|Year : 2021 | Volume
| Issue : 1 | Page : 16-23
Celiac plexus neurolysis for intractable upper abdominal malignant pain: A review article
Anurag Agarwal, Shivani Rastogi, Anuj Gautam, Deepak Malviya, Sujeet Rai, Manoj Giri, Shilpi Mishra, Sandeep Yadav
Department of Anesthesiology, CCM and Pain Medicine, Dr. RMLIMS, Lucknow, Uttar Pradesh, India
|Date of Submission||21-May-2020|
|Date of Decision||10-Jul-2020|
|Date of Acceptance||24-Aug-2020|
|Date of Web Publication||27-Apr-2021|
Dr. Shivani Rastogi
Department of Anesthesiology, CCM and Pain Medicine, Dr. RMLIMS, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Celiac plexus neurolysis (CPN) is an effective intervention of upper abdominal malignant pain. Multiple approaches have been described for performing CPN. This narrative review has been done to evaluate current literature on CPN by different approaches and to determine whether anyone approaches is better. The literature search of PubMed and Google Scholar was done and relevant literature was compiled for the review. The literature was reviewed to find the preferred technique of CPN by different investigators and differences in the outcome and/or complications and side effects. Multiple techniques of CPN such as classic retrocrural approach, antecrural approach, transaortic approach, anterior approach, and transdiscal approach have been used by different researchers. Effective pain relief and improved quality of life (QOL) have been reported to be achieved by all the approaches. Unilateral transaortic approach has been found to be associated with less morbidity owing to single needle and with a lesser volume of neurolytic agent used. The most common imaging method used by a large number of researchers is c-arm fluoroscope, though few authors have recommended computed tomography scan-guided CPN, especially in cases with distorted anatomy due to disease spread or metastasis. This review has focused only on CPN by the pain physicians. Other techniques such as endoscopic ultrasound technique by gastroenterologists and splanchnic radio-frequency ablation have not been compared. CPN is an effective technique for pain control and improved QOL in upper abdominal malignant pain. The selection of approach is largely dependent on the pain physician's choice and does not show the difference in the outcomes.
Keywords: Cancer pain, celiac plexus neurolysis, upper abdominal pain
|How to cite this article:|
Agarwal A, Rastogi S, Gautam A, Malviya D, Rai S, Giri M, Mishra S, Yadav S. Celiac plexus neurolysis for intractable upper abdominal malignant pain: A review article. Indian J Pain 2021;35:16-23
|How to cite this URL:|
Agarwal A, Rastogi S, Gautam A, Malviya D, Rai S, Giri M, Mishra S, Yadav S. Celiac plexus neurolysis for intractable upper abdominal malignant pain: A review article. Indian J Pain [serial online] 2021 [cited 2021 Sep 24];35:16-23. Available from: https://www.indianjpain.org/text.asp?2021/35/1/16/314703
| Introduction|| |
Celiac plexus neurolysis (CPN) is the chemical neurolysis of the visceral afferent fibers that transmit pain from the upper abdominal viscera and is additionally recommended by the WHO Cancer Pain Relief Ladder.,
Pharmacological relief of pain from upper gastrointestinal malignancies begins with nonopioid drugs such as paracetamol, “stepping up” to weaker opioids such as tramadol, and subsequently, more powerful opioids such as morphine or fentanyl., However, certain adverse effects of opioids such as nausea, constipation, somnolence, addiction, confusion, or respiratory depression mark the limitation of these drugs and thus somehow led to failure in achieving adequate analgesia. In these situations, neurodestructive interventional methods involving the main cancer origin pain pathways, such as CPN, seem efficient.
