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									                                                                                                                                                                                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                                                                                                      Produziu-se um fluxo detectável pelo ultrassom com Doppler colorido
Percutaneous celiac plexus neurolysis is an effective method to                                               na ponta de uma agulha fina (22G), pela injeção contínua de solução
relieve pain in advanced abdominal cancer, especially in patients                                             salina, otimizando sua visualização durante a progressão guiada por
with pancreatic carcinoma. It was performed a percutaneous celiac                                             imagem. Esta estratégia permitiu o posicionamento rápido e preciso
plexus neurolysis, using the anterior transgastric route, under general                                       da agulha no espaço pré-aórtico adjacente ao tronco celíaco. Cerca
anesthesia and apneic oxygenation in a patient with an advanced                                               de 30 ml de álcool absoluto foi injetado, de forma a promover a
pancreatic adenocarcinoma and chronic abdominal pain refractory                                               ablação química do plexo nervoso. O procedimento durou apenas
to clinical treatment. A color Doppler ultrasound detectable flow at                                          oito minutos e o paciente referiu uma melhora significativa do quadro
the tip of a Turner-22G needle through continuous injection of saline                                         álgico ao seu término, tendo sido possível a redução significativa da
solution was produced. This technique showed the exact position of                                            prescrição analgésica diária.
the needle dynamically during its progression. Then, 30 ml of ethanol
was infused into the preaortic space. The procedure took around                                               Descritores: Plexo celíaco; Alcoolismo; Ultra-sonografia Doppler em
eight minutes, and the patient expressed significant pain relief and                                          cores; Anestesia; Ultra-sonografia de intervenção; Relatos de casos
decrease in his narcotic analgesics requirements.

Keywords: Celiac plexus; Alcoholism; Ultrasonography, doppler,                                                INtroDUctIoN
color; Anesthesia; Ultrasonography, interventional; Case reports                                              The percutaneous celiac plexus neurolysis (PCN) is an
                                                                                                              efficient technique applied to reduce abdominal pain,
                                                                                                              secondary to inflammatory conditions or retroperitoneal
resUMo
                                                                                                              cancers located in the upper abdomen. Pancreatitis and
A neurólise percutânea do plexo celíaco é um método eficiente para
                                                                                                              advanced tumors arising from the pancreas, stomach,
reduzir a dor em pacientes com neoplasia abdominal avançada,
                                                                                                              esophagus and gallbladder are conditions in this
principalmente em casos de câncer pancreático. Foi realizada uma
neurólise percutânea do plexo celíaco guiada por ultrassom, usando                                            location that may require more aggressive pain control
a via anterior transgástrica e anestesia geral com oxigenação apneica                                         when unresponsive to large doses of narcotic agents(1).
em um paciente portador de adenocarcinoma avançado de pâncreas                                                    This technique consists in an injection of a neurolytic
e dor abdominal crônica refratária a tratamento medicamentoso.                                                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: rodrigogg@einstein.br
    Received on Mar 3, 2009 – Accepted on Jul 13, 2009



                                                                                                                                                                             einstein. 2009; 7(3 Pt 1):361-4
362      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                                           Figure 2. MRI of upper abdomen at celiac artery level. (A) Post-contrast axial
of anesthesia and interventional radiology that have                                            T1 image. (B) Axial T2 image. Large expansive solid mass invading the head of
optimized the procedure were applied.                                                           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
case report
JGF, a 68-year-old male patient, was referred from                                                  In the previous three months, the patient experienced
Vitória, in the state of Espírito Santo, with an advanced                                       an important worsening of his abdominal pain, despite
and non-resectable pancreatic adenocarcinoma, which                                             high doses of opioid analgesics.
was found six months before.                                                                        The Interventional Oncology Group of Hospital
    The abdominal magnetic resonance imaging                                                    Israelita Albert Einstein was, then, requested to perform
(MRI), or cholangio-MRI, depicted a large solid mass                                            a PCN as an adjunctive palliative pain management.
involving the head of pancreas, invading the celiac                                             It was performed a PCN using an anterior transgastric
trunk and the superior mesenteric vessels, with diffuse                                         route, guided by color Doppler ultrasonography (CDU).
dilation of the main pancreatic duct (Figures 2A, 2B                                                Oriented by CDU real time images and under general
and 2C).                                                                                        anesthesia, the anterior abdominal wall was punctured


einstein. 2009; 7(3 Pt 1):361-4
                           Ultrasound-guided percutaneous celiac plexus neurolysis using the anterior transgastric approach and continuous flow apneic ventilation: case report    363



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                                Figures 3. US-guided transgastric PCN. (A) Abdominal puncture. The thin needle
of neurolysis, a moderate postural hypotension for                                    (20 G) is poorly visualized in front of the aorta. (B) The needle position is nicely
five weeks following the procedure, which disappeared                                 depicted after continuous injection of saline. The small flow generated at the
spontaneously.                                                                        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

