Ultrasound-guided percutaneous celiac plexus neurolysis using the

case report
Ultrasound-guided percutaneous celiac plexus neurolysis
using the anterior transgastric approach and continuous
flow apneic ventilation: case report
Neurólise percutânea do plexo celíaco guiada por ultrassom utilizando um acesso
anterior transgástrico e oxigenação apneica de fluxo contínuo: relato de caso
Rodrigo Gobbo Garcia1, Alexandre Maurano2, Marcio Martines dos Santos3, Carlos Leite de Macedo Filho4,
Antonio Luiz Vasconcellos Macedo5, Miguel José Francisco Neto6, Marcelo Buarque Gusmão Funari7
ABSTRACT
Percutaneous celiac plexus neurolysis is an effective method to
relieve pain in advanced abdominal cancer, especially in patients
with pancreatic carcinoma. It was performed a percutaneous celiac
plexus neurolysis, using the anterior transgastric route, under general
anesthesia and apneic oxygenation in a patient with an advanced
pancreatic adenocarcinoma and chronic abdominal pain refractory
to clinical treatment. A color Doppler ultrasound detectable flow at
the tip of a Turner-22G needle through continuous injection of saline
solution was produced. This technique showed the exact position of
the needle dynamically during its progression. Then, 30 ml of ethanol
was infused into the preaortic space. The procedure took around
eight minutes, and the patient expressed significant pain relief and
decrease in his narcotic analgesics requirements.
Keywords: Celiac plexus; Alcoholism; Ultrasonography, doppler,
color; Anesthesia; Ultrasonography, interventional; Case reports
RESUMO
A neurólise percutânea do plexo celíaco é um método eficiente para
reduzir a dor em pacientes com neoplasia abdominal avançada,
principalmente em casos de câncer pancreático. Foi realizada uma
neurólise percutânea do plexo celíaco guiada por ultrassom, usando
a via anterior transgástrica e anestesia geral com oxigenação apneica
em um paciente portador de adenocarcinoma avançado de pâncreas
e dor abdominal crônica refratária a tratamento medicamentoso.
Produziu-se um fluxo detectável pelo ultrassom com Doppler colorido
na ponta de uma agulha fina (22G), pela injeção contínua de solução
salina, otimizando sua visualização durante a progressão guiada por
imagem. Esta estratégia permitiu o posicionamento rápido e preciso
da agulha no espaço pré-aórtico adjacente ao tronco celíaco. Cerca
de 30 ml de álcool absoluto foi injetado, de forma a promover a
ablação química do plexo nervoso. O procedimento durou apenas
oito minutos e o paciente referiu uma melhora significativa do quadro
álgico ao seu término, tendo sido possível a redução significativa da
prescrição analgésica diária.
Descritores: Plexo celíaco; Alcoolismo; Ultra-sonografia Doppler em
cores; Anestesia; Ultra-sonografia de intervenção; Relatos de casos
INTRODUCTION
The percutaneous celiac plexus neurolysis (PCN) is an
efficient technique applied to reduce abdominal pain,
secondary to inflammatory conditions or retroperitoneal
cancers located in the upper abdomen. Pancreatitis and
advanced tumors arising from the pancreas, stomach,
esophagus and gallbladder are conditions in this
location that may require more aggressive pain control
when unresponsive to large doses of narcotic agents(1).
This technique consists in an injection of a neurolytic
agent (usually absolute alcohol or fenol) using a fine
Study carried out at Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.
1
MD at Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.
2
Radiologist at the Radiology Department of Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.
3
Anesthesiologist at Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.
4
Radiologist at the Radiology Department of Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.
5
General Surgeon at Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.
6
Radiologist at the Radiology Department of Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil; Attending Physician at the Emergency Radiology and Interventional Oncology Department
(INRAD) of Hospital das Clínicas of Faculdade de Medicina da Universidade de São Paulo – USP, São Paulo (SP), Brazil.
7
Radiologist; Head of the Imaging Department at Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.
