|Year : 2016 | Volume
| Issue : 3 | Page : 204-206
Splanchnic neurolysis for gallbladder cancer pain
Pravesh Kanthed1, Pradeep Parmar2
1 Choithram Interventional Spine and Pain Centre, Indore, Madhya Pradesh, India
2 Choithram Hospital and Research Centre, Indore, Madhya Pradesh, India
|Date of Web Publication||10-Jan-2017|
601, Sakar Terraces, 2/2 New Palasia, Indore - 452 001, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Abdominal sympathetic blockade is a safe, minimally invasive and proven measure for pain control in intra-abdominal malignancies. Hereby, we report a case of severe abdominal and back pain due to advanced carcinoma gall bladder refractory to oral and transdermal medications, managed successfully by bilateral splanchnic neurolysis using 50% alcohol under fluoroscopy. Pain was significantly relieved immediately after the procedure with a gradual reduction in analgesics consumption. The effect was sustained during follow-up with improved quality of life.
Keywords: Cancer pain, gallbladder malignancy, splanchnic neurolysis
|How to cite this article:|
Kanthed P, Parmar P. Splanchnic neurolysis for gallbladder cancer pain. Indian J Pain 2016;30:204-6
| Introduction|| |
Pain in advanced cases of gallbladder cancer is often neuropathic in origin because of direct metastatic invasion or compression of peripheral nerves. Other causes include infection, bony metastasis, edema, and soft tissue infiltration. 
Celiac plexus block (CPB) is the intervention of choice in intractable pain associated with abdominal malignancies if other modalities have been exhausted and proved ineffective. 
Splanchnic neurolysis is an option in those cases of abdominal malignancies in which celiac plexus is difficult to approach because of tumor mass or other causes. It has similar effects and complications as seen in celiac plexus block.
Hereby, we report a case of successful management of severe abdominal and back pain due to carcinoma Gall Bladder by bilateral splanchnic neurolysis using 50% alcohol under fluoroscopy guidance.
Neurolytic sympathetic block is now a well-established technique for treating the cancer pain. 
No difference in pain outcome is found in patients who underwent splanchnic neurolysis with alcohol versus phenol solutions. 
| Case Report|| |
A 53-year-old homemaker, known the case of Ca Gall Bladder since 6 months having severe abdominal and back pain, was referred to our pain clinic.
The patient was in advanced stage of Gall Bladder malignancy with metastasis in liver, spine, and ribs. She had received 8 cycles of chemotherapy with paclitaxel and gemcitabine with no signs of regression. No curative or palliative surgery was attempted or planned. She had chronic pain of 10/10 score on numeric rating scale originating in the right hypochondrium and radiating to whole abdomen, middle and lower back. She was receiving 120 mg morphine daily with 50 mcg/h fentanyl patch. Pain control was inadequate and associated with constipation which was irresponsive to treatment.
Her past medical and surgical history was not significant. She had a distorted anatomy due to the invasion of celiac plexus region with tumor mass, hence it was not prudent to go for celiac plexus block or neurolysis.
Therefore, bilateral splanchnic neurolysis was planned at a higher level. The procedure was explained to the patient and informed written consent was taken. The patient was kept nil by mouth for 6 h before procedure. The patient was taken to pain laboratory and preloaded with 500 ml NS. The patient was given prone position, and standard monitors were attached, i.e., noninvasive blood pressure cuff, Pulse Oximeter probe, and electrocardiogram electrodes.