Various approaches of CPN have been described in literature depending on the site of injection and route of a needle. These procedures can be done under computed tomography (CT), c-arm fluoroscopy, and ultrasonography guidance to increase the efficacy and decrease the complications. However, there is a lack of evidence suggesting that which approach provides the most effective pain relief with minimal complications; this may be partially due to a lack of well-designed studies comparing different approaches.
| Literature Search|| |
The literature search of PubMed and Google Scholar was done and relevant literature was compiled for the review. The literature was reviewed to find the preferred technique of CPN by different investigators and differences in the outcome and/or complications and side effects.
| History|| |
Percutaneous techniques of celiac plexus and splanchnic nerve block for surgical anesthesia were introduced long back in 1914 by Kappis, but later with the introduction of neuromuscular blocking agents into clinical practice of anesthesia, celiac plexus block went out of favor., Pitkin in 1946 also stated that celiac plexus blockade for surgical anesthesia is only an experimental tool.
As pain medicine emerged as a subspecialty under anesthesiology in the later quarter of the last century, CPN was finally introduced to palliate abdominal pain secondary to a variety of etiologies, especially abdominal malignancies. Gage and Floy in 1947 described the use of CPN in alleviating pain of the pancreatitis and finally in 1964, Bridenbaugh et al. used CPN to treat pain secondary to abdominal malignancies, in the same year, Jones and Gough introduced “alcohol induced neurolysis” of splanchnic nerves. Moore has been credited for the establishment of CPN as an important tool in pain management practice in 1965 by further modified original Kappis's technique using “landmark technique.”, Soon after in 1971, Gorbitz (by use of plain X-ray to facilitate CPN) related radiology to pain management practice and finally in 1979, Hegedüs stressed upon the importance of fluoroscopic guidance in ascertaining correct needle placement and radiocontrast material spread during CPN, which is still the most common method employed by most pain physicians worldwide.
Subsequently, an anterior percutaneous approach was described by Wendling, but the technique was not widely accepted because of the substantial risks that were associated with it. Popper described the use of celiac plexus block as a diagnostic tool to differentiate between the somatic and visceral components of abdominal pain. Jones in 1957 provided the primary description of ethanol-induced neurolysis of the celiac plexus and splanchnic nerves for long-term pain relief.
Image guidance gained popularity in the 1950s to increase the accuracy of needle placement. Haaga and Reich in 1977 described CT-guided celiac plexus block to further increase the accuracy, yet fluoroscopy is the most preferred way among pain physicians owing to less radiation exposure, economical, and easy availability.
| Anatomy|| |
The celiac “plexus” is the largest plexus, innervating the upper abdominal organs (pancreas, gallbladder, diaphragm, liver, spleen, adrenal glands, kidneys, abdominal aorta, mesentery, stomach, small bowel, colon, and therefore, the proximal portion of the transverse colon).
The celiac plexus is situated within the retroperitoneal space posterior to the stomach and pancreas, close to the celiac axis, and it is separated from the vertebral column by the crux of the diaphragm. It comprises a dense network of ganglia around the aorta, with considerable variability in size (0.5–4.5 cm), number (7–11), and position (from the T12–L1 disc space to the middle of the L2 vertebral body). The left celiac plexus is typically located more caudally than its counterpart on the right. Celiac neurolysis may target either the plexus or the ganglia [Figure 1]. The preganglionic sympathetic fibers of the celiac plexus are grouped into the greater (T5–10), lesser (T10–11), and least (T12) splanchnic nerves, and the plexus also receives parasympathetic fibers from the celiac branch of the right vagus nerve.,
| Indications|| |
CPN has been recommended as an interventional approach by the WHO PAIN LADDER in patients suffering from intractable pain due to upper gastrointestinal malignancies such as lower esophagus, stomach, hepatobiliary, pancreas, small intestines, and ascending colon and not relieved from conservative treatment. CPN can also be useful in patients of chronic pancreatitis with abdominal pain.,
| Contraindications|| |
Absolute contraindications for CPN are a lack of patient cooperation and low platelet count/coagulopathy. Relative contraindications for CPN are altered anatomy due to tumor invasion, prior surgery, and bowel obstruction.
Patients taking disulfiram are not good candidates because they can get tachycardia, nausea, vomiting, and headache because of accumulation of acetaldehyde, as the alcohol is not able to be broken down. Patients with drug-seeking behavior and physical dependence may be appropriate for CPN to limit the use of opioid medications for their pain control, but it is critical that patients are carefully selected.,
| Preprocedure Evaluation|| |
Written consent must be ensured and the patients are counseled for the advantages and complications that may occur following or during the procedure. The patient should be explained that the CPN is an adjunctive procedure in the management of cancer-related pain, but it will have no effect on the disease progression.
