Aim: Assessment of Celiac Plexus Block and Neurolysis Outcomes and Technique in the Management of Refractory Visceral Cancer Pain
Methods: A retrospective study was conducted in the Department of Surgery, & Anesthesiology, Rama medical college hospital & research centre, Hapur, UP, India from September 2019 to August 2020. 80 Patients with non resectable abdominal malignancy, moderate or severe abdominal and/or back pain poorly controlled with pharmacotherapy were included in this study. The age, gender, duration of pain, origin of tumor, opioid dosage, type of radiological guidance (i.e., fluoroscopic Vs computed tomography [CT]), single- vs double- needle technique, type of block (i.e., anterocrural, retrocrural, or mixed), immediate vs delayed neurolysis, volume of local anesthetic employed for diagnostic block, use and type of sedation, and volume of alcohol used for neurolysis were examined.
Results: A total of 80 patients underwent CPB with CPN over the period of the study. Mean age was 55.8 years (range 35–77). There were 45 male patients (56.25%) and 35 female patients (43.75%). Duration of pain was equally split, with 40 patients (50%) having pain for less than 6 months and the same number with pain for greater than 6 months. Our sample consisted primarily of patients with pancreatic cancer (70, 87.5%) with the remainder (10, 12.5%) of other visceral origin. 41 tumors were located in the pancreatic head (58.57%), 22 in the body (31.43%), 8 in the tail (11.43%), and 12 in the neck (17.14%). The majority of patients had metastatic disease detected (65, 81.25%), while 5 patients (6.25%) did not have metastatic disease and in 10 patients (15%) this variable was undocumented. The average daily morphine equivalent dose was 248.2 mg (range 0–1165 mg). There were 30 procedures (37.5%) done under fluoroscopic guidance and 50(62.5%) done under CT guidance. Those variables that were clearly associated with a positive outcome included morphine equivalent dose per day below 250 mg and the absence of sedation for the procedure (both P>0.05). Strongly associated with positive outcome but falling just short of statistical significance were the use of CT guidance for the procedure and the use of less than 20 cc volume of local anesthetic for the diagnostic block prior to neurolysis (P< 0.07 and P<0.08, respectively). Logistic regression for those not having sedation predicting a positive outcome revealed an OR of 4.17 (95% CI = 1.12– 15.19). Logistic regression for those on preprocedural morphine equivalent dose below that for the mean for the study sample (248.2 mg/day) predicting a positive outcome yielded an OR of 9.34 (95% CI = 1.62–52.49) Although falling short of statistical significance, there was a trend toward significance found in positive procedural outcomes associated with pain duration less than 6 months (P = 0.17), single rather than double needle technique (P = 0.17), and lesions found in the tail of the pancreas (P = 0.13).
Conclusion: CPN may provide intermediate pain relief to a significant percentage of patients suffering from pancreatic cancer. Candidates likely to experience a positive outcome include those who are on lower doses of opioid analgesics, and have a shorter duration of disease.