Fluoroscopy guided localization of T11 vertebra was performed under direct anteroposterior (AP) view. The endplates of the T11 vertebra were squared. C-arm was moved to the oblique position while keeping a mark on T11 and the edge of diaphragm lateral to the vertebral body was viewed. The point of entry was just below the junction of rib and vertebra. Skin infiltration was made with 2% lignocaine at this point. In same oblique fluoroscopic view, a 16-gauge, 5-cm in troducer needle was inserted and advanced using a gun barrel technique. Lateral view of the C-arm was taken to check the depth of the needle when two-thirds of the introducer needle was inserted. Now the stylet was removed and a 22G, 12 cm, Quincke's spinal needle, bend at tip for easy maneuvering, was inserted. With short thrusts of 0.5 cm at a time, the tip of the needle was advanced anteriorly, keeping in mind that the needle stays hugging the lateral aspect of the T11 vertebral body, close to the costovertebral angle. In the lateral view, the needle was advanced until it reached the junction of anterior one-third and posterior two-thirds of the lateral aspect of the vertebral body [Figure 1]. AP, oblique, and lateral views were taken to confirm the final position of the curved needle on the vertebral body. Iohexol (240) was injected to note that the dye spreads in AP [Figure 2] and lateral views hugging the spine [Figure 3]. Two milliliters of 2% lignocaine was injected before the injection of 8 ml of 50% alcohol, to avoid discomfort by alcohol injection.
|Figure 1: Depth assessment in lateral view. Needle tip at the junction of posterior two-third and anterior one-third of vertebral body.|
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The same procedure was repeated on the opposite side in the same sitting. The patient was discharged after 24 h of observation. There was no untoward event noted during the observation except a self-limiting bout of loose motion 6 h after the procedure.
| Discussion|| |
Gall Bladder is the most common abdominal malignancy in Northern part of India and shows a greater incidence in female sex. 
It is fifth most common cancer of gastrointestinal tract and the most common cause of death from biliary malignancies. 
It is the most aggressive biliary cancer with 5 years survival rate of 5% in advanced cases and mean survival of only 6 months.
The patients usually present late when the disease has already advanced contributing to dismal prognosis at the time of diagnosis. Abdominal pain, fever, jaundice, and loss of weight are prominent features of Gallbladder Cancer with abdominal pain being severe and distressing in advanced metastatic disease.
Celiac plexus is formed by the splanchnic nerves that traverse the posterior mediastinum and enter the abdomen through the diaphragmatic crus to synapse at the right and left celiac ganglia. It is involved in nociceptive transmission from the upper abdominal viscera. The sphlanchnic nerves originate from cell bodies of the intermediolateral cell column (lateral horn) of the T7 to T12 spinal cord segments. Greater (T5-T10), lesser (T10-11), and least (T12) sphlanchnic nerves are comprised of preganglionic efferent and visceral afferent nerve fibers. From the celiac ganglia, the preganglionic efferent fibers then innervate their target visceral structures.
The celiac plexus transmits pain signals originating from all abdominal viscera and the majority of pelvic viscera, including the pancreas, liver, gallbladder, stomach, renal pelvis, ureter, and intestine proximal to the transverse colon. 
Most frequent indication for celiac plexus block is pain secondary to an upper abdominal malignancy, although it is very effective for pain generated by retroperitoneal tumors or metastases. 
Shwita et al. 2015  conducted a study to compare the effects of the retrocrural celiac plexus block versus splanchnic nerve block, under C-arm Guidance for upper gastrointestinal tract tumors on pain relief and the quality of life at a 6-month follow-up. They found that the efficacy of the splanchnic nerve block was clinically comparable to a celiac block.
In our patient, the celiac plexus region was engulfed by the tumor mass, hence we decided on the chemical neurolysis of greater splanchnic nerves using 50% alcohol.
Although it is recommended to perform a diagnostic block with a local anesthetic before proceeding to neurolysis, the predictive value of this is not absolute  and the patient was in extreme agony at presentation.
Pain was relieved significantly after the procedure and the need for adjunctive therapies for pain control was minimized. Constipation was relieved partially, and the need for treatment was abolished because the opioid intake substantially reduced after the procedure. The quality of life improved as the patient reported in the follow-up visits.
| Conclusion|| |
Splanchnic plexus neurolysis is a good but lesser utilized intervention in cases of pain secondary to upper abdominal malignancies. In patients with nodal metastasis engulfing the celiac axis, celiac plexus neurolysis will not work as the neurolytic solution will not reach the plexus. In such cases, splanchnic neurolysis is the intervention of choice to offer pain relief.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]