medsplan.htm

Am J Gastroenterol 1999 Apr ;94(4) :900-5
A prospective randomized comparison of endoscopic ultrasound- and computed tomography-guided celiac plexus block for managing chronic pancreatitis pain.
Gress F, Schmitt C, Sherman S, Ikenberry S, Lehman G
Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, USA.
OBJECTIVE : Computed tomography (CT)-guided celiac plexus neurolysis has been used for controlling the chronic abdominal pain associated with intra-abdominal malignancy and chronic pancreatitis. Endoscopic ultrasound (EUS)-guided celiac plexus neurolysis has been reported to have some success in controlling pain from pancreatic cancer. The aim of this study is to assess the efficacy of EUS-guided celiac plexus block versus CT-guided celiac plexus block for controlling the chronic abdominal pain associated with chronic pancreatitis. METHODS : Patients enrolled were randomly assigned to EUS-guided or CT-guided celiac plexus block. Pain scores were determined pre- and postceliac block for both techniques. Follow-up was obtained by a nurse at 1 day post-block, then weekly thereafter for 24 wk. Patients also rated overall experience with these procedures. The EUS celiac block was performed with a 22-gauge sterile needle inserted into the celiac region with guidance of real-time linear array endosonography followed by injection of 10 ml of bupivacaine (0.75%) and 3 ml (40 mg) of triamcinolone on both sides of the celiac area. RESULTS : Twenty-two consecutive patients (10 men, 12 women), were ultimately enrolled in this study between 7/1/95 and 12/30/95 ; four patients were excluded for protocol violations. We performed EUS-guided celiac block in 10 patients and CT-guided celiac block in eight. A significant improvement in pain scores with reduction in pain medication usage occurred in 50% (five of 10) of patients having the EUS block. The mean postprocedure follow-up was 15 weeks (range : 8-24 wk). Persistent benefit was experienced by 40% of patients at 8 wk and by 30% at 24 wk. In the patients with CT block, however, only 25% (two of eight) had relief. The mean follow-up was 4 wk (range : 2-6 wk). Only 12% (one of eight) had some relief at 12 wk of follow-up. There were no complications. EUS-guided celiac block was the preferred technique among patients who experienced both techniques. A cost comparison between both celiac block techniques shows EUS to be less costly than CT. CONCLUSIONS : EUS-guided celiac block provided more persistent pain relief than CT-guided block and was the preferred technique among the subjects studied. EUS-guided celiac block appears to be a safe, effective, and less costly method for controlling the abdominal pain that can accompany chronic pancreatitis in some patients.

Eur J Radiol 1985 Feb ;5(1) :24-6
CT identification of coeliac ganglia.
Dal Pozzo G, Bozza A, Fargnoli R, Brizzi E
The authors achieved the "in vivo" identification of the coeliac ganglia (C.G.), using computerised tomography (CT). This result was confirmed by autopsies and by CT scans of an anatomical specimen in which the coeliac ganglia had been previously marked. CT allows an exact location of the coeliac ganglia and can be very useful for a precise alcoholic neurolysis of the coeliac plexus.

Anesthesiology 1997 Dec ;87(6) :1301-8
Single-needle celiac plexus block : is needle tip position critical in patients with no regional anatomic distortions ?
De Cicco M, Matovic M, Balestreri L, Fracasso A, Morassut S, Testa V
Centro di Riferimento Oncologico, Istituto Nazionale Tumori Centroeuropeo,
Aviano, Italy. arti@ets.it
BACKGROUND : The "single-needle" celiac plexus block is becoming a popular technique. Despite different approaches and methods used to place the needle, the success of the block depends on adequate spread of the injectate in the celiac area. In the present retrospective study, the influence of needle tip position in relation to the celiac artery on injectate spread was evaluated.
METHODS : Among 138 cancer patients subjected, via an anterior approach, to computed tomography (CT)-guided single-needle neurolytic celiac plexus block, a radiologist, blinded to the aim of the study, retrospectively selected 53 cases with normal anatomy of the celiac area as judged by CT. The decision was based on images obtained before the block. Patients were then classified into either group A (29 patients), in whom the needle tip was caudad to the celiac artery, and group B (24 patients), in whom it was cephalad. To evaluate CT patterns of neurolytic (mixed with contrast) spread, the celiac area was divided on the
frontal plane into four quadrants : upper right and left and lower right and left, as related to the celiac artery. Patient assessments by visual analog scale were reviewed to evaluate the degree of pain relief. Pain relief 30 days
after block was judged as long-lasting. The patterns of contrast spread in relation to the needle position and pain relief according to the number of quadrants with contrast were analyzed. RESULTS : The percentage of cases with four quadrants with contrast was higher when the needle tip was cephalad (58%, group B) than when it was caudad (14%, group A) to the celiac artery (P < 0.01). The percentage of patients with four and three quadrants with contrast was also higher in group B at 79% than in group A at 38% (P < 0.01). A significant difference in long-lasting pain relief was observed between patients with four quadrants with contrast (18 of 18, 100% ; 95% confidence interval [CI], 81-100%) and patients with three quadrants with contrast (5 of 12, 42% ; 95% CI, 15-72%) (P < 0.01). No patients showing two or one quadrant with contrast had long-lasting pain relief. CONCLUSIONS : These findings suggest that, when the celiac area is free from anatomic distortions, and the single-needle neurolytic celiac plexus block technique is used, the needle tip should be positioned cephalad to the celiac artery to achieve a wider neurolytic spread. It also appears that only a complete (four quadrants) neurolytic spread in the celiac area can guarantee long-lasting analgesia.