Pre intervention, patient's coagulation profile, international normalized ratio, partial thromboplastin time, and complete blood count should be assessed. A CT of the abdomen should also be obtained to see the spread of disease and rule out aortic aneurysm, especially if transaortic approach is being planned.
Patient's baseline pain intensity on a subjective scale using visual analog scale (VAS) score, the quality of life (QOL), and the dosage of opioids are recorded.
| Techniques|| |
After obtaining intravenous (IV) access, balanced salt solutions and broad-spectrum third-generation cephalosporin are given, half an hour before the intervention. Basic vital monitoring like pulse oximetry, noninvasive blood pressure monitoring, and electrocardiogram are also applied.
All approaches of CPN, except the anterior approach, are performed within the prone position on a radiolucent operation table under c-arm fluoroscopic guidance [Figure 2]. An anterior approach is usually performed with ultrasound (USG) guidance and in a supine position. It is very important to flush the needle of any remaining neurolytic agent before taking it out to prevent any track and fistula formation.
|Figure 2: Position of patient and anatomical relation of needle in different approaches in axial section|
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Various approaches have been described for CPN [Figure 3]:
|Figure 3: Anatomical relation of needle in different approaches in sagittal section|
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- Posterior (retrocrural) approach-classic approach or Kappis Approach
- Antecrural or transcrural approach
- Transaortic approach
- Transintervertebral disc (transdiscal) approach
- Anterior approach.
| Posterior (Retrocrural) Approach: (Classical Approach)|| |
The technique was originally described by Kappis and refined later by Moore. It involves needle placement posterocephalad to diaphragm within the retrocrural space, the injectate spreads up cephalad blocking solar (celiac) plexus. In the prone position and in antroposterior (AP) view of c-arm fluoroscope, needle insertion points are marked bilaterally caudal to the 12th rib about 7.5 cm, lateral to the midline. After subcutaneous infiltration of local anesthetic, a 22 G 15 cm Quincke spinal/Chiba type needle is inserted on the left side at an angle of 45° from horizontal and advanced following the direction of the 12th rib medially until contact is made with the vertebral body of L1. The needle is then withdrawn a bit and redirected to graze by the vertebral body to a point 1–2 cm beyond the anterior margin of the vertebral body in lateral view of c-arm fluoroscope. The procedure is repeated on the right side and contrast medium is injected after negative aspiration [Figure 4]. Neurolysis is carried out with 15 ml of 100% alcohol diluted with 5 ml of 0.5% bupivacaine through each needle, thus a total of approximately 40 ml of injectate (alcohol/LA) is used in this bilateral technique.
Tewari et al. in their retrospective study compared two techniques of CPN, i.e., retrocrural and transaortic in which they compared both of the groups using VAS score, QOL, morphine consumption and established decreased pain, morphine consumption and improved QOL with better results in classic retrocrural techniques. They found that classic retrocrural techniques are better than transaortic approaches.
Rahman et al. in a retrospective study concluded that low volume of alcohol has proven benefit in QOL, VAS score as well as less chances of complication as compared to the high volume of alcohol being used in bilateral retrocrural CPN.
Wong et al. tested the hypothesis in 100 eligible patients with pancreatic cancer that pain relief following retrocrural CPN with 0.5% bupivacaine and 100% alcohol improves QOL and survival. They concluded that although CPN improves pain relief as compared to systemic analgesic intervention alone, it does not influence QOL or survival. Yamamuro et al. in case series of 142 patients compared the transaortic, retrocrural, and transdiscal approach for CPN and found that all techniques were equally effective, however, they found retrocrural technique as the easiest approach.
