Celiac plexus neurolysis doesn't relieve pain of resectable pancreas cancer

Last Updated: 2015-01-01

By Will Boggs MD

NEW YORK (Reuters Health) - Intraoperative neurolysis of the celiac plexus using ethanol does not relieve pain associated with pancreatic and periampullary adenocarcinoma (PPA), researchers say.

"Surgical resection of pancreatic cancer reduces cancer related pain," Dr. Harish Lavu from Thomas Jefferson University in Philadelphia told Reuters Health by email. "In patients who cannot be resected, nerve blocks help alleviate pain. The combination of nerve block and resection is not superior to resection alone."

Earlier studies have shown that ethanol celiac plexus neurolysis (ECPN) relieves pain in unresectable PPA, but its role in patients with resectable PPA had not been evaluated until now.

Dr. Lavu and colleagues randomly assigned 233 resection patients to intraoperative neurolysis with ethanol and 234 to sham therapy with saline.

At 12 months, there was no difference in proportion of patients with worsening of pain between the ethanol group (22%) and the saline group (18%).

A multivariable mixed effects model suggested that surgical resection of the malignancy alone reduced pain levels to a significant degree among patients with preoperative pain, but the addition of ECPN did not reduce pain further.

Patients with tumors that proved to be unresectable who had no pain at baseline were significantly less likely to have pain at three months if they underwent ECPN than if they were randomized to saline (17% vs 44%; p=0.01), but this rebounded to increased pain levels in the ethanol group by six months (50% versus 38%).

Among patients whose tumors did prove to be resectable, there was no difference in median overall survival between the ethanol group (18.3 months) and the saline group (17.6 months), the authors reported online December 17th in the Journal of the American College of Surgeons.

"In contrast to previous findings in unresectable patients, our data did not demonstrate a significant improvement in pain scores in patients with resectable PPA, suggesting limited to no benefit from the ECPN procedure in this cohort of patients," the researchers conclude.

The only alternatives for these patients, Dr. Lavu said, are oral analgesics and narcotic pain medications.

Dr. Jin Chen, Consultant of Pancreatic Surgery at Huashan Hospital, Shanghai, China, told Reuters Health by email, "According to NCCN guideline of pancreatic cancer and my own experience, ECPN is used to manage the pain of patients with unresectable tumor, especially those late stage cases, and it is the most effective intervention for cancer related pain except medication. Surgery is still the only curative treatment."

"The most important result of this report is: it is not necessary to do the ECPN during the operation for a resectable cancer," Dr. Chen said.

"It is the first paper I have read to investigate the efficacy of ECPN in resectable PPA patients. If the ECPN is useless," Dr. Chen wondered, "what about the neurectomy during operation, which is recommended by some researchers to relieve the possible postoperative pain?"

He also noted that "CPN is the most common nonoperative intervention for the pain of patients with pancreatic cancer, but CPN is usually performed by endoscopic ultrasound (EUS), not during operation."

SOURCE: http://bit.ly/13gemlz

J Am Coll Surg 2014.