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Background: Chronic cancer pain is a widespread public health issue. Studies of cancer patients' pain control consistently reveal that up to half of patients receive inadequate analgesia. Aim: The primary aim of this study was the reduction in numerical rating scale (NRS) score for pain in gastric and pancreatic malignant patients who have undergone USG guided anterior approach coeliac plexus ethanol neurolysis.(CPN) Methods: This is a retrospective cohort study. Secondary outcome measure was a reduction in consumption of oral analgesics and morphine.This procedure was done in an ICU as a bedside procedure. Trial coeliac plexus block was done after identification of celiac trunk using ultrasound, 15 cc of 1% xylocard was given after negative aspiration of blood and under direct visualization. After 30 minutes pain relief was assessed with Numerical rating scale for pain (NRS). Patient was then given 20ml of 60% ethanol after negative aspiration of blood and under direct visualization. Pain relief was documented using NRS immediately and at 24hours, 72 hours,1 week and 3 months. Results 90% of the patients had a pain relief which is significant and did not require any oral analgesics and oral morphine. The remaining 10% of the patients required oral analgesics and oral morphine but the total consumption was reduced. Our study shows highly statistically significant difference between pre-NRS and post immediate-NRS (mean 8.26 ±0.52 and 3.40 ±0.47)(P value <0.0001) and significant decrease in NRS seen after 24 hours,72 hours,1 week,and 3 months. Pre and post procedure morphine consumption shows significant difference in p-value (0.007). Hypotension is most common complication recorded Conclusion USG guided anterior approach coeliac plexus ethanol neurolysis is effective in treating pain associated with gastric and pancreatic malignancy
The incidence of Gastric malignancy is relatively high in southern parts of India particularly in Chennai,and the incidence of pancreatic malignancy is also rising in India.[1] Although surgical resection procedures can be done,only 15-20% presents themselves to the hospital at this stage. Pain associated with gastric and pancreatic malignancy presents mostly as abdominal pain that may radiate to the back. Mid epigastric Pain is the most common symptom in these patients. 80% of patients with advanced pancreatic cancer complain of abdominal and/or back pain.[2] At the time of diagnosis, the disease is often advanced and up to 73% of patients suffer from abdominal pain.[3] Inadequately treated pain can have profound negative effects on the psychosocial and physical well being of the patients and it subjects them to an avoidable anxiety and depression.[4] Morbidity and mortality increase in patients with chronic pain. A good pain relief obtained with coeliac plexus neurolysis can improve the morbidity, mortality and well being of the patient.[5] Coeliac plexus neurolysis is conventionally done under CT, fluoroscopic guidance or endoscopic ultrasound. Most patients come for pain management in more advanced stages of cancer and they have difficulty in lying in prone position or subjecting themselves to endoscopy. A procedure which allows the patient to lie supine and can be done at bedside will be most acceptable one.
AIM
The primary aim of this study was the reduction in Numerical rating scale for pain (NRS) score for pain in gastric and pancreatic malignant patients who have undergone anterior USG guided coeliac plexus ethanol neurolysis (CPN).
The study was conducted at Chronic pain management center in a tertiary care hospital. Hospital ethics committee approval was obtained before starting this study. Gastric and pancreatic malignancy patients with abdominal pain who have undergone coeliac plexus ethanol neurolysis during the period from September 2015 to March 2016 were selected and their data were analyzed retrospectively. This technique of bedside anterior approach ultrasound guided coeliac plexus ethanol neurolysis was done in 30 patients of whom 25 were men and 5 women with a mean age of 44.
INCLUSION CRITERIA:
EXCLUSION CRITERIA:
Pre-assessment of all the patients is done a day before the procedure, relevant history obtained and general examination is done. Ultrasound abdomen and CT abdomen are taken to rule out invasion to vital structures. Normal coagulation profile is ascertained prior to the procedure. Analgesics are stopped on day of procedure. Patients placed on nil per oral orders eight hours prior to the procedure. Patient was taught about breath holding. Expected qualitative and quantitative pain relief was discussed and the anticipated complications are explained and informed consent is obtained. Numerical rating scale used for pain assessment is explained to the patient. With injection cefotaxime 1 gm,one hour prior to the procedure is administered as a prophylactic antibiotic.
