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

Literature

Outcomes of splanchnicectomy for palliation of pain associated with pancreas cancer are encouraging. Results of this procedure for chronic pancreatitis are more readily available in the literature but remain sparse for the treatment of malignant pancreatic disease. Pietrabissa et al. reported on 20 patients who experienced significant improvement in visual analog scores for at least 3 months post-operatively (25). In a study by Lică et al., similar outcomes on another 15 patients were demonstrated (26). At the 2010 Asian Pacific Hepato-Pancreato-Biliary meeting. Vitale et al. presented data on 36 patients who underwent BTS for pancreatic cancer. In that study, mean survival was 229 days and average pain scores dropped from 8.3 to 2.0 on a 0-10 scale. The quality of life survey on these same patients, however, only demonstrated a limited improvement. At our institution we internally reviewed the first 29 patients who underwent BTS. We too found a significant decrease in patient pain scores post-operatively (4.1 to 1.1; P value =0.004) (Figure 5).

Complications

Complications of splanchnicectomy are rare, occurring in less than 2% of patients. Similar to other thoracoscopic procedures, specific complications include pneumothorax, chylothorax, hemothorax, need for thoracotomy, persistent pain, transient hypotension, and diarrhea (3). Pneumothorax was the most commonly reported complication, as two out of the 92 patients reviewed required an unplanned thoracostomy tube.

CONCLUSIONS

Pancreatic cancer is a pervasive disease that is often incurable. As a result, pain control is a key component of palliation of this disease. Given the side effects of high-dose narcotics, interventional approaches focused on neurolysis and/or neurectomy are attractive options. This can be done using a variety of approaches, each of which has been shown to be efficacious with minimal morbidity. Currently published data is heterogeneous, and head-to-head comparisons of each is lacking. Regardless, each approach appears to be safe, effective, and technically easy to perform. There is little reason any patient with this disease should suffer from abdominal pain without an attempt at either celiac plexus block or splanchnicectomy.

Acknowledgements

Disclosure: The authors declare no conflict of interest.

Wesley B. Jones, Phillip Jordan, Maya Pudi

School of Medicine, University of South Carolina, Greenville, SC 29605, USA

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Source: Journal of Gastrointestinal Oncology.
Originally published August 2015.