Pain management of pancreatic head adenocarcinomas that are unresectable: Celiac plexus neurolysis and splanchnicectomy

the ONA take:

Patients with unresectable pancreatic adenocarcinoma should be offered either a celiac plexus neurolysis (CPN) or splanchnicectomy when medical management with narcotic pain medications has failed, according to a study published in the Journal of Gastrointestinal Oncology.

 A CPN is a procedure in which alcohol is typically injected into the bundle of nerves that surrounds the aorta or into the ganglia proper, while a thoracoscopic splanchnicectomy is a minimally invasive procedure to cause definite denervation of the splanchnic nerves. Narcotics are also an option to treat patients experiencing severe pain, but these medications may result in reduced quality of life.

For the study, researchers at the University of South Carolina School of Medicine in Greenville reviewed current literature and their own patients to evaluate the role and outcomes of CPN and splanchnicectomy in pain management for those with incurable pancreatic carcinoma.

Results demonstrated excellent outcomes with regard to pain control with both treatments; however, researchers failed to determine if either technique improved quality of life or survival. The authors note a lack of evidence comparing the two in head-to-head comparisons.

Both techniques were ultimately determined to be safe, effective, and easy to perform, and there is little reason why either CPN or splanchnicectomy should not be attempted to relieve abdominal pain in these patients.

Journal of Gastrointestinal Oncology
Journal of Gastrointestinal Oncology

Background: Pancreatic adenocarcinoma is often incurable at the time of diagnosis. For patients with unresectable or recurrent disease, palliation of pain is a key component of care. Medical management with narcotics has numerous side effects and may be ineffective. Interventions for pain control include celiac plexus neurolysis (CPN) and splanchnicectomy. The purpose of this review is to outline pertinent anatomy, techniques, side effects, complications, and efficacy of interventions for palliation of pain from pancreatic cancer.

Methods: We reviewed current literature, as well as our own patients, to assess the role and outcomes of CPN and splanchnicectomy. Short descriptions of procedural techniques and functional illustrations are provided.

Results: Both CPN and splanchnicectomy have excellent outcomes with regard to pain control. Quality of life and survival, however, have not been conclusively demonstrated to improve with either technique. Data regarding head-to-head comparisons of the two interventions is lacking.

Conclusions: Patients with incurable pancreatic carcinoma should be offered either CPN or splanchnicectomy when medical management with narcotics has failed.

Keywords: Splanchnic nerves; celiac plexus; ganglia sympathetic; pancreatic cancer; palliative care


Submitted Mar 25, 2015. Accepted for publication Apr 24, 2015.

doi: 10.3978/j.issn.2078-6891.2015.052


INTRODUCTION

Adenocarcinoma of the pancreas is the fifth leading cause of cancer death in the world (1). Because patients often present with locally advanced or metastatic disease, curative resection is rarely an option. As a result, intervention for these unfortunate patients is often limited to palliation. The primary goal of palliation is ensuring that patients do not suffer painful effects of cancer progression, like obstruction of the common bile duct and/or duodenum and abdominal pain from malignant infiltration into the celiac plexus.

Up to 90% of patients with pancreatic cancer experience pain (1). Narcotics may be given initially, but significant side effects, such as a reduction in quality of life, have been reported. Because of this, attention has been given to two palliative interventions: celiac neurolysis and splanchnic neurectomy. Both celiac plexus neurolysis (CPN) and splanchnicectomy have been examined and described in the literature for a number of years. The purpose of this paper is to outline pertinent anatomy, techniques, side effects, complications, and the efficacy of CPN and splanchnicectomy for palliation of pain from pancreatic cancer.

Anatomy

Pain from pancreatic cancer is believed to stem from malignant neural invasion and the stimulation of visceral afferent neural fibers which travel from the celiac plexus through the splanchnics (2). A majority of patients report pain in the epigastrium and over half of these same patients complain of associated back pain. Only a minority of patients, however, report back pain without epigastric discomfort (3).

Neurolytic treatment is directed at the celiac plexus, while a neurectomy is performed on the splanchnic nerves, either unilaterally or bilaterally. The celiac plexus is made up of the right and left ganglia, surrounding the aorta at the level of the celiac artery. It consists of visceral afferent, as well as sympathetic, and parasympathetic efferent fibers (4), and is located in the peri-aortic fat pads at the level of the diaphragmatic hiatus and celiac artery. There are commonly two to five celiac ganglia lying between T12 and L2 (5). Sympathetic nerve fibers run from the spinal cord to the sympathetic chain and then synapse in the celiac ganglia. In turn, pain from the foregut and midgut travels retrograde via parasympathetic visceral afferent nerve impulses from the celiac plexus through the splanchnic nerves to the central nervous system.

The splanchnic nerves are easily recognized as neural branches from the sympathetic trunk running anterior and inferiorly toward the diaphragmatic hiatus overlying the thoracic vertebral column. There are three classically described splanchnic nerves: the Greater, Lesser, and Least. Branches at levels T5-T9 most commonly form the greater splanchnic nerves, while the lesser splanchnics are formed from ganglia associated with T8-T12 and the least splanchnic nerves are formed by T10-L1. After being relayed from the splanchnics, stimuli reach the thalamus and cortex of the brain; this information is perceived as pain (6). 

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