Advantages of this method include low rate of complications and larger surface coverage for CPN, whereas disadvantages are secondary to inadvertent puncture the abdominal viscera.
| Ante or Transcrural Approach|| |
Using the same surface markings and landmarks as in retrocrural approach, the needle is advanced 1–2 cm further, piercing the crux of the diaphragm to end anterior and caudad to it in the plane of the aorta. This places needle tips lateral and approximately at the anterior wall of the aorta on the left and at the same depth correspondingly, on the right side. There should not be any resistance during injection [Figure 5]. The contrast media appears as a linear para-aortic spiral with predominance on the left side, at the extent of the upper margin of L2 vertebral body and cephalad when checked by fluoroscopy., Neurolysis is carried out with 15–20 ml of mixture of 100% alcohol and 0.5% bupivacaine given bilaterally.
Catala et al. and Rykowski and Hilgier et al. demonstrated their study by using antecrural CPN using 50% alcohol and showed analgesic and symptomatic effect presumably advantageous for about 4 weeks, but many of their patients were in the advanced stage which limited their study. Akhan et al. and Akhan et al. performed CT-guided antecrural CPN intervention and showed a significant decrease in pain.
| Transaortic Approach|| |
After localization of L1 vertebra in A-P view of c-arm fluoroscope, a 15–25° oblique view is obtained on ipsilateral left side till the tip of the transverse process (TP) is merged with the L1 vertebral body. A 15 cm 22G spinal needle is inserted at the junction of TP and L1 vertebral body in a “gun-barrel fashion” is advanced gradually with intermittent aspiration till the aorta is entered as evinced by appearance of blood. It is advanced further till blood aspiration ceases and then the dye is injected. After confirmation of correct needle placement and dye spread in AP and lateral views, neurolysis is carried out with 15 ml of 100% alcohol diluted 5 ml of 0.5% bupivacaine,.[Figure 6] and [Figure 7].
Bridenbaugh et al. concluded that transaortic CPN is safe, easy, and effective in controlling the pain without any serious complications, while De Medicis and A De Leon-Casasola, De Conno et al., and Wong and Brown et al. found complications like pain during injection (most common), orthostatic hypotension, transient diarrhea, paraplegia, and abdominal aortic dissection (rarest) to be associated with this approach. Amr and Makharita et al. compared transaortic CPN with oral analgesic management for cancer patients and found better and sustained analgesia after intervention.
Transaortic technique is widely used because of its safety and ease. The advantages of this approach are precise positioning of needle, less morbidity due to single needle, and less volume of drug used. Aortic dissection is a very rare but dreadful complication of this approach.
| Transintervertebral Disc Approach|| |
In this technique, the needle is traversed through the intervertebral disc at T12–L1 level with a patient in a prone position. AP and lateral views are done to determine correct needle tip placement (anterolateral to L1 vertebra) and dye spread. As it is also a bilateral technique, 15 ml of 100% alcohol with 5 ml of 0.5% bupivacaine is given bilaterally., Discitis is a distinct complication of this approach which can be prevented with complete surgical asepsis, IV antibiotic prophylaxis, and flushing of needles with normal saline before taking them out [Figure 8] and [Figure 9].
Ina et al. introduced transintervertebral disc approach for CPN in 1996 and showed a significant reduction in pain of pancreatic cancer patients.
| Anterior Approach|| |
Anterior abdominal approach requires placement of needle anterior to the diaphragmatic crux (at or between the celiac or superior mesenteric arteries). The patient is positioned supine on the fluoroscopy table and skin infiltration with LA is administered in the midline epigastrium. A 22G, 15 cm needle is introduced perpendicular to the skin until the needle tip touches the body of the L1 vertebra.,
Muehle et al. and Matamala et al. described the percutaneous anterior approach to the celiac plexus using radiographic or USG guidance, but as during this approach, needle traversed through abdominal viscera and few cases of penetration of the liver, bowel, pancreas, or tumor have been reported in the literature, its safety and efficacy was not established
Dhamija et al. describes the technique of USG-guided CPN using percutaneous anterior approach wherein they concluded that with the use of USG guidance, CPN can be performed in a bedside setting without the need of shifting the patient. They also concluded that the anterior approach is comfortable for the patients in pain and equally effective for pain relief without any increased incidence of complication. Lee in his case series compared the transaortic, retrocrural, and anterior approach for CPN and also found an anterior approach to better with fewer complications.
