Celiac plexus block for pancreatic cancer pain in adults

 

Abstract

Background

Pancreatic cancer causes severe pain in 50 to 70% of patients and is often difficult to treat. Celiac plexus block (CPB) is thought to be a safe and effective technique for reducing the severity of pain.

Objectives

To determine the efficacy and safety of celiac plexus neurolysis in reducing pancreatic cancer pain, and to identify adverse effects and differences in efficacy between the different techniques.

Search methods

We searched Cochrane CENTRAL, MEDLINE, GATEWAY and EMBASE from 1990 to December 2010.

Selection criteria

Randomised controlled trials (RCTs) of CPB by the percutaneous approach or endoscopic ultrasonography (EUS)-guided neurolysis in adults with pancreatic cancer at any stage, with a minimum of four weeks follow-up.

Data collection and analysis

We recorded details of study design, participants, disease, setting, outcome assessors, pain intensity (visual analogue scale (VAS)) and methods of calculation.

Main results

The search identified 102 potentially eligible studies. Judged from the information in the title and abstract six of these concerning the percutaneous block, involving 358 participants, fulfilled the inclusion criteria and were included in the review. All were RCTs in which the participants were followed for at least four weeks. We excluded studies published only as abstracts. We identified one RCT comparing EUS-guided or computed tomography (CT) -guided CPB but its aim was to assess efficacy in controlling chronic abdominal pain associated with chronic pancreatitis rather than pancreatic cancer, so it was excluded.

For pain (VAS) at four weeks the mean difference was -0.42 in favour of CPB (95% confidence interval (CI) -0.70 to - 0.13, P = 0.004, fixed-effect model). At eight weeks the mean difference was -0.44 (95% CI -0.89 to - 0.01, random-effects model). At eight weeks there was significant heterogeneity (I² = 89%).

Opioid consumption was significantly lower in the CPB group than the control group (P < 0.00001). 

Authors' conclusions

Although statistical evidence is minimal for the superiority of pain relief over analgesic therapy, the fact that CPB causes fewer adverse effects than opioids is important for patients. Further studies and RCTs are recommended to demonstrate the potential efficacy of a less invasive technique under EUS guidance.

 

Plain language summary

Celiac plexus block (CPB) in patients with unresectable pancreatic cancer-related pain

Abdominal pain is a major symptom in patients with inoperable pancreatic cancer and is often difficult to treat. Celiac plexus block (CPB) is a safe and effective method for reducing this pain. It involves the chemical destruction of the nerve fibres that convey pain from the abdomen to the brain. We searched for studies comparing CPB with standard analgesic therapy in patients with inoperable pancreatic cancer. We were interested in the primary outcome of pain, measured on a visual analogue scale (VAS). We also looked at the amount of opioid (morphine-like drugs) patients took (opioid consumption) and adverse effects of the treatment. Six studies (358 participants) comparing CPB with standard therapy (painkillers) met our inclusion criteria. At four weeks pain scores were significantly lower in the CPB group. Opioid consumption was also significantly lower than in the control group. The main adverse effects were diarrhoea or constipation (this symptom was significantly more likely in the control group, where opioid consumption was higher). Endoscopic ultrasonography (EUS)-guided CPB is becoming popular as a minimally invasive technique that has fewer risks, but we were not able to find any RCTs assessing this method (current medical literature on this subject is limited to studies without control groups). Although the data on EUS-guided CPB and pain control are promising, we await rigorously designed RCTs that may validate these findings. We conclude that, although statistical evidence is minimal for the superiority of pain relief over analgesic therapy, the fact that CPB causes fewer adverse effects than opioids is important for patients.

 

Resumen

Antecedentes

Bloqueo del plexo celíaco para el dolor por cáncer pancreático en adultos

El cáncer pancreático causa dolor intenso en el 50% al 70% de los pacientes y con frecuencia es difícil de tratar. El bloqueo del plexo celíaco (BPC) se considera una técnica segura y efectiva para reducir la intensidad del dolor.

Objetivos

Determinar la efectividad y la seguridad de la neurólisis del plexo celíaco para aliviar el dolor por cáncer pancreático e identificar los efectos adversos y las diferencias en la efectividad entre técnicas diferentes.

Estrategia de búsqueda

Se realizaron búsquedas en CENTRAL, MEDLINE, GATEWAY y EMBASE desde 1990 hasta diciembre 2010.

Criterios de selección

Ensayos controlados con asignación aleatoria (ECAs) de BPC por enfoque percutáneo o neurólisis guiada por ecografía endoscópica (EE) en adultos con cáncer pancreático en cualquier estadio, con un mínimo de cuatro semanas de seguimiento.

Obtención y análisis de los datos

Se registraron los detalles del diseño de los estudios, los participantes, la enfermedad, el ámbito, los evaluadores de resultado, la intensidad del dolor (escala analógica visual [EAV]) y los métodos de cálculo.

Resultados principales

La búsqueda identificó 102 estudios potencialmente elegibles. Según la información existente en el título y el resumen, seis de estos estudios relacionados con el bloqueo percutáneo y que incluyeron 358 participantes, cumplieron los criterios de inclusión y se incluyeron en la revisión. Todos eran ECAs en los que los participantes tuvieron un seguimiento de al menos cuatro semanas.Se excluyeron los estudios publicados sólo como resúmenes.Se identificó un ECA que comparó el BPC guiado por EE o guiado por tomografía computarizada (TC), pero su objetivo fue evaluar la efectividad para el control del dolor abdominal crónico asociado con la pancreatitis crónica en lugar del cáncer pancreático, por lo que fue excluído.

Para el dolor (EAV) a las cuatro semanas la diferencia de medias fue −0,42 a favor del BPC (intervalo de confianza [IC] del 95%: −0,70 a  0,13; p = 0,004, modelo de efectos fijos). A las ocho semanas la diferencia de medias fue −0,44, IC del 95%: −0,89 a −0,01 (modelo de efectos aleatorios). A las ocho semanas hubo heterogeneidad significativa (I² = 89%).

El consumo de opioides fue significativamente menor en el grupo BPC en comparación con el grupo control (p < 0,00001).

Conclusiones de los autores

Aunque las pruebas estadísticas son mínimas para la superioridad del alivio del dolor sobre el tratamiento analgésico, el hecho de que el BPC cause menos efectos adversos que los opioides es importante para los pacientes. Se recomiendan estudios y ECAs adicionales para demostrar la posible efectividad de una técnica menos invasiva guiada por EE.

Traducción

Traducción realizada por el Centro Cochrane Iberoamericano