|Year : 2021 | Volume
| Issue : 1 | Page : 79-82
Epidural pump implantation in refractory pain in pancreatic carcinoma
Sunny Malik1, Saurabh Joshi2, Shraddha Malik3, Leena Dadhwal4, Samarjit Dey5
1 Department of Pain and Palliative Care, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
2 Department of Pain and Palliative Care, Hospice India, New Delhi, India
3 Department of Anaesthesia, Pain and Critical Care, Rajiv Gandhi Super Speciality Hospital, New Delhi, India
4 Department of Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
5 Department of Anaesthesia, Pain and Critical Care, AIIMS, Raipur, Chhattisgarh, India
|Date of Submission||16-Apr-2020|
|Date of Decision||22-May-2020|
|Date of Acceptance||26-Jul-2020|
|Date of Web Publication||27-Apr-2021|
Dr. Sunny Malik
Department of Pain and Palliative Care, Rajiv Gandhi Cancer Institute and Research Centre, Niti Bagh, New Delhi - 110 049
Source of Support: None, Conflict of Interest: None
Reported is a case of an epidural pump implantation done in a patient with refractory pancreatic cancer pain. The patient was earlier given celiac and splanchnic nerve block and later an epidural pump was implanted when the total oral morphine dose requirements increased to >100 mg/day that led to poor tolerance of its side effects. The patient responded very well to the epidural pump with >50% pain relief.
Keywords: Cancer pain, epidural, pancreatic cancer, pump implantation
|How to cite this article:|
Malik S, Joshi S, Malik S, Dadhwal L, Dey S. Epidural pump implantation in refractory pain in pancreatic carcinoma. Indian J Pain 2021;35:79-82
| Introduction|| |
Pain is one of the most common and distressing symptoms reported by patients suffering from cancer. Inadequately managed chronic cancer pain negatively impacts sleep, mood, and behavior and may also lead to long-term changes at the level of central and peripheral nervous system. Being a multidimensional phenomenon, the treatment required for management of pain is also multimodal. Although the WHO pain management ladder had been the mainstay of cancer pain management since it was first formulated in 1986, more recently, the addition of interventional pain management techniques (peripheral nerve blocks, field blocks, sympathetic neurolysis, epidural block, radiofrequency ablations, etc.) has improved the outcomes, especially in patients with refractory cancer pain not amenable to pharmacotherapy alone. In addition, it also helps to reduce the distressing adverse effect profile of the commonly used opioids and adjuvant medications. There are a multitude of options available for the management of cancer pain. Apart from pharmacotherapy that gives satisfactory pain relief in 75% of the cases up to terminal stages, there are refractory cancer pain cases which need interventions for further pain relief at some point of time.
Although peripheral nerve blocks, field blocks, sympathetic neurolysis, epidural blocks, and radiofrequency ablations are being commonly performed at various tertiary care centers across the country, some specialized interventions such as intrathecal and epidural pump implantation and implantable peripheral nerve field stimulators are also intermittently required, especially if the pain is severe and life expectancy is considerable.
There are cases where an interventional pain management expert has to think and perform some advanced implantable treatment techniques (a tunneled percutaneous catheter which is connected either to an external pump or is a totally implanted system with drug reservoir) where these sympathetic blocks have been repeated over time and time again and the patient is still having pain. We report a case of pancreatic malignancy where we implanted an epidural catheter that was connected to a tunneled percutaneous port for drug administration.