AJR Am J Roentgenol 1993 Nov ;161(5) :1061-3
Percutaneous neurolysis of the celiac plexus via the anterior approach with sonographic guidance.
Gimenez A, Martinez-Noguera A, Donoso L, Catala E, Serra R
Department of Radiology, Hospital de Sant Pau, Facultad de Medicina, Universidad Autonoma, Barcelona, Spain.
OBJECTIVE. The purpose of this study was to evaluate the usefulness of sonographically guided percutaneous neurolysis of the celiac plexus in patients with abdominal tumors or chronic pancreatitis in whom systemic analgesics were ineffective. SUBJECTS AND METHODS. Neurolysis of the celiac plexus was performed in 38 patients, 34 with neoplastic disease and four with chronic pancreatitis. Under sonographic guidance, a 22-gauge needle was advanced by the anterior route to the area above the celiac plexus, and 30-40 ml of 50% alcohol was injected. Pain relief was assessed 1 week, 6 months, and 1 year after the procedure. Patients subjectively rated the pain after treatment as totally relieved, partially relieved, or unchanged. RESULTS. At 1 week and at 6 months after treatment, pain was totally relieved in 61% of patients, partially relieved in 31%, and unchanged in 8%. After 1 year, pain was totally relieved in 39%, partially relieved in 52%, and unchanged in 9%. The complications observed were five cases of mild diarrhea and one case of retroperitoneal pain, which subsided with conservative treatment. CONCLUSION. The anterior, sonographically guided approach appears to be as successful as other percutaneous techniques for neurolysis of the celiac plexus.

Surg Endosc 1997 Mar ;11(3) :239-44
Ultrasound-guided alcoholization of celiac plexus for pain control in oncology.
Caratozzolo M, Lirici MM, Consalvo M, Marzano F, Fumarola E, Angelini L
IV Clinica Chirurgica, Universita degli Studi di Roma "La Sapienza," Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy.
BACKGROUND : Treatment of inoperable pancreatic cancer pain is of paramount importance. The ineffectiveness of pharmacological agents has led many investigators to recommend chemical neurolysis of the celiac ganglions for pain control. This procedure may be performed under either fluoroscopic or computed tomography (CT) guidance, or it may accompany laparotomy. The authors describe a modified sonographically (ultrasound-US)-guided technique for alcoholization of the celiac ganglions. METHODS : Twelve patients underwent the neurolytic procedure. Nine of 12 suffered from pancreatic cancer. The remaining three were affected by inoperable hepatic, gastric, or colon cancer, respectively, with multiple hepatic metastases. US-guided alcohol neurolysis was performed by an anterior approach. In the last four patients, PIA (percutaneous injection alcohol) needles, modified by the authors, replaced the spinal needles employed in the first eight patients to inject the alcohol. Pain and pain relief were rated according to a Simple Descriptive Scale (SDS), and treatment success was gauged by declining opiate doses and need for pharmacological therapy. Results after treatment performed using different needles were compared. RESULTS : Procedure-related mortality was zero. Complications of the neurolytic procedure included left pleural effusion in one patient and mild diarrhea in two other patients. Positive, negative, and indeterminant results were noted in nine (75%, p < 0.001), two, and one patient(s), respectively. CONCLUSIONS : The neurolytic technique, although far from being considered a routine procedure, appears to provide patients with safe and effective pain relief for pain unresponsive to conventional medical treatment.

