (CPN) in patients with upper abdominal cancer pain. METHODS: Thirty-five patients with upper abdominal cancers tortured by intractable upper abdominal pain underwent CEUS-guided CPN with ethanol. The pain alleviation and opioid intake were observed and evaluated during a 3-month follow-up after CPN. The dispersion of alcohol around the aorta was evaluated on 3D-CEUS. Complications were assessed during CPN and at follow-up. RESULTS: All of the 35 patients' CPN was successfully achieved. Pain relief was observed in 28 (80%), 20 (57.1%), 27 (77.1%), 20 (57.1%), and 10 (29.4%) patients immediately, 1 day, 1 month, 2 months, and 3 months after CPN, respectively. The agent dispersion around the aorta on CEUS images of 28 patients who showed pain relief was at least 90° of the circumference around the aorta. The median duration of pain alleviation was 2.7 months (95% confidence interval [CI], 2.5-2.9). Less than half of the patients had minor complications including irritant pain at the puncture site (8 of 35; 22.9%), diarrhea (4 of 35; 11.4%), nausea and vomiting (3 of 35; 8.6%), and post-procedural hypotension (1 of 35; 2.9%). CONCLUSIONS: CEUS-guided CPN is a safe and effective method to alleviate refractory upper abdominal pain in patients with upper abdominal cancers. CEUS image allows the visualization of puncture path and observation of drug dispersion. The pain relief is relevant to the dispersion of neurolytic agent around the aorta. KEY POINTS: • CEUS-guided celiac plexus neurolysis (CPN) is feasible and easy. • It allows direct visualization of the diffusion of the neurolytic agent in the retroperitoneal anatomic space. • CEUS-guided CPN improves safety of CPN by clearly delineating the needle path.

Neurolisis del plexo celiaco en cáncer de páncreas / Neurolysis of the celiac plexus in pancreas cancer

Introducción: El cáncer en Cuba constituye la primera causa de mortalidad en edades de 15 a 64 años y la segunda en mayores de 65, los tumores digestivos ocupan la tercera posición en las neoplasias malignas y la afección pancreática el cuarto lugar dentro de estas. Objetivo: Presentar la evolución de un paciente con un tumor de páncreas y una supervivencia de más de 6 meses al cual se le realizó neurolisis del plexo celiaco. Presentación del caso: Paciente masculino de 64 años de edad con el diagnóstico de adenocarcinoma de cuerpo y cola de páncreas sin criterio quirúrgico con dolor de severa intensidad que imposibilita el inicio del tratamiento adyuvante para lo cual se le realizó neurolisis del plexo celiaco bilateral, con 7 mL de fenol al 10 por ciento por cada lado, vía posterior retrocrural bajo seguimiento con intensificador de imágenes, y se administró tratamiento coadyuvante vía oral a base de antidepresivos tricíclicos, analgésicos y ansiolíticos debido al componente mixto del dolor oncológico. Conclusiones: El bloqueo neurolitico del plexo celiaco asociado a terapia farmacológica analgésica convencional por vía oral proporcionó un alivio total del dolor por neoplasia de páncreas de forma inmediata y duradera, se logró mejorar el estado general del paciente lo cual facilitó el inicio de la terapia adyuvante oncológica(AU)

Introduction: In Cuba, cancer is the leading cause of death at ages 15-64 and the second at ages over 65, digestive tumors occupy the third position among malignancies and pancreatic affection the fourth place among these. Objective: To present the evolution of a patient with a pancreatic tumor and survival of more than 6 months who underwent neurolysis of the celiac plexus. Case presentation: A 64-year-old male patient diagnosed with adenocarcinoma of the body and tail of the pancreas without surgical criteria, with pain of severe intensity that made it impossible to start adjuvant treatment, for which he underwent neurolysis of the bilateral celiac plexus, with 7 mL of phenol-10 percent per side, through the retrocrural posterior space with follow-up with image intensifier, and oral adjuvant treatment was administered with tricyclic, analgesic and anxiolytic antidepressants due to the mixed component of oncological pain. Conclusions: The neurolytic block of the celiac plexus associated with conventional oral analgesic pharmacological therapy provided total relief of pain from pancreatic cancer in an immediate and lasting way. It was possible to improve the general state of the patient, which facilitates the start of adjuvant oncology therapy(AU)

Combined Celiac Ganglia and Plexus Neurolysis Shortens Survival, Without Benefit, vs Plexus Neurolysis Alone.