| Case Report|| |
A 60-year-old normotensive and nondiabetic male patient referred to a pain clinic with severe upper abdominal pain. He was diagnosed as a case of carcinoma pancreas with liver metastasis. After an initial treatment with stereotactic body radiotherapy, he was on gemcitabine- and paclitaxel-based chemotherapy. Gradually increasing tumor mass and liver metastasis were the causes of the abdominal pain. He was first managed conservatively using nonsteroidal anti-inflammatory drugs (diclofenac-sustained release tablets 100 mg once daily for 5 days) and antidepressant duloxetine 20 mg at night. Due to severe pain intensity, morphine-sustained release tablets 30 mg twice daily were started after titration of the dose with immediate-release preparations. With increasing doses of morphine, the patient started complaining of excessive sleepiness and constipation. Because of the increasing doses of opioids and their side effects, he underwent transaortic celiac plexus neurolysis after a diagnostic injection and later on bilateral splanchnic radiofrequency ablation, which provided pain relief for a period of 8–9 months. In the due course of time, the patient had progression of disease and the opioid (oral morphine) dose was increased to >100 mg/day. Because of the bothersome side effects, he was planned for epidural pump implantation. Intrathecal pump implantation could not be done due to financial constraints. After getting a good pain relief (>50%) with gradual escalation of the epidural test dose morphine to 6 mg, the patient was implanted with a Vygon Mini-Sitimplant. It was introduced from the L2–L3 intervertebral space (IVS) as shown in [Figure 1] and the tip of the catheter was placed from T9–T10 IVS [Figure 2]. The tip was confirmed with dye spread that went up to T8–T9 IVS. The catheter was tunneled under the skin [Figure 3], and the port reservoir was placed in a subcostal pocket. It was then connected to a Dosi-Fuser® epidural pump with markings 1–7 (0.1% ropivacaine with 10 mg morphine in 250 ml) through a butterfly needle skin started at 3 mL/h [Figure 4], [Figure 5], [Figure 6]. The patient was advised with increased dosage of 5–7 mL/h for ½ h in case of breakthrough pain episodes. Pump refilling is being done from time to time. Oral opioids were stopped, psychological counseling continued, antiemetics/proton pump inhibitors/anxiolytics were started, and the patient is on home-based palliative care for the past 6 months. One resident doctor from the pain and palliative care team was sent for regular home visits for refilling of the pump and antiseptic care.
|Figure 4: Epidural port (Vygon Mini-Sitimplant) to be connected to the Dosi-Fuser pump|
Click here to view
| Discussion|| |
Based on the Indian Council of Medical Research (ICMR) registry data, the burden of cancer in India is estimated to be 1.45 million new cases each. The ICMR provides population-based data from 28 networked cancer registries throughout the country. Similarly, the International Agency for Research on Cancer GLOBOCAN project predicts India's cancer burden to increase to around 1.7 million by 2035., More than 75%–80% of these newly diagnosed cases have advanced disease and thus have a high need for control of pain and other symptoms alongside subjecting them to oncological treatment. The WHO estimates that 25% of all cancer patients die with unrelieved pain.
A multidisciplinary team approach (including oncologists and pain and palliative medicine physicians) with “common goals of care” at all points of time in the treatment is much needed, especially in Indian patients. With the rapidly expanding specialty of interventional pain management (since Waldman first described the term in 1996) and its penetration into cancer care, many patients are now being benefitted for management of pain by interventional pain techniques.
Our patient was diagnosed with pancreatic carcinoma and his pain was being managed with the WHO step-ladder approach till his pain became significant (due to progressive metastatic disease) and he also starting experiencing adverse effects such as constipation and sedation, which became bothersome for him (mention dose of opioid, this would be preprocedure dose). The patient was first counseled about the adverse effects of opioids and adjuvants and how it becomes better and what he needs to expect out of the current treatment. Foreseeing the need of interventional pain management, we also discussed the same in detail with him and his family. They were provided adequate time to assimilate information and turn up with any queries in the next hospital visit. The patient then underwent transaortic celiac plexus alcohol neurolysis after diagnostic local anesthetic block, with subsequent bilateral ablation of splanchnic nerves through radiofrequency. With this, the patient had significant pain relief for about 8–9 months with supplementation of lower doses of opioids and adjuvants (mention the postprocedure). Over the past next 1 month, the dose of morphine was again increased to 100 mg/day (or something like this), and the patient again started complaining of bothersome constipation and sleepiness with inability to interact with the family, which made him feel sad and isolated. At this point, issues such as expectancy, survival, cost-effectiveness, and improved quality of life with better pain control were discussed with the treating team. A consensus was then made among the family members and the treating team to proceed with a percutaneous tunneled catheter into the epidural space along with a port attached to a prefilled external reservoir pump and a test dose of 3-mg morphine with ropivacaine 0.1% was given. After the initial test dose that resulted in better pain control and the pump was implanted.
The first clinical use of an implantable intrathecal opioid delivery device was demonstrated in 1981 for use in chronic pain of malignancy. The efficacy and safety of this modality was supported by a succession of studies, establishing it as an alternative therapy for chronic pain states. While morphine, because of its history, duration of action, and ease of use, remains the gold standard of intraspinal analgesia, such modalities are definitely successful for pain relief in malignancy but is a costly affair.