Corresponding author: Rodrigo Gobbo Garcia – Rua Passo da Pátria, 1.294 – apto. 353 – Bela Aliança – CEP 05085-903 – São Paulo (SP), Brasil – Tel.: 11 3832-3673 – e-mail: [email protected]
Received on Mar 3, 2009 – Accepted on Jul 13, 2009
einstein. 2009; 7(3 Pt 1):361-4
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Garcia RG, Maurano A, Santos MM, Macedo Filho CL, Macedo ALV, Francisco Neto MJ, Funari MBG
needle inserted in the retroperitoneum, adjacent to
the nervous fibers and ganglia of the celiac plexus. The
neurolytic medication disrupts the neural network,
destroying the pain pathways(2).
The most utilized access routes to PCN are anterior
transabdominal or posterior transcrural guided by
fluoroscopy, ultrasonography (US) or computed
tomography (CT) scan(1-2) (Figure 1).
Figure 1. Access routes to PCN. A: anterior transgastric/transpancreatic. B:
posterior transcrural. C: anterior oblique transgastric; IVC: inferior vena cava
The US-guided technique, using an anterior route,
is faster and cheaper than the CT-guided method(3-4).
However, the sonographic approach requires much
more individual skills and training in interventional
radiology. The most relevant drawback of US-guidance
is the poor visualization of thin needles during their
progression, with the potential of the needle’s improper
positioning(2,4-5).
The objectives of this case report are to review the
technical and clinical aspects of image-guided PCN, and
to describe one case in which some special techniques
of anesthesia and interventional radiology that have
optimized the procedure were applied.
CASE REPORT
JGF, a 68-year-old male patient, was referred from
Vitória, in the state of Espírito Santo, with an advanced
and non-resectable pancreatic adenocarcinoma, which
was found six months before.
The abdominal magnetic resonance imaging
(MRI), or cholangio-MRI, depicted a large solid mass
involving the head of pancreas, invading the celiac
trunk and the superior mesenteric vessels, with diffuse
dilation of the main pancreatic duct (Figures 2A, 2B
and 2C).
einstein. 2009; 7(3 Pt 1):361-4
Figure 2. MRI of upper abdomen at celiac artery level. (A) Post-contrast axial
T1 image. (B) Axial T2 image. Large expansive solid mass invading the head of
the pancreas (white arrows), and circumferentially involving the celiac artery
(arrowheads). D: duodenum. (C) MR-Cholangiopancreatography. Diffuse dilation
of the main pancreatic duct (W), and cystic changes/side-branches dilation at
pancreatic head (*). GB: gallbladder; CBD: common bile duct; ST: stomach
In the previous three months, the patient experienced
an important worsening of his abdominal pain, despite
high doses of opioid analgesics.
The Interventional Oncology Group of Hospital
Israelita Albert Einstein was, then, requested to perform
a PCN as an adjunctive palliative pain management.
It was performed a PCN using an anterior transgastric
route, guided by color Doppler ultrasonography (CDU).
Oriented by CDU real time images and under general
anesthesia, the anterior abdominal wall was punctured
Ultrasound-guided percutaneous celiac plexus neurolysis using the anterior transgastric approach and continuous flow apneic ventilation: case report
with a long thin needle (Turner biopsy needle, 15 cm
x 22 G – Cook Medical™, USA), through the stomach
to reach the retroperitoneal space around the celiac
plexus. The perforation of the pancreas was not required
because it was chosen an ascending oblique route in the
upper abdomen, moving ventrally and superiorly to that
organ (Figure 1, route C).
A special modality of general anesthesia, called
continuous flow apneic ventilation was used, which
consists of orotracheal intubation and full curarization for
prolonged time (up to ten minutes), obviating incursions
of the thoracic and abdominal wall. For that, a continuous
flow of free oxygen is provided by a sterile endotracheal
canule positioned just above the carina, allowing adequate
oxygenation and minimizing CO2 retention(6).
Interruption of the respiratory movements allowed
excellent control of the abdominal structures, rendering
the procedure faster and more precise.
