Background & Aims

Pancreatic cancer (PC) is the fourth-leading cause of cancer-related death, with over 80% of patients having unresectable disease upon diagnosis. 70% of this population is experiencing cancer-related pain, and opioid treatment is still associated with inadequate pain relief in more than half of the patients. In the past decades, celiac plexus neurolysis (CPN) has gained a significant role in pain management. Our study aims to identify the most effective approach for managing pain in individuals with unresectable PC with the smallest risk for adverse events.

Methods

We registered the study on PROSPERO (CRD42023477094) and systematically searched five major scientific databases on the 29th of October, 2023. Only randomised controlled trials (RCTs) reporting on adult patients diagnosed with unresectable PC and cancer-related pain undergoing medical or interventional treatment were considered eligible. The main intervention groups were endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN), percutaneous celiac plexus neurolysis (P-CPN), intraoperative celiac plexus neurolysis (I-CPN), and pharmacological therapy (opioids). Our outcomes of interest were pain and adverse events. Pooled means and proportions were calculated with 95% confidence intervals (CIs), and a random-effects model was applied.

Results

After title-abstract and full-text article selection, 1644 patients of 21 RCTs were found eligible. The pain was assessed using the 11-point Visual Analogue Scale from randomisation at 4 weeks. Pain values at baseline were 6.09 (CI: 4.24-7.94) for EUS-CPN, 6.67 (CI: 5.20-8.14) for P-CPN, 6.23 (CI:4.74-7.72) for I-CPN, and 6.47 (CI: 5.02-7.93) for opioids. At one month, the overall pain score was 1.30 (CI: 0.68- 1.92) for EUS-CPN, 2.27 (CI: 1.63-2.91) for P-CPN and 2.80 (CI: 2.17-3.42) for opioids. At two and three months after randomisation, there was a slow but continuous increase in pain scores for all treatment groups. Opioids showed the highest risk for nausea and vomiting, while pooled proportions for diarrhoea were 0.11 (CI:0.05–0.22) with EUS-CPN and 0.23 (CI:0.14–0.35) with P-CPN. Pooled proportions for cardiovascular AEs were 0.13 (CI:0.04–0.39) for EUS-CPN and 0.26 (CI:0.14–0.45) for P-CPN.

Conclusions

Our study shows that celiac plexus neurolysis provides pain control with fewer adverse events associated, with EUS-CPN having the most promising results. However, further RCTs with higher sample sizes are needed to confirm our findings.

References

1.Arcidiacono_PGG, Calori_G, Carrara_S, McNicol_ED, Testoni_PA. Celiac plexus block for pancreatic cancer pain in adults. Cochrane Database of Systematic Reviews 2011, Issue 3. Art. No.: CD007519. DOI: 10.1002/14651858.CD007519.pub2.

2.Wong et al., Effect of Neurolytic Celiac Plexus Block on Pain Relief, Quality of Life, and Survival in Patients with Unresectable Pancreatic Cancer – A Randomized Controlled Trial JAMA. 2004; 291:1092-1099

3.Dong et al., Neurolytic Splanchnic Nerve Block and Pain Relief, Survival, and Quality of Life in Unresectable Pancreatic Cancer: A Randomized Controlled Trial, Anesthesiology 2021; 135:686–98

4.Gao et al., A randomized clinical trial of nerve block to manage end-stage pancreatic cancerous pain, Tumor Biol. (2014) 35:2297–2301

5.Kanno et al., Efficacy of EUS-guided celiac plexus neurolysis compared with medication alone for unresectable pancreatic cancer in the oxycodone/fentanyl era: a prospective randomized control study, Gastrointest Endosc 2020;92:120-30

6.Zhang et al., Effect of Neurolytic Celiac Plexus Block Guided by Computerized Tomography on Pancreatic Cancer Pain, Dig Dis Sci (2008) 53:856–860

7.Polati et al., Prospective randomized double-blind trial of neurolytic coeliac plexus block in patients with pancreatic cancer, British Journal of Surgery 1998, 85, 199–201

8.Abdelbaser I, Shams T, El-giedy AA, Elsedieq M, Ghanem MA. Neurólisis del plexo celiaco intraoperatoria directa frente a percutánea guiada por tomografía computarizada en el cáncer de páncreas no operable: estudio aleatorizado, controlado y de no inferioridad. Rev Esp Anestesiol Reanim. 2022;69:71—78.

9.Bang et al., EUS-guided celiac ganglion radiofrequency ablation versus celiac plexus neurolysis for palliation of pain in pancreatic cancer: a randomized controlled trial (with videos), Gastrointest Endosc 2018; 1-9.

Presenting Author

Ioana Creanga-Murariu

Poster Authors

IOANA IRINA REZUS

MD, PhD-student

Centre for Translational Medicine, Semmelweis University, Budapest, Hungary

Lead Author

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Ioana Creanga-Murariu

Advanced Research and Development Center for Experimental Medicine (CEMEX)

Lead Author

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Anett Rancz

Centre for Translational Medicine, Semmelweis University, Budapest, Hungary

Lead Author

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MAHMOUD OBEIDAT

Centre for Translational Medicine, Semmelweis University, Budapest, Hungary

Lead Author

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RENATA PAPP

Centre for Translational Medicine, Semmelweis University, Budapest, Hungary

Lead Author

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Dániel Sándor Veres

Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, Hungary

Lead Author

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Bogdan-Ionel Tamba

Advanced Research and Development Center for Experimental Medicine (CEMEX); Iasi

Lead Author

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Péter Hegyi

Centre for Translational Medicine, Semmelweis University, Budapest, Hungary

Lead Author

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BRIGITTA TEUTSCH

Centre for Translational Medicine, Semmelweis University, Budapest, Hungary

Lead Author

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Topics

  • Specific Pain Conditions/Pain in Specific Populations: Visceral Pain – Gastrointestinal/Abdominal