Numeric rating scale (NRS) for pain is used to assess the pain intensity. It is a segmented numeric version of visual analogue score that best reflects the intensity of pain. it is a 11 point numeric scale starting from 0 representing no pain and 10 representing the worst possible pain.
Patient’s are given USG guided diagnostic trial coeliac plexus block with 10 cc of 1% preservative free lignocaine .The block is considered successful if the NRS pain score comes down by four points and the pain relief duration is more than four hours.
The USG guided anterior coeliac plexusethanol neurolysis is done as a bedside procedure after successful diagnostic block. Patient was placed in a supine position, i.v. access obtained and preloading with one litre of RL was done. ECG, NIBP, SPO2 were connected. Strict aseptic precautions for preparation of parts and sterile draping for the USG probe were followed .A SIUI ultrasound machine having a convex transducer of 3-5Mhz is used for this procedure. Probe is placed in the epigastric region in a transverse orientation . Aorta and the vertebrae are identified. Confirmation of the aorta is done by color flow monitor and power doppler. Transducer is moved obliquely upwards and the coeliac trunk was identified as a branch of artery originating anterior from the aorta. Tilting of the probe enabled the view of the common hepatic artery and the splenic artery, by placing the transducer in a longitudinal direction we are able to visualize aorta and its coeliac trunk in longitudinal section. With the probe in transverse orientation, local anesthesia with 2 % lignocaine 4 cc was given and a 22G 15 cm needle was introduced through an out of plane sonographic technique. Once needle tip is confirmed near the target area,which can be either side of the coeliac trunk, using hydro localisation with 5ml of saline. 10 ml of 1%lignocaine without preservative is injected after negative aspiration of blood. 20ml of 60% ethanol is injected after hydr localisation and negative aspiration for blood. Spread of ethanol around the coeliac trunk is confirmed sonographically observed hydrolocalization(2). Dexamethasone 8mg and 2 ml of 1% lignocaine given before withdrawing the needle. Patient is monitored for 3 hrs before shifting to the ward. Numeric rating scale (NRS) for pain is recorded immediately after injection, 24 and 72 hours post injection. Patient are instructed to report after 1 week and also at 3 months for evaluation of pain
STATISTICAL ANALYSIS
Paired sample t test was used compare continuable variable, a two-sided P < 0.05 was considered statistically significant. All statistical analysis was carried out using SPSS version 16.
A total of thirty patients are selected, pancreatic malignancy constituted twenty patients and ten patients had gastric malignancy. (figure-1)
Figure 1 Selection of Patients
All the patients are on tramadol 200 mg orally for pain relief and seven of them were taking 20-40 mg oral morphine.Twenty five males and five females with median age of 46.5 have undergone USG guided anteriorcoeliac plexus alcohol neurolysis.
Twenty five patients had good pain relief immediately, 24 hours, 72 hours, one week and 3 months after the procedure.Three patients reported neurolytic pain immediately but reported good pain relief after that episode.
