Initial report of laparoscopic celiac plexus block for pain relief in patients with unresectable pancreatic cancer.

摘要

Pancreatic adenocarcinoma is the fifth leading cause of cancer death in the US, and at the time of diagnosis the majority of patients have advanced disease that is not amenable to resection. Pain is a frequent presenting symptom, and nearly all patients will experience pain during the course of the disease. Effective palliation of this symptom has been shown to improve a variety of quality-of-life parameters, and has been suggested to improve survival.Methods used for controlling pain include nonsteroidalantiinflammatory agents; narcotics administered orally, IV, or transdermally; and neurolytic celiac plexus block (NCPB). Described techniques for NCPB include percutaneous CT-guided injection, operative injection at the time of laparotomy, thoracoscopic neurolysis, and endoscopic ultrasonography-guided celiac injection. All of these techniques have been shown to be effective at relieving pain in patients with pancreatic cancer. NCPB can be associated with transient hypotension or transient diarrhea. When NCPB is performed at the time of operation, and under direct visualization, no major adverse effects have been identified.The first NCPB was described by Kappis in 1914, and the majority of these procedures have since been performed using a posterior percutaneous approach. This approach uses a long needle that is passed under CT guidance alongside the first lumbar vertebra to position the tip anterior to the spine. Transcrural, transaortic, and retrocrural methods have also been described. More recently, anterior percutaneous approaches have been described with CT and ultrasonography guidance, which areuseful alternatives, but carry the possibility of intraabdominalcomplications. Lillemoe and coauthors reported a prospective randomized trial of operative NCPB performed at the time of laparotomy. This trial noted no complications associated with direct injection. Improvements in pain, mood, and life expectancy were observed in patients who underwent NCPB and the majority of patients without preexisting pain never reported substantial pain until death.To our knowledge, laparoscopic celiac plexus block has not been reported in humans, although it has been tested in pigs. The purpose of this report is to describe a technique for NCPB that allows the surgeon, at the time of laparoscopy for staging, to perform NCPB for palliation of pain in patients found to have unresectable disease.