Radiographics 1996 Nov ;16(6) :1289-304 ; discussion 1304-6
Interventional radiologic procedures with CT guidance in cancer pain management.
Gangi A, Dietemann JL, Schultz A, Mortazavi R, Jeung MY, Roy C
Department of Radiology B, University Hospital of Strasbourg, France.
Reduction of pain without systematic side effects can be achieved in advanced stages of cancer with precise percutaneous techniques guided with computed tomography (CT). CT guidance allows exact needle positioning, reducing complications and improving the results. Regional analgesia with neurolytic block (neurolysis) is achieved by injection of alcohol or phenol and involves intentional destruction of a nerve or nerves to interrupt nociceptive pathways for weeks or months. Percutaneous alcoholization of bone metastasis is indicated in patients with painful, severe, osteolytic bone metastasis if conventional anticancer therapy is ineffective and high doses of opiates are necessary to control pain and when rapid pain relief is necessary. Bone packing with acrylic glue (methyl methacrylate) is used to prevent pathologic fractures and pain in patients with vertebral body tumors and acetabular metastasis. With these techniques, the radiologist is able to play an active role in pain management and in improving the quality of life of patients with malignancies.

AJR Am J Roentgenol 1993 Sep ;161(3) :633-6
CT-guided celiac ganglion block with alcohol.
Lee MJ, Mueller PR, vanSonnenberg E, Dawson SL, D'Agostino H, Saini S, Cats
AM
Department of Radiology, Massachusetts General Hospital, Boston 02114.
Celiac ganglion block has been performed without radiologic guidance by surgeons or anesthetists since it was first described by Kappis [1] in 1914. Radiographic guidance for celiac block was first reported in the 1950s [2], and more recently, radiologists have used CT to guide needle placement [3-5]. With CT guidance, more directed positioning of the needle is possible, allowing alcohol to be deposited in the specific ganglion areas. This article reviews our collective experience with CT-guided celiac ganglion block.

Radiol Med (Torino) 1993 May ;85(5) :648-52
[Percutaneous neurolysis of the celiac plexus. Description of a new CT-guided technique and preliminary results].
[Article in Italian]
Pinzani A, Micheletto G, Bortolami A, Ravasini R
Servizio di Radiologia, Ambulatorio di Terapia del Dolore, Venezia.
June 1991 to June 1992, twelve CT-guided percutaneous celiac plexus neurolyses were performed by a new simplified technique with the patient in left-hand side decubitus and a single right lumbar needle access. CT guidance allows the interventional radiologist to locate the best access point on the skin, to give the needle the appropriate depth and inclination to avoid passing through pleura, parenchyma and vessels, and finally to check the correct position of the needle tip and the spread of neurolytic solution. In left-hand side decubitus, fat and loose connective tissue around ganglia and vessels expands much more, thus allowing the alcohol-contrast medium solution to spread easily and evenly getting to both celiac ganglia by gravity. The analgesic value of celiac plexus neurolysis has been proved complete and lasting. The technique is quick and safe (apart from inevitable hypotension due to splanchnic vasodilatation).

Ann Surg 1993 May ;217(5) :447-55 ; discussion 456-7
Chemical splanchnicectomy in patients with unresectable pancreatic cancer. A prospective randomized trial.
Lillemoe KD, Cameron JL, Kaufman HS, Yeo CJ, Pitt HA, Sauter PK
Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland.
OBJECTIVE : A prospective, randomized, double-blind study was completed comparing intraoperative chemical splanchnicectomy with 50% alcohol versus a placebo injection of saline in patients with histologically proven unresectable pancreatic cancer. METHODS : Standardized assessment of pain, mood, and disability due to pain was completed preoperatively and at 2-month intervals until death. Chemical splanchnicectomy with alcohol was performed in 65 patients, whereas 72 patients received the placebo. The two groups were similar with respect to age, sex, location, and stage of tumor, operation performed, the use of postoperative chemo- and radiation therapy, and initial assessment scores for pain, mood, and disability. RESULTS : No differences in hospital mortality or complications, return to oral intake, or length of hospital stay were observed. Mean pain scores were significantly lower in the alcohol group at 2-, 4-, and 6-month follow-up and at the final assessment (p < 0.05). To further determine the effect of chemical splanchnicectomy, patients were stratified into those with and without preoperative pain. In patients without preoperative pain, alcohol significantly reduced pain scores and delayed or prevented the subsequent onset of pain (p < 0.05). In patients with significant preoperative pain, alcohol significantly reduced existing pain (p < 0.05). Furthermore, patients with preexisting pain who received alcohol showed a significant improvement in survival when compared with controls (p < 0.0001). CONCLUSION : The results suggest that intraoperative chemical splanchnicectomy with alcohol significantly reduces or prevents pain in patients with unresectable pancreatic cancer.