BACKGROUND & AIMS: Pancreatic cancer produces debilitating pain that opioids often ineffectively manage. The suboptimal efficacy of celiac plexus neurolysis (CPN) might result from brief contact of the injectate with celiac ganglia. We compared the effects of endoscopic ultrasound-guided celiac ganglia neurolysis (CGN) vs the effects of CPN on pain, quality of life (QOL), and survival. METHODS: We performed a randomized, double-blind trial of patients with unresectable pancreatic ductal adenocarcinoma and abdominal pain; 60 patients (age 66.4±11.6 years; male 66%) received CPN and 50 patients (age 66.8±10.0 years; male 56%) received CGN. Primary outcomes included pain control and QOL at week 12 and survival (overall median and 12 months). Secondary outcomes included morphine response, performance status, secondary neurolytic effects, and adverse events. RESULTS: Rates of pain response at 12 weeks were 46.2% for CGN and 40.4% for CPN (P = .84). There was no significant difference in improvement of QOL between the techniques. The median survival time was significantly shorter for patients receiving CGN (5.59 months) compared to (10.46 months) (hazard ratio for CGN, 1.49; 95% CI, 1.02-2.19; P = .042), particularly for patients with non-metastatic disease (hazard ratio for CGN, 2.95; 95% CI, 1.61-5.45; P < .001). Rates of survival at 12 months were 42% for patients who underwent CPN vs 26% for patients who underwent CGN. The number of adverse events did not differ between techniques. CONCLUSION: In a prospective study of patients with unresectable pancreatic ductal adenocarcinoma and abdominal pain, we found CGN to reduce median survival time without improving pain, QOL, or adverse events, compared to CPN. The role of CGN must be therefore be reassessed. Clinicaltrials.gov no: NCT01615653.

Low Volume Neurolytic Retrocrural Celiac Plexus Block for Visceral Cancer Pain: Retrospective Review of 507 Patients with Severe Malignancy Related Pain Due to Primary Abdominal Cancer or Metastatic Disease.

BACKGROUND: Abdominal pain from primary cancer or metastatic disease is a significant cause of pain for patients undergoing treatment for the disease. Patient's pain may be resistant to conventional analgesics. The need for timely pain relief in order to facilitate further care in the cancer treatment plan should be a priority. OBJECTIVES: The aim of this retrospective observational review was to assess the relief given with a low volume neurolytic retrocrural celiac plexus nerve block, the duration of the procedure, the duration of relief, the reduction in daily opioid consumption, and the improvement of quality of life in a patient suffering from incapacitating abdominal pain due to primary abdominal malignancy or abdominal metastatic disease. Patients were given a neurolytic celiac plexus block without previous diagnostic block due to multiple comorbidities. STUDY DESIGN: This is a retrospective, observational study. METHODS: Five hundred and seven patients were studied and data at 5 months for 455 patients were retained at the end of the review. They were evaluated in the pain center prior to and after the neurolytic retrocrural celiac plexus nerve block under fluoroscopic guidance. They were assessed on duration of procedure, pain scores (numeric rating scale 0-10), daily opioid consumption, quality of life improvement (simple yes or no question at 3 months) and routine follow-up during treatment for the cancer for 6 months or end of life. All data was gathered by extensive chart review and placed on a spreadsheet for analysis. RESULTS: Follow-up was completed 6 months after the procedure. Pain scores, daily opioid consumption, and quality of life showed improvement for the duration of the study. There was some return in pain during the fourth to sixth month due to disease progression and the anticipated duration of the neurolytic agent. Some short duration known side effects did occur. An initial vascular contrast uptake of 6.7% was noted during the procedure while utilizing digital subtraction angiography with fluoroscopy. LIMITATIONS: A larger sample size would be ideal, as well as, a prospective trial with a control group, but this is unrealistic in our patient population. A proven quality of life questionnaire would be beneficial. Comparing alcohol, phenol and radiofrequency thermocoagulation would be interesting to equate duration, effect, and side effects. CONCLUSION: Low volume neurolytic retrocrural celiac plexus nerve block with phenol is a safe procedure providing up to 6 months of pain relief and is an effective, well-established, minimally time-consuming procedure for abdominal pain due to primary malignancy or metastatic spread. KEY WORDS: Celiac plexus, neurolytic, abdominal cancer pain, pain, retrocrural, cancer pain.