Ischia et al., Eisenberg et al., and Ogawa et al. compared three different techniques of CPN for unresectable pancreatic cancer and found that all the techniques are equally effective with low side effect profiles.
| Neurolytic Agents|| |
Alcohol and aqueous phenol are the common neurolytic agents that are used for CPN. Alcohol, in a concentration of 50%–100%, is the agent of choice. Most researchers have used alcohol in a concentration of 75%–100% and have found it effective with minimal side effects, no studies with a head-to-head comparison of alcohol concentration could be found.
The mechanism of action for alcohol had been explained as a process involving extraction of cholesterol/phospholipid and cerebroside from the neural membranes and by precipitation of mucoproteins and lipoprotein. Volume of injectate is typically 25 ml through each needle in all bilateral techniques (classic retrocrural/antecrural/transdiscal), 50 ml (single needle anterior technique), and 15–30 ml (transaortic). More favorable results are reported with higher concentration, but the potential for neurological complication also increases. Disadvantages include that it cannot be mixed with radiocontrast media (real-time radiographic documentation difficult), pain on injection, neuritis (flushing saline required before removing needle), and undesirable spread to lumbosacral plexus and sacral canal.
Phenol, used in a concentration of 5%–10%, has neurolytic action by virtue of causing protein coagulation and necrosis when directly applied to the nerves. It has a slower onset and shorter duration of action and is considered to be less efficacious than alcohol. Its high vascular affinity may preclude its use or warrants extreme caution owing to the proximity of major blood vessels. Although highly viscous and difficult to inject, its easy miscibility with radiocontrast media outscores alcohol in respect to the performance of CPN in terms of real-time radiographic documentation. Moreover, its immediate local anesthetic effect obviates any pain on injection. Aqueous phenol 10% with iodinated contrast medium is commercially available and the mixture remains stable for 3 month.,,
| Complications|| |
CPN is a relatively safe procedure with rare major complications where most of the reported complications are transient. Back pain is the most common complication, occurring in majority of patients, and is thought to result from neurolysis of sensory nerve fibers within the celiac plexus. Anterior abdominal pain is rare after a posterior approach, and its presence should alert the interventionist to possible peritoneal irritation. Orthostatic hypotension is another common complication. Hypotension results from the decreased sympathetic tone, causing vasodilatation and for this adequate fluid replacement with IV fluid is necessary to maintain an adequate blood pressure.
Transient diarrhea is a common complication of CPN, although the mechanism for diarrhea is not completely understood; it may be caused by decreased intestinal transit time and increased peristaltic activity resulting from unopposed parasympathetic activity. It is usually self-limiting in nature. Chronic diarrhea is rare and often refractory to treatment. A few studies have reported that atropine and octreotide, a somatostatin analog, may be useful in managing chronic diarrhea resulting from CPN.
Other severe complications include neurologic injuries such as monoplegia and anal and bladder sphincter dysfunction, pneumothorax, aortic dissection, local hematoma, pleuritis, and retroperitoneal abscess. Neurologic complications usually result from inadvertent injection of neurolytic agent into the spinal artery that supplies the medulla spinalis, leading to spinal ischemia. Attention to details, meticulous technique, and image guidance is very important to prevent serious complications.,,,,
Few comparative studies along with their intervention, objectives, and conclusions are shown in [Table 1].
| Conclusions|| |
Reviewing the literature, we found that all techniques of CPN were equally effective for palliation of abdominal pain. Most researchers have used the neurolytic agent alcohol in a concentration of 75%–100% and have found it effective with minimal side effects.
Hence, we conclude that CPN is an effective, percutaneous minimally invasive pain intervention for management of severe intractable pain due to upper abdominal malignancies and with minimal morbidity and rare serious side effects, so it should be employed more often in the multimodal management of pain of upper abdominal malignancies.
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Conflicts of interest
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]