Atallah postulated the use of epidural space for pain relief in cancer pain for 3–6 months. The epidural space is filled with connective tissue, fat, blood vessels, and are crossed by the spinal nerve roots and the tunneling of epidural catheter and subcutaneous port implantation reduces the chances of infection at the exit site that can contaminate the epidural space.
Rodrigues et al. introduced a technique of drug delivery into the intrathecal space through an external continuous ambulatory drug delivery pump and a reservoir bag of 250 mL containing preservative-free morphine 25 mg (concentration of 0.1 mg/mL) and ropivacaine 0.15% (concentration of 1.5 mg/mL). They used a Vygon Mini-Sitimplant for permanent intrathecal port implantation in a case series of five cancer pain patients of different malignant origin. Hence, we combined the above two techniques and implanted a Vygon Mini-Sitimplant under the skin and connected to an external reservoir (Dosi-Fuser pump) of 250 ml with 0.1% ropivacaine and 10 mg morphine and programmed at 3–5 mL/h. Over a period of 3 days, oral morphine was gradually stopped. The tip of the catheter was kept at T11 level, and a good dye spread was confirmed reaching up to T8–T9 levels. This was in view of taking care of pain relief from the pancreas as well as lymph nodes in the abdomen. The patient was discharged home after 2 days. He was followed up at home by our home care team, and he attended regular outpatient follow-up. Regular aseptic dressing was done on each visit.
| Conclusion|| |
Interventional pain management is gradually becoming an indispensable part of cancer pain management. A combination of pharmacological and interventional measures would give better symptomatic relief to patients with lesser adverse effects of opioids and adjuvants. In this case, we discuss a cost-effective and affordable alternative to intrathecal pump implantation. Precautions with the pump and dosing instructions are carefully explained and closely monitored.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Fine PG. Long-term consequences of chronic pain: Mounting evidence for pain as a neurological disease and parallels with other chronic disease states. Pain Med 2011;12:996-1004.
Vargas-Schaffer G. Is the WHO analgesic ladder still valid? Twenty-four years of experience. Can Fam Physician 2010;56:514-7, e202-5.
Ground S, Zech D, Schug SA, Lynch J, Lehmann KA. Validation or World Health Organization guidelines for cancer pain relief during the last days and hours of life. J Pain Symptom Manage 1991;6:411-22.
Gehdoo RP. Cancer pain management. Indian J Anaesth 2006;50:375-90. [Full text]
Sharma DC. Cancer data in India show new patterns. Lancet Oncol 2016;17:e272.
Mallath MK, Taylor DG, Badwe RA, Rath GK, Shanta V, Pramesh CS, et al
. The growing burden of cancer in India: Epidemiology and social context. Lancet Oncol 2014;15:e205-12.
Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394-424.
Forman D, Ferlay J. The global and regional burden of cancer. Stewart BW, Wild CP, editors. World Cancer Report 2014. Geneva, Switzerland: WHO Press; 2014;16-54.
Portenoy RK. Treatment of cancer pain. Lancet 2011;377:2236-47.
Thomas EM, Weiss SM. Nonpharmacological interventions with chronic cancer pain in adults. Cancer Control 2000;7:157-64.
Manchikanti L, Boswell MV, Raj PP, Racz GB. Evolution of interventional pain management. Pain Physician 2003;6:485-94.
Onofrio BM, Yaksh TL, Arnold PG. Continuous low-dose intrathecal morphine administration in the treatment of chronic pain of malignant origin. Mayo Clin Proc 1981;56:516-20.
Knight KH, Brand FM, Mchaourab AS, Veneziano G. Implantable intrathecal pumps for chronic pain: Highlights and updates. Croat Med J 2007;48:22-34.
Atallah JN. Management of cancer pain. In: Vadivelu N, Urman RD, Hines RL, editors. Essentials of Pain Management. New York: Springer; 2011. p. 597-628.
Rodrigues JS, Gupta P, Saksena S, Butani M. A case series discussing the intrathecal drug delivery system to improve the quality of life in terminal cancer patients. Indian J Pain 2018;32:179-83.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]