Reg Anesth 1990 Mar-Apr ;15(2) :103-5
Teflon epidural catheter placement for intermittent celiac plexus blockade and celiac plexus neurolytic blockade.
Humbles FF, Mahaffey JE
Department of Anesthesiology, Medical University of South Carolina, Charleston 29425.
A 58-year-old with acute/chronic pancreatitis was treated with celiac plexus blockade. A percutaneous teflon catheter was placed for intermittent blockade and used for definitive neurolysis. There were no complications using this approach to celiac plexus blockade.

Ann Oncol 1999 ;10 Suppl 4 :278-80
Endoscopic palliative treatment of advanced pancreatic cancer : thoracoscopic splanchnicectomy and laparoscopic gastrojejunostomy.
Giraudo G, Kazemier G, Van Eijck CH, Bonjer HJ
Department of Surgery, University Hospital Dijkzigt, Rotterdam, The Netherlands.

DESIGN : Evaluation of thoracoscopic splanchnicectomy and laparoscopic gastrojejunostomy as endoscopic palliative treatment of advanced pancreatic cancer. PATIENTS AND METHODS : Between November 1993 and September 1998 we performed 16 thoracoscopic splanchnicectomies and 6 laparoscopic gastrojejunostomies in patients with an advanced pancreatic cancer admitted to the Department of Surgery of University Hospital Rotterdam-Dijkzigt. These patients either did not achieve adequate pain control with medication or presented serious problems of gastric outlet obstruction, or both. RESULTS : There were fourteen patients (9 men and 5 women) with mean age of 51.8 years (range 28-83), mean BMI of 21.1 (range 17.2-27.2), ASA score I in 2, II in 11, III in 1. We performed 2 left, 2 right and 4 bilateral thoracoscopic splanchnicectomies, 4 laparoscopic gastrojejunostomies and 2 combined endoscopic procedures (bilateral thoracoscopic splanchnicectomy and laparoscopic gastrojejunostomy). The overall average operation ("skin to skin") time was 86 minutes (range 75-100) for bilateral thoracoscopic splanchnicectomies, 63 minutes (range 60-65) for unilateral splanchnicectomies, 88 minutes (range 65-115) for laparoscopic gastrojejunostomies and 190 minutes (range 180-200) for the combined procedure. Blood loss was insignificant with a median of 50 ml (range 30-150). The conversion's rate to open surgery was 4.5%. There were no intraoperative complications. The overall average postoperative mobilization was in 1.9 days (range 1-4) and the overall median postoperative hospital stay was 7 days (range 2-24). There was no mortality at 30 days after endoscopic procedures and the morbidity rate was 21.4%. The postoperative analgesic requirement was considerably reduced with a successful rate was 83.3%. The resolution of gastric outlet obstruction has been complete in all laparoscopic gastrojejunostomies. CONCLUSIONS : Our results show the feasibility and safety of these minimally invasive approaches such as endoscopic palliative treatment of complications of advanced pancreatic cancer.

