Transhiatal bilateral splanchnicotomy for pain control in pancreatic cancer: basic anatomy, surgical technique, and immediate results in fifty-one cases.

Abstract

The greater splanchnic nerves are largely responsible for innervation of the supramesenteric viscera; their section is known to be efficient to relieve pancreatic pain. Transhiatal splanchnicotomy (THS) is easily performed through a midline laparotomy. The nerve trunks are readily identified in the submediastinal space, far from the pancreatic cancer motivating splanchnicotomy, and can be sectioned safely and completely. After carrying out an anatomic study to determine the level of origin and mode of constitution of the greater splanchnic nerve trunk and its relations to the posterior and lower mediastinum, 51 patients underwent THS for intractable pain caused by unresectable pancreatic adenocarcinoma. THS alone was performed in 22 cases. THS was performed in association with biliary tract diversion or gastroenteroanastomosis in the other cases. All tumors were considered unresectable during surgery, and no patient was operated on with the sole purpose of performing THS. Two deaths (3.9%) were unrelated to THS. Specific morbidity was 6% (one pneumothorax, one chylothorax, and one splenic injury). Immediate postoperative functional results were good in 86.3% of patients treated by THS alone (group 1) and in 80.7% of patients treated by THS and bypass (group II). Functional results decreased to 72.7% in group I and 62.1% in group II, 3 months after surgery. In conclusion, THS appears to be an efficient technique for relief of pancreatic neoplastic pain and need not be combined or confused with medical percutaneous methods of neurolysis.