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Published in Bobby Krishnachetty, Abdul Syed, Harriet Scott, Applied Anatomy for the FRCA, 2020
Bobby Krishnachetty, Abdul Syed, Harriet Scott
The coeliac plexus is the largest sympathetic plexus located in the upper abdomen at the origin of the coeliac trunk from the abdominal aorta (T12/L1 level). It is made of the right and the left ganglia: the right ganglion lies posterior to the inferior vena cava and the left lies posterior to the origin of the splenic artery (Figure 7.10).
Diagnosing and treating pain
Published in Mervyn Dean, Juan-Diego Harris, Claud Regnard, Jo Hockley, Symptom Relief in Palliative Care, 2018
Mervyn Dean, Juan-Diego Harris, Claud Regnard, Jo Hockley
This is caused by disorders of the internal organs due to tumor, ischemia, or inlammation.54 Cardiac pain and bowel distension are examples. Liver metastases can cause pain, but only if the liver capsule is stretched or inlamed. Damage to the celiac plexus or the lumbosacral plexus by tumor or fibrosis can cause a visceral neuropathic pain. It can be difficult to separate visceral neuropathic pain (gabapentin – opioid) from compression of the celiac plexus (which might benefit from opioids + steroids) or a soft tissue pain due to retroperitoneal disease.
Development of palliative medicine in the United Kingdom and Ireland
Published in Eduardo Bruera, Irene Higginson, Charles F von Gunten, Tatsuya Morita, Textbook of Palliative Medicine and Supportive Care, 2015
The celiac plexus block by a neurolytic drug is most effective for visceral pain of the upper abdomen and is a representative nerve block procedure for cancer patients. The celiac plexus receives afferent nerve fibers from upper abdominal organs such as stomach-transverse colon, pancreas, intestines, liver, and gallbladder. This block is most suitable for pancreatic cancer and gallbladder cancer and other upper abdominal cancers. Â 42 It is important to make a clear diagnosis if pain at the upper abdomen is a visceral pain or somatic pain as this block would be ineffective for pain related to the spinal nerve system, even if it is felt in the upper abdomen. With the advancement of diagnostic imaging technology such as Computer Assisted Tomography or CAT scan and Ultrasonography (USG), many different approaches are now reported. There is no statistically significant difference in clinical efficacy among conventional posterior approaches or between retrocrural technique, transaortic approach, and splanchnic neurolysis. A celiac plexus block can achieve analgesic effects in 70%-80% of patients immediately after nerve block. It is reported that until death, 60%-75% of patients maintained analgesic effects. Â 43 A recent development in the approach is to puncture the celiac plexus directly via the posterior stomach wall under ultrasound guidance (Figure 47.5). Â 44
Pharmacotherapeutic options for pancreatic ductal adenocarcinoma
Published in Expert Opinion on Pharmacotherapy, 2022
Muhammad Sardar, Alejandro Recio-Boiles, Kabir Mody, Christian Karime, Sreenivasa R Chandana, Daruka Mahadevan, Jason Starr, Jeremy Jones, Mitesh Borad, Hani Babiker
Pain is common in advanced pancreatic cancer patients and should be addressed aggressively [94]. Celiac plexus neurolysis could be effective in select patients as pain could be primarily related to tumors proximity to the celiac plexus [95]. Obstructive jaundice is also common in patients with pancreatic head tumors and can be relieved by endoscopic placement of stents [96]. Metal stents are less likely to occlude as compared to plastic stents (median duration of patency 8–12 vs 2–5 months), however, they are more expensive and difficult to remove [97,98]. Pancreatic cancer patients can also develop gastric outlet obstruction and options include endoscopically placed expandable metal stents or palliative gastrojejunostomy [99,100]. Painful bone lesions or bleeding can be treated with palliative RT.
Feasibility study of MR-guided pancreas ablation using high-intensity focused ultrasound in a healthy swine model
Published in International Journal of Hyperthermia, 2020
Lukas Christian Sebeke, Pia Rademann, Alexandra Claudia Maul, Claudia Schubert-Quecke, Thorsten Annecke, Sin Yuin Yeo, Juan Daniel Castillo-Gómez, Patrick Schmidt, Holger Grüll, Edwin Heijman
Despite its moderately low incidence, pancreatic cancer (PaC) caused 4.5% of all cancer fatalities worldwide in 2018, making it the seventh most likely cause of cancer-related deaths [1]. PaC exhibits the lowest 5-year relative survival rate of any cancer [2]. This stems from a confluence of unfavorable characteristics, namely the late onset of symptoms, rapid involvement of the adjacent arteries, early development of metastases, and the ineffectiveness of systemic therapy [3–6]. As a result, resection is often impossible at time of diagnosis, leaving patients with limited therapeutic options, such as palliative chemotherapy [7]. The growing tumor mass often leads to complications, including duodenal- or biliary obstruction that requires the placement of stents or surgical intervention [7,8]. Furthermore, the pressure exerted on the surrounding nerves often induces abdominal and back pain, which is currently treated according to the WHO guidelines recommending a combination of analgesics escalating from nonopioids to strong opioids and adjuvant treatments [9,10]. In case the pain cannot be alleviated in this manner, celiac plexus block (CPB) and celiac plexus neurolysis (CPN) is applied [7]. However, the effectiveness of these techniques has been questioned and has not shown a significant benefit in quality of life over a placebo in a double-blinded randomized control trial [11]. Thus, patients diagnosed with advanced PaC are in urgent need of alternative treatment options and effective analgesia free of debilitating side-effects. Thermal ablation of PaC using high-intensity focused ultrasound (HIFU) offers a noninvasive method for tumor debulking and pain reduction and has therefore been explored in several clinical studies since the beginning of the century [12–21].
Interventional pain management in patients with cancer-related pain
Published in Postgraduate Medicine, 2020
Celiac plexus blocks have been widely acknowledged to treat pain in pancreatic cancer and could be used in managing pain in cancers involving lower esophagus, stomach, gall bladder, and bowel [9–11]. Unilateral blockade and lower injectate volume can minimize the side-effects of diarrhea and postural hypotension. Other serious complications like pneumothorax, vascular injury, retroperitoneal hematoma and hematuria, and serious neurological injury have been reduced with improved imaging guidance with fluoroscopy, CT and endoscopic ultrasound-guided approaches to inject lower volumes precisely. Radiofrequency ablation and retrocrural block of the splanchnic nerves are often effective in patients where celiac plexus blockade is not possible or ineffective due to tumor infiltration [7]. Hence, there is a compelling argument for early referral for neurolytic celiac plexus blocks for managing pain in patients diagnosed with pancreatic cancer, as it would become technically difficult to approach the plexus through the tumor mass. Additionally, there are significant cost benefits as most of these interventions are carried out as day case procedures and could prevent lengthy hospital or hospice stays to titrate opiates and other medications to effect. This could also help prevent the negative impact on quality of life due to the undesirable side effects of systemic medications. Superior and inferior hypogastric plexus blocks can be effective for pelvic cancer pain and ganglion impar block is often used to manage pain in localized anal cancers [12]. Ischemic and other sympathetically mediated pain in the lower limb could respond to lumbar sympathetic blockade, while stellate ganglion and T1-2 sympathetic block can be used to manage pain in head and neck cancers and upper limb pain.