Innovative use of magnesium oxide in the treatment of "neuralgia of the celiac plexus of rheumatic origin" by G. Moscati in 1923

We presented and discussed one interesting medical prescription by doctor Giuseppe Moscati (1880-1927), who prescribed magnesium oxide (magnesia usta) to a patient with the diagnosis of "neuralgia of the celiac plexus of rheumatic origin". Besides the traditional use of magnesium as antacid remedy at the time, we raised the hypothesis that magnesium could be administered by Moscati in order to treat the neuralgia itself. Considering the scientific background of Moscati at the school of Filippo Bottazzi (1867-1941), a father of Italian biochemistry, we suggested that the doctor tried to apply the preliminary concepts acquired from electrophysiological studies on magnesium to his clinical practice. Only after decades, magnesium was recognized a fundamental ion in the energy metabolism and in contributing to maintain the ionic intracellular homeostasis, including for neurons.

Major Laparoscopic Intraperitoneal Surgery Performed With Combined Bilateral Subcostal Transversus Abdominal Plane Block and Celiac Plexus Block, Intravenous Sedation Without Tracheal Intubation: A Feasibility Study of 3 Cases.

OBJECTIVES: Major abdominal surgery usually requires general anesthesia with tracheal intubation and may be supplemented with neuraxial anesthesia to provide intraoperative and postoperative pain relief. Attempts at using only neuraxial anesthesia for major abdominal surgery have often been shown to be poorly effective. This report demonstrates that laparoscopic colonic surgical procedures can be performed with ultrasound-guided blocks (bilateral transversus abdominal plane block and celiac plexus block) and intravenous sedation, while avoiding general or neuraxial anesthesia. CASE REPORT: We report our preliminary experience in 3 patients (all American Society of Anesthesiologists physical status III) who underwent laparoscopic colonic surgery without general anesthesia. Intraoperative visceral analgesia was provided by single-injection ultrasound anterior celiac plexus block to which was added a bilateral subcostal transversus abdominal plane block to obtain parietal analgesia. Light intravenous sedation was added. Surgical exposure was satisfactory, and no patient complained of any symptom during the procedure. No adverse effect was recorded. Postoperative pain was minimal, and recovery was enhanced with mobilization and walking within hours after surgery. Patient satisfaction was excellent. CONCLUSIONS: To date, celiac plexus block has been used almost exclusively to relieve pancreatic cancer pain. This is the first report in which it is shown that major intra-abdominal surgery can be performed almost exclusively with regional anesthesia while avoiding adverse effects and problems associated with either general or neuraxial anesthesia. In addition, prolonged postoperative pain relief facilitated early recovery.

Celiac Plexus Block as a Predictor of Surgical Outcome for Sympathetically Mediated Abdominal Pain in a Case of Suspected Median Arcuate Ligament Syndrome: A Case Report.

Median arcuate ligament syndrome (MALS), also known as celiac artery compression syndrome, is an uncommon condition classically characterized by chronic abdominal pain, weight loss, and abdominal bruit. Chronic mesenteric ischemia caused by intermittent compression of the celiac artery by the MAL provokes upper abdominal pain that is sympathetically mediated via the celiac plexus. Because it is a diagnosis of exclusion, diagnosis of MALS in the clinical setting is typically challenging. We present an atypical case which highlights the utility of celiac plexus block as both an assistant diagnostic tool and a predictor of surgical outcomes for suspected MALS.

Bilateral vs. unilateral endoscopic ultrasound-guided celiac plexus neurolysis for abdominal pain management in patients with pancreatic malignancy: a systematic review and meta-analysis.