Ann Oncol 1999 ;10 Suppl 4 :265-8
Pain management of pancreatic cancer.
Andren-Sandberg A, Viste A, Horn A, Hoem D, Gislason H
Department of Surgery, Haukeland University Hospital, Bergen, Norway.
Quality of life is receiving increasing attention as a criterion for the assessment of treatment, not least for surgery, in pancreatic cancer. In exocrine pancreatic cancer there are three main symptoms that must be dealt with : pain, loss of weight and jaundice. All of them seriously impair quality of life, but most often pain is the most feared by the patients. Despite this, the intensity and the quality of the pain is all too often only scantly described. In 85 consecutive patients with newly diagnosed pancreatic cancer we have prospectively registered the quality and quantity of their pain and correlated it to tumor and patient characteristics. It was found that about one fourth of the patients were totally pain free and half of all suffered a pain decribed by two or less on a Visual Analogue Scale. Only one in ten had severe pain. Although more and more patients were treated with morphine, it was still about one third of all patients that had no or only little pain in the last part of their life. Pain had a strong correlation to survival. This may be due to secondary effects like depressing the mood of the patient and reducing the food intake, but is probably more often a reflection of that generalized cancer induces more pain. Analgesic drugs are the cornerstone of the pharmacologic management of pain due to pancreatic cancer. A significant part of the patients do well with only paracetamol and nonsteroidal antiinflammatory agents. Combining these agents with narcotic analgesics can enhance pain control while lessening the dose of narcotics. A wide range of narcotics are available as well as different modes for delivery : regular pills, slow release forms, injections, subcutaneous injections, epidurals etc. Each patient's pain management should be individualized, based on the intensity of pain, the type of pain and the side effects. It is essential not only to describe the medication, but also to follow-up the development of the pain and the patient's total experience of the situation. As an alternative to narcotics, plexus celiac blocks have been used with somewhat different result ; in the hands of the experts the percutaneous approach is usually sufficient, but in the hands of other also poor results are reported. During the last years thoracoscopic splanchnicectomy has been tried as a complement giving long-standing pain relief with little or no side effects in the majority of patients. With this approach the sympathic fibers lead by the symphathetic chain and further by the nervus splanchnicus major, minor and minoris are divided. The denervation is easily done and can be performed bilaterly in one seance. This method will probably be used more often as the technique is now well described.

J Laparoendosc Adv Surg Tech A 1999 Jun ;9(3) :273-6
Management of chylothorax after thoracoscopic splanchnicectomy.
Selzer DJ, Howard TJ, Kesler KA
Department of Surgery, Indiana University School of Medicine, Indianapolis
46202, USA. DJSelzer@aol.com
Thoracoscopic splanchnicectomy is a minimally invasive procedure used in the treatment of recalcitrant abdominal pain in patients with chronic pancreatitis or pancreatic carcinoma. Chylothorax, an uncommon complication of thoracoscopic splanchnicectomy, may lead to a protracted, costly hospital course of treatment usually consisting of central venous hyperalimentation, restricted oral intake, and tube thoracostomy. In our series of 25 patients who underwent thoracoscopic splanchnicectomy, 2 developed postoperative chylothorax. Both patients failed conservative management and ultimately underwent operative reintervention, at which time, leaking lymphatics were easily identified and closed using minimally invasive techniques. On the basis of this experience, we advocate early thoracoscopic reintervention in patients with chylothorax after thoracoscopic splanchnicectomy.

Semin Laparosc Surg 1996 Mar ;3(1) :29-33
Thoracoscopic Splanchnicectomy for Chronic, Severe Pancreatic Pain.
Andren-Sandberg A, Zoucas E, Lillo-Gil R, Gyllstedt E, Ihse I
Department of Thoracic Surgery, University Hospital, Lund, Sweden
Fourteen patients with pancreatic cancer, 2 with cancer of the papilla of Vater, and 14 with chronic pancreatitis were operated on with bilateral thoracoscopic splanchnicectomy caused by severe chronic pain. The median follow-up time was 13 months. Twenty patients were followed up for 3 months and 14 for at least 6 months. The surgical results were evaluated prospectively, both with visual analogue scale (VAS) and with documentation of the consumption of analgesics at elective follow-up after 1 week and 1, 3, 6, and 12 months postoperatively. All 30 patients stated that the characteristics of their pain had changed at recovery from anaesthesia, but only 6 of them reported immediate complete pain relief. All but 1 of the 14 patients with chronic pancreatitis had clearly reduced pain as evaluated by VAS 1 month after the operation, and this beneficial effect remained for the whole study period. Furthermore, the need for analgesics decreased. Also, in the 16 patients with cancer, there was on average a marked relief of pain from 1 week and onwards. The 6 cancer patients with survival more than 3 months had reduced pain for the remaining period of their lives. It seems that the final pain relief is persistent as is the reduced consumption of analgesics. There was no correlation between the number of cut nerves and pain relief as evaluated by VAS. Three patients were reoperated on for intrathoracic bleeding the evening after the operation, and one had transient pain located to one of the port sites. Otherwise, there were no postoperative complications. The operation time was short and the length of hospital stay in most patients was 24 hours or less. It was concluded that thoracoscopic splanchnicectomy appears to be a promising and relatively simple treatment for severe chronic pancreatic pain. Further studies are needed to establish its role in the management of intractable pancreatic pain.