Two patients had moderate pain and are continued morphine till the study period. preprocedure .it decreased to 2.60 at three months post procedure.NRS recorded was 8.26 Our study shows highly statistically significant difference between pre-NRS and post immediate-NRS (mean 8.26 ±0.52 and 3.40 ±0.47)(P value <0.0001) and significant decrease in NRS seen after 24 hours,72 hours,1 week,and 3 months.(figure-2)
Figure 2 NRS Score From Pre-Procedure Up To Three Months
Pre and post procedure tramadol consumption shows significant difference in p-value(<0.0001) .(figure-3)
Figure 3 Oral Tramadol Consumption From Pre-Procedure Till Three Days
p
Figure 4 Oral Morphine Consumption
Pre and post procedure morphine consumption shows significant difference in p-value (0.007).(figure-4)
Figure 5 Complications Documented During The Study
Hypotension is most common complication recorded.Complications rate reported are statistically insignificant in this study.(figure-5)
WHO advocates pain relief as a right to cancer patients. Patients who are suffering from cancer related pain expects relief from pain as an important and desirable aspect of cancer management. Pancreatic and gastric malignancy patients can have pain relief by having oral analgesics or morphine. In most of the cases their oral therapy is not adequate and so patients need to undergo interventional pain management like coeliac plexus neurolysis as done in this study.[6]
Coeliac plexus neurolysis is mostly done under fluoroscopic method but USG guided, anterior percutaneous approach is gaining acceptance. This procedure is equally efficient in reducing pain as that of fluoroscopy guided posterior approach.[2]
Being done under real time it can minimize the possibility of intravascular injections and USG guidance enables as to deposit the drug around the coeliactrunk.[2] The coeliac plexus is found more consistently around coeliactrunk rather than first lumbar vertebrae, which the fluoroscopy guided technique uses as its landmark.So its pain relief is found to be statistically significant. USG guidance also let us to view the organs that we traverse during the injection.
Ultrasound guided intervention eliminates radiation to the performer and the patient. This can augment the acceptance of the procedure by the patient and the physician.Adequately treated pain can improve the physical and emotional wellbeing of the patients.
Tadros M et. al., done a similar study and found that ultrasound guided CPN is a safe and effective method of reducing pain of upper abdominal cancer with no major complications and high success rate.[6]
Our study results found to be similar with Caratozzolo M et. al., study of Ultrasound-guided alcoholization of coeliac plexus for pain control in upper abdominal malignancies.[7]
Ghai Aet. al., in their study noted sonographic CPN is an efficient, safe, and fast method for relieving pain in the upper abdominal malignancy. The use of ultrasound helps in real time needle placement, and helps to examine the drug spread around aorta. Our study also found the real time imaging is an advantage with USG guidance.[1]
Being done in supine position it minimizes the discomfort of lying prone during fluoroscopic method and this is the most important aspect as this will increase the patient cooperativeness when doing the procedure. In our study it is done as a bedside ICU procedure thus eliminating the need for having a dedicated space and it brings down the logistical time required to shift the patients for the procedure.[8]
Sehgal S et. al., showed coeliacethanol neurolysis is more effective in reducing pain and leads to decreased opioid requirements and thus their related side effects, and thus preventing deterioration in quality of life in such patients.[9]
Mary P et. al., have reported utility of the anterior approach and the real time colour ultrasound guidance in cancer patient lead to 93% success rate for ultrasound guidance in comparison with 100% for CT-guidance, our study success rate is also similar.[10]
Our study shows similarity with percutaneous neurolytic coeliac plexus block by Nitschke A et. al., in documenting significant improvement of abdominal pain and decreased narcotic use and in reporting major complications. This study also shows similar results in terms of patient comfort, direct visualization of Vascular structures. It also documents that traversing abdominal structures including bowel and liver is generally well tolerated.[11]
Davies D studied patient who underwent neurolytic coeliac plexus block over a period of 5 years found that incidence of major complication was one case per 683 blocks.[12]
Eisenberg E et. al., have concluded in their meta analysis of neurolytic coeliac plexus block for cancer pain that NCPB have long lasting benefit in 70-90%of patients with pancreatic and intraabdominal cancers and severe adverse effects are uncommon.[13]
USG guided anterior percutaneous Ethanol CPN will increase the patient cooperativeness by allowing them to be supine and in a .bedside setting. For the performer it is mostly a single puncture technique, giving real time view of vascular structures and abdominal organs and its complication rates are low. It gives statistically validated improvement in pain relief and subsequent physical and emotional improvement for the patient. Since radiation hazard is eliminated, we can hope this intervention technique will be embraced more both by the patient and physician.
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