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      Neurolytic celiac plexus block for pain control in unresectable pancreatic cancer.

      The American Journal of Gastroenterology

      Abdominal Pain, drug therapy, etiology, Autonomic Nerve Block, methods, Celiac Plexus, drug effects, Humans, Neoplasm Staging, Pain Measurement, Palliative Care, Pancreatic Neoplasms, complications, pathology, Severity of Illness Index, Treatment Outcome

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          Abstract

          A major focus of palliation in patients with unresectable pancreatic cancer is pain control. The aim of this systematic review was to examine the efficacy and safety of neurolytic celiac plexus blockade (NCPB) compared with standard treatment in randomized controlled trials (RCTs) involving patients with unresectable pancreatic cancer. An electronic search was completed (1966 through August, 2005) for RCTs comparing NCPB versus control (standard treatment and/or sham NCPB) in patients with unresectable pancreatic cancer. The primary outcome was pain measured on a 10-point visual analogue scale (VAS). Secondary outcomes included opioid usage, adverse effects, quality of life (QOL), and survival. All outcomes were assessed at 2, 4, and 8 wk. Five RCTs involving 302 patients (NCPB, N = 147; control, N = 155) met the inclusion criteria. Mean age was 61.0 +/- 4.3 yr. Compared with control, NCPB was associated with lower VAS scores for pain at 2, 4, and 8 wk (weighted mean difference [WMD]-0.60, 95% CI -0.82 to -0.37). Opioid usage (in mg/d oral morphine) was also reduced at 2, 4, and 8 wk (WMD -85.9, 95% CI -144.0 to -27.9). NCPB was associated with a reduction in constipation (relative risk 0.67, 95% CI 0.49-0.91), but not other adverse events. No differences in survival were observed. QOL could not be adequately analyzed due to differences in outcome scales among studies. In patients with unresectable pancreatic cancer, NCPB is associated with improved pain control, and reduced narcotic usage and constipation compared with standard treatment, albeit with minimal clinical significance.

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          Most cited references 14

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          Resected adenocarcinoma of the pancreas?616 patients: results, outcomes, and prognostic indicators

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            Effect of neurolytic celiac plexus block on pain relief, quality of life, and survival in patients with unresectable pancreatic cancer: a randomized controlled trial.

            Pancreatic cancer is an aggressive tumor associated with high mortality. Optimal pain control may improve quality of life (QOL) for these patients. To test the hypothesis that neurolytic celiac plexus block (NCPB) vs opioids alone improves pain relief, QOL, and survival in patients with unresectable pancreatic cancer. Double-blind, randomized clinical trial conducted at Mayo Clinic, Rochester, Minn. Enrolled (October 1997 and January 2001) were 100 eligible patients with unresectable pancreatic cancer experiencing pain. Patients were followed up for at least 1 year or until death. Patients were randomly assigned to receive either NCPB or systemic analgesic therapy alone with a sham injection. All patients could receive additional opioids managed by a clinician blinded to the treatment assignment. Pain intensity (0-10 numerical rating scale), QOL, opioid consumption and related adverse effects, and survival time were assessed weekly by a blinded observer. Mean (SD) baseline pain was 4.4 (1.7) for NCPB vs 4.1 (1.8) for opioids alone. The first week after randomization, pain intensity and QOL scores were improved (pain intensity, P .10), and QOL (P =.46) were not significantly different between groups. In the first 6 weeks, fewer NCPB patients reported moderate or severe pain (pain intensity rating of > or =5/10) vs opioid-only patients (14% vs 40%, P =.005). At 1 year, 16% of NCPB patients and 6% of opioid-only patients were alive. However, survival did not differ significantly between groups (P =.26, proportional hazards regression). Although NCPB improves pain relief in patients with pancreatic cancer vs optimized systemic analgesic therapy alone, it does not affect QOL or survival.
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              Chemical splanchnicectomy in patients with unresectable pancreatic cancer. A prospective randomized trial.

              A prospective, randomized, double-blind study was completed comparing intraoperative chemical splanchnicectomy with 50% alcohol versus a placebo injection of saline in patients with histologically proven unresectable pancreatic cancer. Standardized assessment of pain, mood, and disability due to pain was completed preoperatively and at 2-month intervals until death. Chemical splanchnicectomy with alcohol was performed in 65 patients, whereas 72 patients received the placebo. The two groups were similar with respect to age, sex, location, and stage of tumor, operation performed, the use of postoperative chemo- and radiation therapy, and initial assessment scores for pain, mood, and disability. No differences in hospital mortality or complications, return to oral intake, or length of hospital stay were observed. Mean pain scores were significantly lower in the alcohol group at 2-, 4-, and 6-month follow-up and at the final assessment (p < 0.05). To further determine the effect of chemical splanchnicectomy, patients were stratified into those with and without preoperative pain. In patients without preoperative pain, alcohol significantly reduced pain scores and delayed or prevented the subsequent onset of pain (p < 0.05). In patients with significant preoperative pain, alcohol significantly reduced existing pain (p < 0.05). Furthermore, patients with preexisting pain who received alcohol showed a significant improvement in survival when compared with controls (p < 0.0001). The results suggest that intraoperative chemical splanchnicectomy with alcohol significantly reduces or prevents pain in patients with unresectable pancreatic cancer.
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                Author and article information

                Journal
                17100960
                10.1111/j.1572-0241.2006.00967.x

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