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Short case #2 for the Final

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Short case #2 for the Final
Photo by Diana Polekhina / Unsplash

A 54 year old woman with metastatic pancreatic cancer has severe upper abdominal pain despite regular oral analgesia including strong opiates.

What analgesic options are there for this patient?

  • Optimisation of oral analgesic - increasing doses, trialling alternative opioids
  • Parenteral analgesia - buprenorphine or fentanyl patches
  • Regional anaesthesia - coeliac plexus block, splanchnic nerve block

What are the indications for a coeliac plexus block?

  • Visceral cancer pain from upper abdominal organs - pancreas, stomach liver, gallbladder, transverse colon, spleen, kidneys, and proximal ureters
  • Chronic pancreatitis - rarely

The success rate is apparently 80–90% for pancreatic cancer pain

What are the contraindications?

Absolute

  • Patient refusal
  • Uncontrolled local or systemic infection
  • Large aortic aneurysm
  • Allergy to relevant medications
  • Severe hypovolaemia/hypotension

Relative

  • Deranged clotting
  • Severe cardiac or pulmonary disease
  • Spinal anatomical abnormality

What are the complications of coeliac plexus block?

  • Procedural failure
  • Inadequate analgesia
  • Bleeding and retroperitoneal haematoma
  • Trauma to surrounding structures
  • Infection
  • Hypotension due to loss of sympathetic tone
  • Diarrhoea due to unopposed parasympathetic tone
  • Paralysis - spinal injury or injection into anterior spinal artery

Please describe the anatomy of the coeliac plexus

  • Largest autonomic plexus supplying the upper abdomen
  • Found at L1
  • Posterior to stomach and pancreas
  • Anterior to diaphragmatic crura and aorta
  • Lateral to IVC

Nerves

  • Greater Splanchnic nerve- Sympathetic fibres from T5 to T9
  • Lesser splanchnic nerve - Sympathetic fibres from T10 to T11
  • Least splanchnic nerve - Sympathetic fibres from T12
  • The coeliac plexus also receives parasympathetic input from the coeliac branch of the vagus nerve

Describe how you would perform a coeliac plexus block

Preparation

  • Consent and ID check of patient
  • IV access
  • Full AAGBI monitoring
  • Skilled assistance
  • Emergency airway and resuscitation equipment
  • Imaging - fluoroscopy or CT
  • Prone position, with or without sedation

The procedure

  • Bilateral insertion at L1 around 7.5cm from midline
  • Needle contacts L1 vertebral body
  • Aspiration to exclude intravascular needle placement
  • Injection of radio-opaque contrast to exclude epidural spread
  • Local anaesthesia injection to assess efficacy
  • If effective then neurolytic injected

The procedure can also be done under CT or US guidance.

What neurolytic is used?

  • 4-6% aqueous phenol
  • 50% ethanol
  • Bupivacaine is used for non-malignant pain

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