CONTEXT: Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) by bilateral or unilateral approach is widely used in palliative abdominal pain management in pancreatic cancer patients, but the analgesic effect and relative risks of the two different puncture routes remain controversial. OBJECTIVES: The aim of this systematic review was to evaluate the analgesic efficacy and safety of bilateral EUS-CPN compared with unilateral EUS-CPN. METHODS: An electronic database search was performed for randomized controlled trials comparing bilateral and unilateral approaches of EUS-CPN using the Pubmed, Cochrane Library, Web of Science, Google Scholar, and CNKI databases. Meta-analysis was performed using RevMan 5.3 after screening and methodological evaluation of the selected studies. Outcomes included pain relief, treatment response, analgesic reduction, complications, and quality of life (QOL). RESULTS: Six eligible studies involving 437 patients were included. No significant difference was found in short-term pain relief [SMD = 0.31, 95% CI (- 0.20, 0.81), P = 0.23] and response to treatment [RR = 0.99, 95% CI (0.77, 1.41), P = 0.97] between the bilateral and unilateral neurolysis groups. However, only the bilateral approach was associated with a statistically significant reduction in the postoperative use of analgesics [RR = 0.66, 95% CI (0.47, 0.94), P = 0.02] compared to the unilateral approach. A descriptive analysis was performed for complications and QOL. CONCLUSION: The short-term analgesic effect and general risk of bilateral EUS-CPN are comparable with those of unilateral EUS-CPN, but our evidence supports the conclusion that the bilateral approach significantly reduces postoperative analgesic use.

Novel treatment protocol for ameliorating refractory, chronic pain in patients with autosomal dominant polycystic kidney disease.

Autosomal dominant polycystic kidney disease (ADPKD) patients can suffer from chronic pain that can be refractory to conventional treatment, resulting in a wish for nephrectomy. This study aimed to evaluate the effect of a multidisciplinary treatment protocol with sequential nerve blocks on pain relief in ADPKD patients with refractory chronic pain. As a first step a diagnostic, temporary celiac plexus block with local anesthetics was performed. If substantial pain relief was obtained, the assumption was that pain was relayed via the celiac plexus and major splanchnic nerves. When pain recurred, patients were then scheduled for a major splanchnic nerve block with radiofrequency ablation. In cases with no pain relief, it was assumed that pain was relayed via the aortico-renal plexus, and catheter-based renal denervation was performed. Sixty patients were referred, of which 44 were eligible. In 36 patients the diagnostic celiac plexus block resulted in substantial pain relief with a change in the median visual analogue scale (VAS) score pre-post intervention of 50/100. Of these patients, 23 received a major splanchnic nerve block because pain recurred, with a change in median VAS pre-post block of 53/100. In 8 patients without pain relief after the diagnostic block, renal denervation was performed in 5, with a borderline significant change in the median VAS pre-post intervention of 20/100. After a median follow-up of 12 months, 81.8% of the patients experienced a sustained improvement in pain intensity, indicating that our treatment protocol is effective in obtaining pain relief in ADPKD patients with refractory chronic pain.

Pain Outcomes in Patients Undergoing CT-Guided Celiac Plexus Neurolysis for Intractable Abdominal Visceral Pain.

The purpose of this study was to assess outcomes in patients who have undergone celiac plexus neurolysis (CPN) as treatment for refractory abdominal visceral pain at a tertiary care medical center. This study involved retrospective analysis of all patients who had undergone computed tomography (CT)-guided CPN over a 7-year period, as identified in the medical record. Cases were categorized into 1 of 3 groups-group 1: patients getting at least moderate improvement in pain but with improvements subsiding within 2 days; group 2: patients with some sustained pain relief but still requiring heavy doses of narcotics; group 3: patients with major or complete sustained reduction in pain where the narcotic dose was able to be reduced. One hundred thirty-eight cases were identified, 51 of which had no or insufficient follow-up, leaving 87 cases for analysis. Of the 87 cases, 31 (36%) were categorized as group 1, 21 (24%) as group 2, and 35 (40%) as group 3. There were no statistical differences in outcomes based on patient age, gender, time since diagnosis, or type of cancer. Documented postoperative complications were diarrhea (11 cases) and 1 case each of obtundation, hypotension, and presyncopal event. We conclude that patients undergoing CT-guided CPN for abdominal visceral pain achieve moderate or major short-term pain relief in a majority of cases. The procedure is safe with minimal complications.

The Effectiveness of Alcohol Versus Phenol Based Splanchnic Nerve Neurolysis for the Treatment of Intra-Abdominal Cancer Pain.