DIscUssIoN
PCN is an effective tool for palliative pain management,                              severe coagulopathy, active abdominal infection or
which has been traditionally overlooked by medical                                    sepsis(7). The celiac plexus is a series of one to five
community, despite its advantages.                                                    ganglia composed of a dense network of interconnecting
    Effective pain relief has been reported in up to                                  presynaptic sympathetic nerve fibers, derived from
85% of the patients with chronic abdominal pain due                                   T5-T12 splanchnic nerves. It is located anterior to the
to both benign and malignant conditions, also reducing                                crura of the diaphragm, over the anterolateral wall of
the narcotic analgesics required and the narcotic-dose                                the aorta bilaterally, and just caudal to the level of the
related side effects(5,7).                                                            origin of celiac artery.
    The contraindications to the procedure are very                                       It supplies sympathetic, parasympathetic, and visceral
limited, generally related to anticoagulant therapy,                                  sensory afferent fibers to the pancreas, liver, biliary tract,


                                                                                                                                                        einstein. 2009; 7(3 Pt 1):361-4
364      Garcia RG, Maurano A, Santos MM, Macedo Filho CL, Macedo ALV, Francisco Neto MJ, Funari MBG



gallbladder, renal pelvis and ureter, spleen, mesentery,                                        very precise imaging guidance optimized by continuous
and bowel proximal to the transverse colon(2,7).                                                flow apneic ventilation and CDU. The association of
    The pharmacological-induced celiac plexus block                                             these techniques allowed performing a very fast and
impairs pain circuits in those organs(2).                                                       accurate procedure.
    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).                                                                acKNoWLeDGMeNts
    The best results are obtained to relieve pain caused by                                     We thank Daniel Costa, MD (Beth Israel Deaconess
neoplasms in the upper abdomen, especially pancreatic                                           Medical Center, Boston, USA), for his suggestions in
tumors. The extension of cancer invasion and eventual                                           this paper.
postoperative changes may compromise the outcomes,
by limiting the spread of the neurolytic agent around
the celiac trunk(8).                                                                            reFereNces
    The most frequent collateral effects are related to                                         1. Eisenberg E, Carr DB, Chalmers TC. Neurolytic celiac plexus block for treatment
sympathetic block: hypotension (up to 30%, disappearing                                            of cancer pain: a meta-analysis. Anesth Analg. 1995;80(2):290-5.
after 12 hours in most cases) and diarrhea (up to 60%,                                          2. Waldman SD, Patt RB. Splanchnic and celiac plexus nerve block. In: Waldman
with good recovery after 48 hours)(4-5).                                                           SD, editor. Pain management. Philadelphia: Elsevier; 2007. p. 1265-8.
    Severe neurological impairment, like paraplegia,                                            3. Romanelli DF, Beckmann CF, Heiss FW. Celiac plexus block: efficacy and safety
                                                                                                   of the anterior approach. AJR Am J Roentgenol. 1993;160(3):497-500.
lower limb paresia and paresthesia are very rare (less
                                                                                                4. De Cicco M, Matovic M, Bortolussi R, Coran F, Fantin D, Fabiani F, et al. Celiac
than 1% of cases) and exclusively associated with the
                                                                                                   plexus block: injectate spread and pain relief in patients with regional anatomic
posterior transcrural approach. These complications are                                            distortions. Anesthesiology. 2001;94(4):561-5.
attributed to direct lesion of spinal cord or to alcohol-                                       5. Fugère F, Lewis G. Coeliac plexus block for chronic pain syndromes. Can J
induced thrombosis of anterior spinal artery(9). They do                                           Anaesth. 1993;40(10):954-63.
not occur, therefore, in patients undergoing the anterior                                       6. Babinski MF, Sierra OG, Smith RB, Leano E, Chavez A, Castellanos A. Clinical
transabdominal approach.                                                                           application of continuous flow apneic ventilation. Acta Anaesthesiol Scand.
                                                                                                   1985;29(7):750-2.
                                                                                                7. Titton RL, Lucey BC, Gervais DA, Boland GW, Mueller PR. Celiac plexus
coNcLUsIoN                                                                                         block: a palliative tool underused by radiologists. AJR Am J Roentgenol.
                                                                                                   2002;179(3):633-6.
PCN is a safe and efficient palliative tool for pain
                                                                                                8. Giménez A, Martínez-Noguera A, Donoso L, Catalá E, Serra R. Percutaneous
management in selected cases of chronic abdominal                                                  neurolysis of the celiac plexus via the anterior approach with sonographic
diseases.                                                                                          guidance. AJR Am J Roentgenol. 1993;161(5):1061-3.
    It was described one case of PCN performed by an                                            9. Davies DD. Incidence of major complications of neurolytic coeliac plexus block.
anterior transgastric approach, using fine needle and                                              J R Soc Med. 1993;86(5):264-6.




einstein. 2009; 7(3 Pt 1):361-4

								
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