Letter to the Editor regarding “CT guided neurolytic blockade of the coeliac plexus in patients with advanced and intractably painful pancreatic cancer”
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Ulf E. Kongsgaard
Dear Editor
I read with interest the article by Jan Henrik Rosland and John Terje Geitung addressing the important topic of neurolytic blockade of the coeliac plexus in unresectable pancreatic cancer [1]. I pointed out many years ago that this is still a very useful therapeutic strategy and should be a therapeutic alternative for patients with intractable cancer pain [2]. What is important, however, is that these patients must be treated in a multidisciplinary setting, offering surgical, endoscopic, oncologic and palliative treatment, as soon as pancreatic pain is diagnosed. We must remember that although pain is a challenge in many patients, icterus, nausea, weight loss, fatigue, mood changes, diabetes, pancreatitis, hormonal disturbances, gastric retention and ascites are symptoms that also need to be addressed. What is interesting is that in some cases, a successful neurolytic blockade will not only ease pain, but can also have effect on other symptoms [3].
It is important to select the most suitable treatment depending on patients’ actual medical state and the predicted outcome [4]. However, pain intensity will differ between patients, and it is difficult to identify the patients who will benefit from a blockade compared to conventional pain therapy.
There are arguments for early us of neurolytic blockades [5, 6], but although there are practice guidelines published [7], there is still a debate when to do a block, insert a neuraxial catheter, or try conventional pharmacotherapy.
There are different methods for performing the block. CT-guided neurolytic blockade is well established. As mentioned by Roseland, endoscopic ultrasound guided blockade is used in many centers. Also, it should be pointed out that this blockade is also feasible through thoracoscopy [8].
Roseland is probably right in claiming that conventional, high-quality, controlled studies are difficult in this patient population. However, larger observational, registry studies, if performed through international collaboration, should add sound knowledge. Although interesting and well written, I am not so sure that yet another small observational study including 11 patients, and with vague conclusions, will guide us in the future.
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Conflict of interest: None declared.
References
[1] Rosland JH, Geitung JT. CT guided neurolytic blockade of the coeliac plexus in patients with advanced and intractable painful pancreatic cancer. Scand J Pain 2018;18:247–51.10.1515/sjpain-2017-0185Suche in Google Scholar PubMed
[2] Kongsgaard UE, Bjorgo S, Hauser M. Neurolytic blocks for cancer pain – still a useful therapeutica strategy. Tidsskr Nor Laegeforen 2004;124:481–3.Suche in Google Scholar
[3] Brian MY, Myers RP. Neurolytic Celiac plexus block for pain control in unresectable pancreatic cancer. Am J Gastroenterol 2007;102:430–8.10.1111/j.1572-0241.2006.00967.xSuche in Google Scholar PubMed
[4] Masuda T, Kuramoto M, Shimada S, Ikeshima S, Yamamoto K, Nakamura K, Baba H. Splanchnectomy for pancreatic cancer pain. Biomed Res Int 2014;2014:941726.10.1155/2014/941726Suche in Google Scholar PubMed PubMed Central
[5] Wyse JM, Chen YI, Sahai AV. Celiac plexus neurolysis in the management of unresectable pancreatic cancer: when and how. World J Gastroenterol 2014;20:2186–92.10.3748/wjg.v20.i9.2186Suche in Google Scholar PubMed PubMed Central
[6] Yoon DM, Yoon KB, Baek IC, Ko SH, Kim SH. Predictors of analgesic efficacy of neurolytic celiac plexus block in patients with unresectable pancreatic cancer. Support Care Cancer 2018;26:2023–30.10.1007/s00520-018-4043-2Suche in Google Scholar PubMed
[7] Wyse JM, Battat R, Sun S, Saftoiu A, Siddiqui AA, Leong AT, Arturo Arias BL, Fabbri C, Adler DG, Santo E, Kalaitzakis E, Artifon E, Mishra G, Okasha HH, Poley JW, Guo J, Vila JJ, Lee LS, Sharma M, Bhutani MS, et al. Practice guidelines for endoscopic ultrasound-guided celiac plexus neurolysis. Endosc Ultrasound 2017;6:369–75.10.4103/eus.eus_97_17Suche in Google Scholar PubMed PubMed Central
[8] Bhutiani N, Cheadle GA, Bahr MH, Vitale GC. Comparative efficacy of bilateral thoracoscopy splanchnicectomy for intractable pain secondary to pancreatic cancer vs chronic pancreatitis. J Am Coll Surg 2017;224:566–71.10.1016/j.jamcollsurg.2016.12.048Suche in Google Scholar PubMed
©2018 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved.
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- Editorial comment
- Support for mirror therapy for phantom and stump pain in landmine-injured patients
- Lifting with straight legs and bent spine is not bad for your back
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