 |
       |
|
|
NEUROLYTIC COELIAC PLEXUS BLOCK (NCPB) : A Ten-Year Review of 212 Cases (1991-2000)
DK Baheti
Chief, Pain Management Clinic, Associate Professor, Anaesthesiology, Bombay Hospital Institute of Medical Sciences, 12, New Marine Lines, Mumbai 400 020.
A review of 212 cases of neurolytic coeliac plexus block (NCPB) between 1991-2000 (Ten years), at Pain Management Clinic of Bombay Hospital is presented. The review includes the demography of patients, types of cases, technique, degree and duration of pain relief or otherwise is reported. The fifty cases of NCPB reported earlier by same author1 are included in this review.
Out of 212 cases 110 patients were pain free for period of twelve weeks or more; in 88 were pain free for period of one to twelve weeks and 5 patients were pain free up to one week. In 7 patients there was no or little pain relief, which lasted for few hours only. In one patient procedure was abandoned because of temporary paraplegia.
In 82% cases the degree of pain relief was excellent i.e. reduction in visual analogue scale (VAS) from 10 to 2 and in 14% of cases pain relief was good i.e. reduction in VAS from 10 to 4-5 and in 4% of cases there was no pain relief at all.
In this study 96% of cases had good to excellent pain relief, however the duration of pain relief was varied.
The side effects were, pain at puncture site in fifteen patients; hypotension up to 60 mm of Hg in ten patients; diarrhoea in three patients; shoulder pain in five patients and temporary paraplegia for one hour in one patient.
INTRODUCTION
Neurolytic coeliac plexus block, though invasive is a useful modality, in relief of upper abdominal pain. The common causes of chronic, intractable upper abdominal pain are, pancreatic malignancy; neoplasm’s involving distal oesophagus, stomach, liver, gall bladder, adrenal, kidney and from the branches of coeliac plexus and coeliac ganglion. The site of pain may be in epigastria, right or left hypochondriac region and it is associated with or without reference to the upper back.
The coeliac plexus supply is located deep within the rertoperitoneum, in front of vertebral column i.e. thoracic twelve and lumbar first vertebra. The placement of needle for coeliac plexus block has potential dangerous complications, such as puncturing of inferior vena cava, aorta, pleura, peritoneum and dura. The use of fluoroscopy or of computerized tomography (CT) has markedly reduced these omplications.
There are various approaches for NCPB described in the literature. The most common one is posterior approach described by Kappis [2] and popularized by Moore. [3] The other approaches are anterior approach, transaortic by Ischia et al [4] and deliberated perforation of diaphragmatic crura under CT guided by Singler. [5] In this series the posterior approach either under fluoroscopy or CT guided was used.
The side effects and complications reported are pneumothorax, chylothorax, pleural effusion, convulsion and paraplegia. Brown [6] reported pneumothorax in two out of 130 patients and Thomson et al [7] had partial lower extremity paralysis in one out of 114 patients.
MATERIAL AND METHODS
Two hundred and twelve patients were admitted for NCPB at Bombay Hospital and Medical Research Centre between, 1991 and 2000. The investigations done were complete blood count, bleeding and clotting time and HIV. A special informed consent was obtained from all the patients.There were 144 were males and 68 were females and minimum age was 11 years and maximum was 67 years.
Out of 212 the NCPB was performed in 211 patients and in one patient procedure was abandoned due to temporary paraplegia.
The patients with various types of diseases admitted for NCPB are shown in Table 1.
TABLE 1 Types of cases Number of cases
Carcinoma of pancreas 105 Chronic pancreatitis A - Alcoholic 42 B - Other 38 Carcinoma of Gall Bladder 6 Carcinoma of Stomach 15 Pancreatic cyst 8 Carcinoma of kidney and ureter 3 Retroperitoneal tumours 4 Total 212
Procedure :
The monitoring of ECG and blood pressure was done. An intravenous line was set up. In this series the coeliac plexus block was done by posterior approach with two needles. After preparation of the area, inj. lignocaine 2% 5-10 ml injected about six to eight centimeter away from midline of spinous process of lumbar first vertebra.
A 15 cm specially prepared indigenous blunt tip needle was directed towards either the body of thoracic twelve or upper border of lumbar first vertebra under the fluoroscopic or CT guidance. The second needle was also directed towards the body of thoracic twelve or lumbar first vertebra. The position of the needle was confirmed under fluoroscopy or under CT. After repeated negative aspiration a nonionic contrast, Inj. Omnipaque (lohexol) 3 to 5 ml was injected through both the needles. The spread of the dye was confirmed under fluoroscopy or under CT. The spread of the dye was documented by X-ray. As a protocol one X-ray plate was given to patient and another was kept for departmental record. After the repeated negative aspiration inj. alcohol 50% 20 to 25 ml injected slowly over period of 30 to 60 seconds, on each side. The patient often complained of pain in the retroperitoneal area however this pain lasted for few minutes only.
In this series 198 cases were done under the fluoroscopy and 14 were under CT.
RESULTS
The duration of pain relief achieved is depicted in Table 2
TABLE 2
No. of Cases Duration of Pain Relief 110 Twelve weeks or More 88 Four to twelve weeks 5 Few hours to one week 7
No relief 1 Procedure abandoned
The degree and percentage of pain relief on VAS is shown in Table 3
TABLE 3
Degree of Pain Relief- By Reduction of Visual Analogue Scale (VAS) Percentage of patients With pain relie 1 to 2 82% (Excellent) 10 to 4-5 14% (Good) No relief 4% (Poor)
SIDE EFFECTS AND COMPLICATIONS :
The side effects and complications encountered in this review are described in Table 4.CONCLUSIONS
The NCPB relieves upper abdominal pain is well documented, in western literature. However from India this may be the first review of 212 cases of intractable upper abdominal pain relieved by NCPB is presented.In conclusion we suggest that NCPB should be a modality of choice to relieve upper abdominal pain of any cause.
TABLE 4 Symptoms and Signs No. of Cases Duration Management
Pain at puncture site 15 6-24 hrs hot water bag Fomentation + Tab. Paracetamol Hypotension from 130 to
60 mm systolic10 4-8 hrs Inj. Mephentine Inj. Ringer’s lactate Diarrhoea 3 24 hrs Antidiarrhoeal drug Oral + iv fluids Shoulder pain 5 12-24 hrs Tab. Paracetamol Temporary Paraplegia 1 one-hour Inj. Mephentine 30 mg Inj. Ringer lactate 600 ml
REFERENCES
1.Baheti DK. Neurolytic coeliac plexus block for upper abdominal malignancies : review of 50 cases. The Pain Clinic 1997; 10 (1) : 47-49.
2.Kappis M. Sensibilital and lokale anesthesia in Chirurgischen gebit der bauchhole mit besoderer berucksichtigung der splanicus. Brus Beitraage Zur Klin Cher 1919; 15 : 161.
3.Moore DC. Regional Block, 4th edn. Springfield III, Charles C. Thomas. 1975.
4.Ischia S, Luzzani A, Ishica A, et al. A new approach to the neurolytic block of the celiac plexus : The transthoracic technique. Pain 1983; 16 : 333.
5.Brown DL, Bully CK, Quiel EC. Neurolytic celiac plexus block for pancreatic cancer pain. Anesthe Analg 1987; 66 : 869-73.
6.Thompson GE, Moore DC, Braidenbaugh LD. Abdominal pain and alcohol celiac plexus block. Anesth Analg 1977; 56 : 1-5.