UNLABELLED: Pancreatic and other upper abdominal organ malignancies can produce intense visceral pain syndromes that are frequently treated with splanchnic nerve neurolysis (SNN) or celiac plexus neurolysis (CPN). Although commonly performed with either alcohol or phenol, there is scant literature on the comparative effectiveness, duration of benefit, and complication profile comparing the 2 agents. This study presents a retrospective chart review of 93 patients who underwent SNN for cancer-related abdominal pain in order to describe patient characteristics, examine comparative efficacy, duration of benefit, and incidence of complications with alcohol vs. those of phenol. Consistent with previous studies, SNN reduced reported pain scores while not significantly reducing opioid consumption. No difference in pain outcomes was found comparing alcohol versus phenol based neurolytic techniques. Celiac axis tumor infiltration and pre-procedural local radiation therapy did not change the effectiveness of the procedure. Our data demonstrated that 44.57% of patients had = 30% pain reduction while 43.54% did not have pain reduction. Interestingly, the procedure produced significant improvements in anxiety, depression, difficulty thinking clearly, and feeling of well-being. In addition, no difference in complications was seen between the agents either. SNN was an effective and relatively safe procedure for the treatment of pain associated with pancreatic and other upper abdominal organ malignancies in our sample of patients. Choice of neurolytic agent can appropriately be left to the clinical judgment and local availability of the treating physician. The change in ancillary symptoms has a theoretical basis that supports a biopsychosocial model of pain since changes in one target area (pain) impact other related ones (depression and anxiety). KEY WORDS: Celiac plexus, splanchnic nerves, neurolysis, nerve block, alcohol, ethanol, phenol, pain, cancer pain, abdominal pain, visceral pain, symptom assessment.

MRI-guided celiac plexus neurolysis for pancreatic cancer pain: Efficacy and safety.

PURPOSE: To prospectively determine the efficacy and safety of magnetic resonance imaging (MRI)-guided celiac plexus neurolysis (CPN) for pancreatic cancer pain. MATERIALS AND METHODS: In all, 39 patients with pancreatic cancer underwent 0.23T MRI-guided CPN with ethanol via the posterior approach. The pain relief, the opioid intake, and pain interference with appetite, sleep, and communication in patients were assessed after CPN during a 4-month follow-up period. The complications were also evaluated during or after CPN. RESULTS: CPN procedures were successfully completed for all patients. Minor complications included diarrhea (9 of 39; 23.1%), orthostatic hypotension (14 of 39; 35.9%), and local backache (20 of 39; 51.3%). No major complication occurred. Pain relief was observed in 36 (92.3%), in 15 (40.5%), and in 11 (35.5%) patients at 1-, 2-, and 3-month visits, respectively. The median duration of pain relief was 2.9 months (95% confidence interval [CI], 2.4-3.4). The opioid intake significantly decreased at the 1-, 2-, and 3-month visits (P < 0.001, < 0.001, = 0.001 respectively), and there was significant improvement in sleep at the 1-, 2-, and 3-month visits (P < 0.001, < 0.001, = 0.001 respectively), and appetite and communication were significantly improved at the 1- and 2-month visits (all P < 0.001); all compared with baseline. CONCLUSION: MRI-guided CPN appears to be an effective and minimally invasive procedure for palliative pain management of pancreatic cancer. J. MAGN. RESON. IMAGING 2016;44:923-928.

Long-Term Blood Pressure Control Effect of Celiac Plexus Block with Botulinum Toxin.

Celiac plexus block (CPB) is one of the main treatment options for patients resistant to conventional antihypertensive drugs. We present a case of resistant hypertension (RHTN) that was treated with CPB using botulinum toxin. An 18-year-old male patient with RHTN, who suffered from persistent hypertension even after combination therapy and a renal denervation procedure, was referred to our pain center for CPB. CPB using botulinum toxin following the use of only local anesthetics resulted in control of systolic blood pressure (BP) at ~150 mmHg for at least three months.

[Ganglion block. Celiac plexus neurolysis]. / Ganglienblockade. Neurolyse des Plexus coeliacus.