J Chir (Paris) 1997 Dec ;134(7-8) :322-4
[Splanchnicectomy using thoracoscopy].
[Article in French]
Arnaud JP, Cervi C, Tuech JJ, Bergamaschi R
Departement de Chirurgie Viscerale, C.H.U.-Angers.
A technique of thoracic splanchnicectomy under video thoracoscopic control is reported. This simple and non aggressive procedure is indicated for very painful forms of pancreatic cancer and for some cases of chronic pancreatitis. It should relieve pain for a longer period than splanchnic nerve injection or radiotherapy.

Ann Thorac Surg 1998 Mar ;65(3) :810-3
Thoracoscopic splanchnicectomy for control of intractable pain in pancreatic cancer.
Le Pimpec Barthes F, Chapuis O, Riquet M, Cuttat JF, Peillon C, Mouroux J,
Jancovici R
Service de Chirurgie Thoracique, Hopital Laennec, Paris, France.
BACKGROUND : Pain is the most distressing feature of pancreatic cancer. Thoracoscopic splanchnicectomy, first performed in 1993, has caused a resurgence of interest in surgical treatment of such excruciating pain. METHODS : Twenty patients underwent splanchnicectomy for pancreatic cancer pain over a period of 50 months. All were opiate dependent and unable to pursue normal daily life activities. We evaluated the type of splanchnicectomy performed and the long-term results procured. RESULTS : The number of splanchnicectomies was 24 : unilateral videothoracoscopic splanchnicectomy, n = 11 ; unilateral videothoracoscopic splanchnicectomy with associated vagotomy, n = 5 ; and bilateral videosplanchnicectomy, n = 4. There was no postoperative complication. Pain was totally relieved and drug addiction stopped in 16 patients : 10 with unilateral videothoracoscopic splanchnicectomy, 2 with unilateral videothoracoscopic splanchnicectomy and associated vagotomy, and 4 with bilateral videosplanchnicectomy. Pain was not relieved after 4 unilateral videothoracoscopic splanchnicectomies, but bilateralization was not attempted in that subgroup. CONCLUSIONS : Unilateral videothoracoscopic splanchnicectomy is the treatment of choice of intractable pancreatic pain, affording drug cessation and recovery of daily activity in most patients. Failure may be treated secondarily by bilateralization with excellent results. Bilateral videosplanchnicectomy need not be performed by first intention.

Anesthesiology 1996 Apr ;84(4) :980-3
Performance of local anesthetic and placebo splanchnic blocks via indwelling catheters to predict benefit from thoracoscopic splanchnicectomy in a patient with intractable pancreatic pain.
Strickland TC, Ditta TL, Riopelle JM
Department of Anesthesiology, Louisiana State University Medical Center, New Orleans, USA.

Presse Med 1995 Jun 3 ;24(20) :928-32
[Bilateral splanchnicectomy by transhiatal approach in pain of pancreatic origin. 37 cases].
[Article in French]
Bali B, Deixonne B, Rzal K, Sawhi A, Squali J, Poiree G, Lapeyrie H
Departement de Chirurgie digestive et de Cancerologie, CHU Caremeau, Nimes.
OBJECTIVES : Surgical splanchnicectomy remains a useful means to relieve pain induced by malignant tumours of the pancreas and chronic pancreatitis. We report our experience in 37 patients. METHODS : Between 1983 and 1993, 37 patients underwent transhiatal bilateral splanchnicectomy ; 32 had a non-resectable adenocarcinoma and 5 chronic pancreatitis. In all cases, morphine had been required for pain relief. RESULTS : Symptomatic pain relief was immediately achieved, with complete sedation in 84.3% of the cases. Prolonged antalgic effect continued for the survival period in 84.3%. Mean post-operative follow-up was 12.7 weeks corresponding to mean survival in 32 patients with pancreatic tumour. Post-operative mortality was 21.6% with no direct relationship with neurectomy. Specific morbidity related to pleural drainage was 10.8%. CONCLUSION : Compared with other surgical procedures, trans-hiatal bilateral splanchnicectomy is a simple technique which can be performed whatever the stage of the locoregional tumour extension. In patients without an indication for exploratory laparoscopy, percutaneous chemical neurolysis is still indicated, even if the long-term result is less effective. In case of failure or technical impossibilities, thoracoscopic splanchnicectomy should be performed.

