Managing pain in patients with pancreatic cancer can be extremely challenging. There are a multitude of oral, sublingual, and transdermal medications available for treating this pain; however, their use is sometimes limited by side effects, cost, or polypharmacy. One such group of medications often limited by side effects includes opioid analgesics, which are frequently used to treat pain in patients with pancreatic cancer. Although opioid analgesics can provide adequate pain relief in some patients, many develop nausea, vomiting, constipation, and other deleterious side effects as the doses are increased. As the utility of endoscopy continues to expand, celiac plexus neurolysis (CPN) represents a unique approach to treating the severe pain associated with pancreatic cancer.

The celiac plexus represents a group of nerves located in the abdomen that innervate the pancreas and play a role in transmitting the pain associated with pancreatic cancer to the brain. CPN can be accomplished via several different routes: endoscopically, surgically, or percutaneously. Prior to any procedure, it is important to perform a comprehensive medication reconciliation, particularly about use of anticoagulant and antithrombotic medications that may place the patient at increased risk of bleeding.

Endoscopic ultrasound (EUS) helps identify the celiac plexus and allows for the direct administration of an anesthetic, bupivacaine, and concentrated alcohol (typically > 95%), which has bactericidal properties. During the procedure, patients should be closely monitored for signs and symptoms that are associated with hypotension, which can occur with EUS-CPN secondary to the sympathetic nerve blockade that is caused by the aforementioned agents. Occasionally, the alcohol is replaced by a steroid injection such as triamcinolone, at which point prophylactic antibiotics are sometimes administered.

Continue Reading

Several meta-analyses have reported adequate pain control with EUS-guided CPN. Two of these analyses reported between 73% and 80% efficacy in controlling abdominal pain in patients with pancreatic cancer undergoing EUS-CPN.1,2 Onset of pain relief can be relatively rapid, however, patients can occasionally experience increased abdominal pain immediately after the procedure.3 The duration of pain relief is variable, ranging from weeks to as long as 3 months. One study by Wyse and colleagues showed that patients had greater pain relief at 1 month compared with 3 months.4 

Severe complications after EUS-CPN are rare but can include infection and bleeding. Relatively benign complications include temporary hypotension, diarrhea, and postprocedural pain. Infections are typically not common and prophylactic antibiotics are not routinely recommended because the highly concentrated alcohol injected is bactericidal.

Unfortunately, there are no head-to-head studies comparing the various routes of CPN and their outcomes. Future studies comparing the different routes of administering CPN may prove useful in optimizing patient outcomes. Still, EUS provides a unique way to perform CPN, while at the same time playing a diagnostic role by providing a way to obtain tissue samples for pathology. 

References

  1. Kaufman M, Singh G, Das S, et al. Efficacy of endoscopic ultrasound-guided celiac plexus block and celiac plexus neurolysis for managing abdominal pain associated with chronic pancreatitis and pancreatic cancer. J Clin Gastroenterol. 2010;44(2):127-134.
  2. Puli SR, Reddy JB, Bechtold ML, et al. EUS-guided celiac plexus neurolysis for pain due to chronic pancreatitis or pancreatic cancer pain: a meta-analysis and systematic review. Dig Dis Sci. 2009;54(11):2330-2337.
  3. Levy MJ, Topazian MD, Wiersema MJ, et al. Initial evaluation of the efficacy and safety of endoscopic ultrasound-guided direct Ganglia neurolysis and block. Am J Gastroenterol. 2008;103(1):98-103.
  4. Wyse JM, Carone M, Paquin SC, et al. Randomized, double-blind, controlled trial of early endoscopic ultrasound-guided celiac plexus neurolysis to prevent pain progression in patients with newly diagnosed, painful, inoperable pancreatic cancer. J Clin Oncol. 2011; 29(26):3541-3546.

Topics:

In The Clinic Pain Management Pancreatic Cancer