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Celiac plexus block for pancreatic cancer pain in adults

  • Review
  • Intervention

Authors


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.

アブストラクト

成人における膵癌疼痛に対する腹腔神経叢ブロック

背景

膵癌は50~70%の患者に重度の疼痛を引き起こし、治療が困難な場合が多い。腹腔神経叢ブロック(CPB)は、疼痛の重症度を低下させるための安全で有効な手法であると考えられている。

目的

膵癌疼痛を軽減する方法としての腹腔神経叢神経破壊術の有効性と安全性を評価し、有害作用を確認するとともに、異なる手法との有効性の差異を調べること。

検索戦略

Cochrane CENTRAL、MEDLINE、GATEWAY、EMBASEを1990年から2010年12月まで検索した。

選択基準

あらゆる病期の膵癌成人患者を対象に経皮的アプローチまたは超音波内視鏡(EUS)下神経破壊術によるCPBを実施し、4週間以上の追跡を行ったランダム化比較試験(RCT)。

データ収集と分析

試験デザイン、参加者、疾患、環境、アウトカム評価者、疼痛強度(視覚的アナログ尺度[VAS])、および計算方法の詳細を記録した。

主な結果

検索により、適格の可能性がある102件の研究を同定した。標題および抄録の情報から判断して、102件のうち、358例の参加者を対象にした経皮的ブロックに関する6件の研究が選択基準に合致したため、レビュー対象として選択した。研究はすべて、参加者を4週間以上にわたって追跡したRCTであった。抄録のみが発表されている研究は除外した。EUS下CPBまたはコンピュータ断層撮影法(CT)下CPBと比較した1件のRCTを同定したが、膵癌ではなく慢性膵炎による慢性腹痛の管理における有効性を評価することが試験の目的であったため、除外した。4週目時点の疼痛(VAS)については、CPBに優位性があり、平均差は-0.42[95%信頼区間(CI)-0.70~-0.13、P=0.004、固定効果モデル]であった。8週目時点の平均差は-0.44(95%CI -0.89~-0.01、ランダム効果モデル)。8週目時点では、有意な異質性が認められた(I2 = 89%)。CPB群は対照群に比較してオピオイドの消費量が有意に低かった(P < 0.00001)。

著者の結論

他の鎮痛療法と比較して疼痛緩和の優位性を示す統計的エビデンスはわずかであるが、CPBはオピオイドよりも有害作用が少ないという事実は患者にとって重要である。EUS下で行う侵襲性の低い手技の有効性を明らかにするためには、さらなる試験およびRCTを実施することが推奨される。

訳注

Translated by: MINDS

Translation supported by:

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.

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