Ann Chir 1994 ;48(11) :1025-8
[Circulatory arrest after splanchnic neurolysis with phenol in unresectable cancer of the pancreas].
[Article in French]
Lalanne B, Baubion O, Sezeur A, Tricot C, Gaudy JH
Service de Chirurgie Generale et Digestive, Hopital Rothschild, Paris.
One of the treatments for pain in patients with unresectable pancreatic cancer is chemical splanchnicectomy by phenol. We report two cases of severe cardiac arrhythmia followed by circulatory arrest, during intraoperative chemical splanchnicectomy. The cardiac toxicity of phenol is known in plastic surgery (face peeling). The reasons for this toxicity are not well known. We recommend that phenol be replaced by alcohol during chemical splanchnicectomy, because of its safety.

Anesthesiology 1992 Apr ;76(4) :534-40
Three posterior percutaneous celiac plexus block techniques. A prospective, randomized study in 61 patients with pancreatic cancer pain.
Ischia S, Ischia A, Polati E, Finco G
Institute of Anesthesiology and Intensive Care, University of Verona, Ospedale Policlinico Borgo Roma, Italy.
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.

Cancer 1996 Aug 1 ;78(3 Suppl) :605-14
Palliation. Surgical and otherwise.
Lillemoe KD, Pitt HA
Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
Carcinoma of the pancreas remains a disease with a grim prognosis. The majority of patients are not resectable for cure at the time of presentation, with less than 20% of affected patients surviving 1 year after diagnosis. Because cure is unlikely for most patients, palliation of symptoms (obstructive jaundice, duodenal obstruction, and pain) is of primary importance. Obstructive jaundice is the most common presenting symptom for cancer of the pancreas and can be managed by both surgical and nonoperative techniques. Although prospective randomized studies support an early advantage to the nonoperative techniques, concern for late complications, including recurrent jaundice and duodenal obstruction, favor a surgical approach. The management of pain due to unresectable carcinoma of the pancreas remains a significant problem. A recent prospective randomized study has shown that intraoperative chemical splanchnicectomy with 50% alcohol significantly relieves or prevents pain when compared with a placebo treatment. For patients not undergoing surgery, a percutaneous celiac nerve block can be performed quickly with overall good results. The decision to perform nonoperative versus surgical palliation for pancreatic cancer is influenced by the patient's symptoms, overall health status, projected survival, and the expected procedure-related morbidity and mortality. The major advantage for surgical palliation is the ability of a single procedure to combine adequate long term palliation for all three primary symptoms of the disease. Most surgical series report acceptable hospital morbidity and mortality, and a reasonable postoperative length of hospital stay.

Ann Gastroenterol Hepatol (Paris) 1991 Jun ;27(4) :163-6
[Percutaneous alcoholization of the celiac plexus under echographic guidance : an alternative to splanchnicectomy ? Study of 21 cases].
[Article in French]
Bastid C, Schonenberg P, Guedes J, Sahel J
Service d'Hepato-Gastroenterologie, Hopital Sainte-Marguerite, Marseille.
Celiac plexus block is usually performed under fluoroscopic or tomodensitometric guidance. We report on a new procedure using sonographic guidance. The patient lies in supine position. We use a real-time sonograph (Kontron Sigma 1 AC) with a 3.5 MHz probe. On a transverse plane, the celiac axis is localized emerging from aorta. After local anesthesia, the tip of the spinal needle (177 mm, 22 G) is placed close to aorta (about 5 mm) on both sides. 10 to 15 ml of 1 per cent lidocaine then 10 to 15 ml of absolute alcohol are injected on each side. 21 patients (10 males, 11 females, mean age : 61) underwent the procedure. They presented with cancer of the pancreas in 14 cases, metastatic nodes in 3 cases, cholangiocarcinoma in 2 cases and chronic calcifying pancreatitis (CCP) in 2 cases. No pain relief occurred in 3 patients (14 per cent). On of those presented with CCP but the endoscopic cystic diversion of a small cyst was successful to eradicate pain. Partial pain relief occurred in 5 cases (24 per cent). Total pain relief was obtained in 13 cases (62 per cent). No complication related to the treatment was observed. Sonography is a simple and safe method of guidance to perform alcohol block of the celiac plexus. The anterior approach may prevent neurologic complications related to other methods of guidance.