To improve US visualization of the fine needle
during its insertion, a CDU detectable flow at the tip
of a Turner-22G needle through continuous injection of
saline solution was produced. This technique revealed
the exact position of the needle dynamically during its
progression (Figures 3A, 3B and 3C), as well its location
in relation to the celiac trunk – the major vascular
landmark to localize the celiac plexus.
After the correct positioning of the needle tip in the
vicinity of the celiac plexus was ensured, in a midline
plane in front of the aorta, 30 ml of absolute alcohol
was injected, trying to achieve an extensive alcoholic
infiltration of the periaortic soft tissues.
The retroperitoneal puncture and alcohol
injection took exactly eight minutes. There were no
complications.
The patient reported marked pain relief, which
perceived already in the recovery room, right after
the procedure lasting until the time of his death, five
months later. He presented as a mild collateral effect
of neurolysis, a moderate postural hypotension for
five weeks following the procedure, which disappeared
spontaneously.
DISCUSSION
PCN is an effective tool for palliative pain management,
which has been traditionally overlooked by medical
community, despite its advantages.
Effective pain relief has been reported in up to
85% of the patients with chronic abdominal pain due
to both benign and malignant conditions, also reducing
the narcotic analgesics required and the narcotic-dose
related side effects(5,7).
The contraindications to the procedure are very
limited, generally related to anticoagulant therapy,
363
Figures 3. US-guided transgastric PCN. (A) Abdominal puncture. The thin needle
(20 G) is poorly visualized in front of the aorta. (B) The needle position is nicely
depicted after continuous injection of saline. The small flow generated at the
needle tip is detectable by ultrasound Doppler (small red and blue area at the
needle tip), improving accuracy of procedure. (C) Alcohol injection at the vicinity
of the celiac plexus
severe coagulopathy, active abdominal infection or
sepsis(7). The celiac plexus is a series of one to five
ganglia composed of a dense network of interconnecting
presynaptic sympathetic nerve fibers, derived from
T5-T12 splanchnic nerves. It is located anterior to the
crura of the diaphragm, over the anterolateral wall of
the aorta bilaterally, and just caudal to the level of the
origin of celiac artery.
It supplies sympathetic, parasympathetic, and visceral
sensory afferent fibers to the pancreas, liver, biliary tract,
einstein. 2009; 7(3 Pt 1):361-4
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Garcia RG, Maurano A, Santos MM, Macedo Filho CL, Macedo ALV, Francisco Neto MJ, Funari MBG
gallbladder, renal pelvis and ureter, spleen, mesentery,
and bowel proximal to the transverse colon(2,7).
The pharmacological-induced celiac plexus block
impairs pain circuits in those organs(2).
PCN may provide total or partial relief of pain,
lasting up to six months to one year, as after that new
pain routes may regenerate(3-4).
The best results are obtained to relieve pain caused by
neoplasms in the upper abdomen, especially pancreatic
tumors. The extension of cancer invasion and eventual
postoperative changes may compromise the outcomes,
by limiting the spread of the neurolytic agent around
the celiac trunk(8).
The most frequent collateral effects are related to
sympathetic block: hypotension (up to 30%, disappearing
after 12 hours in most cases) and diarrhea (up to 60%,
with good recovery after 48 hours)(4-5).
Severe neurological impairment, like paraplegia,
lower limb paresia and paresthesia are very rare (less
than 1% of cases) and exclusively associated with the
posterior transcrural approach. These complications are
attributed to direct lesion of spinal cord or to alcoholinduced thrombosis of anterior spinal artery(9). They do
not occur, therefore, in patients undergoing the anterior
transabdominal approach.
CONCLUSION
PCN is a safe and efficient palliative tool for pain
management in selected cases of chronic abdominal
diseases.
It was described one case of PCN performed by an
anterior transgastric approach, using fine needle and
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very precise imaging guidance optimized by continuous
flow apneic ventilation and CDU. The association of
these techniques allowed performing a very fast and
accurate procedure.
ACKNOWLEDGMENTS
We thank Daniel Costa, MD (Beth Israel Deaconess
Medical Center, Boston, USA), for his suggestions in
this paper.
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