Computed Tomography-guided Percutaneous Bilateral Neurolytic Celiac Plexus Block with Alcohol for Upper Abdominal Visceral Cancer Pain.

Abstract

Background: The neurolytic celiac plexus block (NCPB) can be introduced through the posterior para-aortic, anterior para-aortic, posterior transaortic, or endoscopic anterior para-aortic puncture approach, as well as the posterior approach via the intervertebral disc. To reduce the complications of puncture, this block's original manual blind puncture technique can be improved upon by using a C-arm fluoroscope, computed tomography (CT), or an ultrasound, the last of which may be endoscopic.

Objective: To observe the distribution of absolute alcohol and its analgesic effect on cancer-induced upper abdominal visceral pain during percutaneous NCPB through the anterior and posterior diaphragmatic crura under CT guidance.

Study design: Clinical research study.

Setting: Department of Anesthesiology and Pain Medical Center, Jiaxing, People's Republic of China.

Methods: Thirty-eight patients (19 men and 19 women) with advanced carcinomatous epigastric pain were enrolled in this study. The patients were 47-88 (mean, SD: 64.9 ± 8.8) years old, weighed 37-62 kg (mean, SD: 51.6 ± 12.3), and had a grade III or IV physical status on the classification system established by the American Society of Anesthesiologists. The left and right punctures were made through the T12-L1 intervertebral space under CT guidance. The left side was punctured through the paravertebral and diaphragmatic crura to the anterolateral side of the anterior abdominal aorta of the diaphragmatic crus; and the right side was punctured via the posterior approach through the intervertebral disc to the posterior abdominal aorta of the diaphragmatic crus and then to the exterior. A solution consisting of 8 mL of 1% lidocaine and 1 mL of 30% iohexol was injected. If this injectate wholly or partly surrounded the abdominal aorta, then injecting anhydrous alcohol was deemed practicable. Fifteen mL of absolute alcohol containing 10 mL iohexol were injected into the left and right sides 15 minutes later. The alcohol diffusion was observed by CT. The pain Visual Analog Scale was used to evaluate the analgesic effect before NCPB and one hour, one week, one month, 3 months, and 6 months after the treatment. Any treatment-related complications were recorded.

Results: All patients were punctured at the predetermined position under CT guidance. Among the 23 patients whose injection of absolute alcohol surrounded the abdominal aorta completely, 19 (82.6%) stopped taking analgesic drugs altogether; of the 8 patients whose injection of absolute alcohol surrounded 75% of the abdominal aorta, 6 (75%) stopped taking oxycodone. In the 7 patients whose injection of absolute alcohol surrounded only 50% of the abdominal aorta, the pain was alleviated to varying degrees, but only 2 (28.6%) stopped taking oxycodone completely, and the other 5 patients still needed oral oxycodone. No abdominal bleeding, abdominal infection, or paraplegia occurred.

Limitations: The results of this study require further research with more clinical data to confirm them. The main limitation is the small sample size and the lack of a double-blind controlled comparison between the intragastric and extragastric injection administration method.

Conclusion: An NCPB that uses CT-guided double-needle puncture through the anterior and posterior diaphragmatic crura can improve absolute alcohol's ability to surround the corresponding segment of the abdominal aorta and block the greater and lesser splanchnic nerves and celiac plexus when injected. This approach to the NCPB has a better analgesic effect on patients with intractable visceral cancer pain in the upper abdominal area.