Anesth Analg 1998 Apr ;86(4) :845-6
Diaphragmatic paralysis complicating alcohol splanchnic nerve block.
Rosenthal JA
Department of Anesthesiology, University of Michigan Medical Center, Ann
Arbor 48109-0048, USA. rosenthl@umich.edu

Radiol Med (Torino) 1997 Jun ;93(6) :739-42
[Computerized tomography-guided neurolytic block of the splanchnic nerve].
[Article in Italian]
Cariati M, Henriquet F, Fiorentini F, De Martini G, Pretolesi F, Roy MT,
Martinoli C
I Divisione di Radiologia, Universita di Genova.
CT-guided neurolytic splanchnic nerve block is a technique for relieving abdominal cancer pain ; the goal is the alcoholic neurolytic interruption of the sensitive structures in retroperitoneal space. CT yields accurate anatomical detailing and the course for needle placement and alcohol spread. January, 1993, to July, 1996, twenty-one bilateral splanchnic nerve blocks were performed through the posterior access. Forty-eight hours after alcoholization, 14 patients (66%) had complete pain regression ; 52% of the patients needed no analgesics for 6 to 54 days and only 9 patients (42%) needed another low opioid therapy. Complications included hypotension and diarrhea in all cases. One had a cardiac arrest and died 8 days after the procedure. There were no other complications. The whole procedure usually lasted 60 min (range : 45 to 90 min). Splanchnic nerve neurolysis is a useful treatment in the patients with severe chronic abdominal pain. It is used as a second line treatment when large lesions change celiac anatomy and complicate the percutaneous block of the celiac plexus.

J Comput Assist Tomogr 1996 Jan-Feb ;20(1) :157-60
Retrocrural splanchnic nerve alcohol neurolysis with a CT-guided anterior transaortic approach.
Fields S
Department of Radiology, Hadassah University Hospital, Jerusalem, Israel.
Retrocrural splanchnic nerve alcohol neurolysis with a CT-guided anterior transortic approach, a new method for splanchnic block alleviation of chronic abdominal pain, is described. Ten patients with chronic abdominal pain requiring narcotic treatment, six with pancreatic carcinoma, one with gastric carcinoma, two with chronic pancreatitis, and one with pain of unknown etiology, were referred for splanchnic nerve neurolysis. With CT guidance, a 20 gauge needle was placed through the aorta into the retrocrural space at T11-T12, and 5-15 ml 96% alcohol was injected into the retrocrural space. Following the procedure, 6 of 10 patients were pain free, 2 patients had temporary pain relief, and 2 patients were without response. There were no significant complications. CT-guided anterior transaortic retrocrural splanchnic nerve alcohol neurolysis is technically feasible, easier to perform than the classic posterolateral approach, and may have less risk of complications. The success rate in this initial trial was reasonable and, therefore, this technique provides an additional method for the treatment of abdominal pain.

Pain 1993 Dec ;55(3) :363-6
CT-guided neurolytic splanchnic nerve block with alcohol.
Fujita Y
Department of Anesthesiology, Kawasaki Medical School, Okayama, Japan.
Over a 3-year period, neurolytic abdominal visceral sympathectomy was performed bilaterally with 15 ml of alcohol solution (14 ml of alcohol and 1 ml of contrast material) through each needle under CT guidance to relieve upper abdominal or back pain in 27 cancer patients. Using the CT monitor, our intention was to achieve splanchnic nerve neurolysis rather than celiac plexus neurolysis. After determining the trajectory for needle placement on the CT image at the L1 level, the needles were inserted bilaterally with a simple guide apparatus. The needle tips were successfully positioned in the retrocrural space in 48 (83%) of 54 insertions. Pain was substantially relieved in 20 of 21 patients receiving bilateral splanchnic nerve neurolysis. Tissue pressure was significantly higher after alcohol injection when the needle tips were located in the retrocrural space than when they were placed in the anterocrural space. CT images after alcohol injection revealed antero- and posterocrural spread in 11 of 21 patients who received bilateral splanchnic nerve neurolysis. It was speculated that the alcohol spread through the aortic hiatus or gaps of the diaphragmatic crura. No neurologic complications were encountered. It is concluded that CT guided alcohol splanchnic nerve neurolysis is an effective treatment for upper abdominal cancer pain, and that 15 ml of alcohol solution through each needle is enough for splanchnic nerve neurolysis.