BACKGROUND: Pain originating from the organs of the upper abdomen, especially in patients suffering from inoperable carcinoma of the pancreas or advanced inflammatory conditions, is difficult to treat in a significant number of patients. STANDARD RADIOLOGICAL PROCEDURES: Computed tomography (CT) guided neurolysis is the most commonly used technique for neurolysis of the celiac plexus. Ethanol is used to destroy the nociceptive fibers passing through the plexus and provides an effective means of diminishing pain arising from the upper abdomen. METHODS: Using either an anterior or posterior approach, a 22 G Chiba needle is advanced to the antecrural space and neurolysis is achieved by injecting a volume of 20-50 ml of ethanol together with a local anesthetic and contrast medium. PERFORMANCE: In up to 80% of patients suffering from tumors of the upper abdomen, CT-guided celiac plexus neurolysis diminishes pain or allows a reduction of analgesic medication; however, in some patients the effect may only be temporary necessitating a second intervention. In inflammatory conditions, celiac neurolysis is often less effective in reducing abdominal pain. PRACTICAL RECOMMENDATIONS: The CT-guided procedure for neurolysis of the celiac plexus is safe and effective in diminishing pain especially in patients suffering from tumors of the upper abdomen. The procedure can be repeated if the effect is only temporary.

A prospective, randomized, double-blind, placebo controlled trial on the efficacy of ethanol celiac plexus neurolysis in patients with operable pancreatic and periampullary adenocarcinoma.

BACKGROUND: Ethanol celiac plexus neurolysis (ECPN) has been shown to be effective in reducing cancer-related pain in patients with locally advanced pancreatic and periampullary adenocarcinoma (PPA). This study examined its efficacy in patients undergoing PPA resection. STUDY DESIGN: There were 485 patients who participated in this prospective, randomized, double-blind placebo controlled trial. Patients were stratified by preoperative pain and disease resectability. They received either ECPN (50% ethanol) or 0.9% normal saline placebo control. The primary endpoint was short- and long-term pain and secondary endpoints included postoperative morbidity, quality of life, and overall survival. RESULTS: Data from 467 patients were analyzed. The primary endpoint, the percentage of PPA patients experiencing a worsening of pain compared with preoperative baseline for resectable patients, was not different between the ethanol and saline groups in either the resectable/pain stratum (22% vs 18%, relative risk [RR] 1.23 [0.34, 4.46]), or the resectable/no pain stratum (37% vs 34%, RR 1.10 [0.67, 1.81]). In multivariable analysis of resected pancreatic ductal adenocarcinoma (PDA) patients, there was a significant reduction in pain in the resectable/pain group, suggesting that surgical resection of the malignancy alone (independent of ECPN) decreases pain to a significant degree. CONCLUSIONS: In this study, we demonstrated a significant reduction in pain after surgical resection of PPA. However, the addition of ECPN did not synergize to result in a further reduction in pain, and in fact, its effect may have been masked by surgical resection. Given this, we cannot recommend the use of ECPN to mitigate cancer-related pain in resectable PPA patients.

Celiac plexus block in the management of chronic abdominal pain.

Chronic abdominal pain is a devastating problem for patients and providers, due to the difficulty of effectively treating the entity. Both benign and malignant conditions can lead to chronic abdominal pain. Precision in diagnosis is required before effective treatment can be instituted. Celiac Plexus Block is an interventional technique utilized for diagnostic and therapeutic purposes in the treatment of abdominovisceral pain. The richly innervated plexus provides sensory input about pathologic processes in the liver, pancreas, spleen, omentum, alimentary tract to the mid-transverse colon, adrenal glands, and kidney. Chronic pancreatitis and chronic pain from pancreatic cancer have been treated with celiac plexus block to theoretically decrease the side effects of opioid medications and to enhance analgesia from medications. Historically, the block was performed by palpation and identification of bony and soft tissue anatomy; currently, various imaging modalities are at the disposal of the interventionalist for the treatment of pain. Fluoroscopy, computed tomography (CT) guidance and endoscopic ultrasound assistance may be utilized to aid the practitioner in performing the blockade of the celiac plexus. The choice of radiographic technology depends on the specialty of the interventionalist, with gastroenterologists favoring endoscopic ultrasound and interventional pain physicians and radiologists preferring CT guidance. A review is presented describing the indications, technical aspects, and agents utilized to block the celiac plexus in patients suffering from chronic abdominal pain.