Plexus celiac neurolysis Interventional radiology - educational ppt

1. IDEA
Celiac plexus neurolysis
INDICATIONS TIPS & TRICKS OUTCOME
An under-used pain control procedure?
PROCEDURE
Dr. Davide Castiglione

2. Types of PAIN
• Somatic pain : well localized
skin and deep tissue
• Visceral pain : poorly localized
visceral organs
• Neuropathic pain :neurologic symptoms
nerves

4. IDEA
PAIN
CELIAC PLEXUS BLOCK
or NEUROLYSIS

5. Celiac plexus neurolysis
The celiac plexus is the largest visceral plexus
and is located deep in the retroperitoneum,
over the anterolateral surface of the aorta
and around the origin of the celiac trunk. It
serves as a relay center for nociceptive
impulses that originate from the upper
abdominal viscera, from the stomach to the
proximal transverse colon.
Celiac plexus neurolysis, with agents such as
ethanol, is an effective means of diminishing
pain that arises from these structures.
Invaluable therapeutic option in the
management of intractable abdominal pain in
patients with upper abdominal malignancy
CT-guided celiac plexus neurolysis: a review of anatomy, indications, technique, and tips for successful treatment. Radiographics. 2011 Oct;31(6):1599-

6. • Patients with persistent and intractable abdominal pain
caused by pancreatic, gastric, esophageal, or biliary
malignancy, as well as metastatic liver cancer and malignancy
associated with retroperitoneal lymph node metastasis
• relief from severe longlasting abdominal pain in patients with
chronic pancreatitis
• Palliation of severe, intractable nausea/vomiting in patients with
inoperable pancreatic cancer
• Pain refractory to level 3 analgesics (opioids) or intolerance
INDICATIONS
Wang PJ, Shang MY, Qian Z, Shao CW, Wang JH, Zhao XH. CT-guided percutaneous neurolytic celiac plexus block technique. Abdom Imaging 2006

7. ABSOLUTE
• Severe uncorrectable
coagulopathy
• Severe local or
intraabdominal infection
• Bowel obstruction Increased
risk of perforation due to
common effects on bowel
motility
CONTRAINDICATIONS
RELATIVE
• Abdominal aortic
aneurysm or aortic mural
thrombus
• Eccentric origin of celiac
axis
• Obscuration of
retroperitoneal fat planes
by large soft tissue masses

8. GOAL
PROCEDURE
Destruction of celiac plexus via direct injection of ethanol,
-Retroperitoneal
-Embedded in the fat
anterior to the aorta, just
caudal to the level of
origin of the celiac artery
-94% of the celiac ganglia
are located at the level of
T12 or L1
Anatomy
Zhang XM, Zhao QH, Zeng NL, et al. The celiac ganglia: anatomic study using MRI in cadavers. AJR Am J Roentgenol
2006;186(6):1520–1523

9. IMAGING GUIDANCE
PROCEDURE

10. CHECKLIST
PROCEDURE
• Coagulation profile
• Baseline pain intensity
• Neurologic and cardiologic exam
• Fasting
CT IMAGING AND PLANNING
EQUIPMENT
- #11 blade
- 21-g Chiba needle(s)
- 5- to 10-cc syringes
- Lidocaine: Both for
subcutaneous and target injection
- Dilute contrast
- 100% ethanol
- Normal saline

11. PATIENT POSITION AND APPROACHES
PROCEDURE
-Prone
-Supine
-Lateral decubitus
Posterior paravertebral
antecrural Anterior trans-organ

12. PATIENT POSITION AND APPROACHES
PROCEDURE «There’s always a way»
Transaortic approach
Transorgan

13. Bilateral Posterior paravertebral approach
PROCEDURE
1. Unhenanced CT scan
2. Localize celiac artery and celiac plexus
3. Select punture site, angle and depth of the needle entry
4. The point of needle entry is cleaned with antiseptic solution, and a sterile field is prepared
5. Subcutaneous infiltration with 1% lidocaine
6. The 21G needle is advanced 1–2 cm anterior to the aorta, between the diaphragmatic crura and the pancreas,
at the level between the celiac trunk and the SMA (ASPIRATE)
7. 5 mL of diluted iodinated contrast material is injected into the antecrural space (free diffusion of contrast
material)
8. 40 mL (20 mL on each side) of absolute ethanol (95%–100%) is injected through the needle and into the
antecrural space
9. Before the needle is withdrawn, 2–5 mL of
10. normal saline solution is injected to minimize the
11. risk of spreading any neurolytic agent that remains in the needle and prevent the burning pain that results from
leakage of neurolytic agent into the puncture route

14. PROCEDURE
• Close monitoring
• Risk of hypotension
• 12h rest
Postprocedure care

15. COMPLICATIONS
PROCEDURE
- 96% Back pain – shoulder pain due to diaphragm irritation
- 10-52% Orthostatic hypotension (decreased sympathetic tone, causing vasodilatation and
relatively low blood volume and cardiac output)
- 44% Transient diarrhea
Major complications rate 2%
Neurologic injuries
Monoplegia and anal and bladder sphincter dysfunction, pneumothorax, arterial
injury (eg, dissection), local hematoma, pleuritis, transient hematuria, pericarditis,
intervertebral disk injury, and retroperitoneal abscess
(inadvertent injection of neurolytic agent into the spinal artery that supplies the spinal cord, resulting in spinal ischemia)
Kaufman M, Singh G, Das S, et al. Efficacy of endoscopic ultrasound-guided celiac plexus block and celiac plexus neurolysis for managing abdominal
pain associated with chronic pancreatitis and pancreatic cancer. J Clin Gastroenterol 2010;44(2): 127–134.

16. TIPS & TRICKS
• Patient education (reduce opiate
requirements and limit its side effects !!!!!
• Early is better ! (within 2 months of the onset of pain
results in more-complete pain relief than when it is performed
later in the disease process)
• The two most important factors that affect destruction of the
celiac plexus are the amount of neurolytic agent injected and the
degree of diffusion of the neurolytic agent in the antecrural
space (adding contrast material to the neurolytic solution)
Ischia S, Ischia A, Polati E, Finco G. Three posterior percutaneous celiac plexus block techniques. A prospective, randomized study in 61 patients with
pancreatic cancer pain. Anesthesiology 1992;

17. OUTCOME
• Long-lasting benefit in 70%–90% of patients with various upper abdominal
cancers
• In pancreatic cancer, celiac plexus neurolysis abolishes pain in 10%–24% of
patients when used alone and in 80%–90% of patients when combined with
other treatment options (strong level of evidence)
• The major benefit of celiac plexus neurolysis is in the reduced rate of analgesic
consumption and lower incidence of drug-related adverse effects
2 - 4 - 8 week decrease opioid usage : -39,9mg ; -53,7mg ; -80,5mg
Ischia S, Polati E, Finco G, Gottin L, Benedini B. 1998 Labat lecture: the role of the neurolytic celiac plexus block in
pancreatic cancer pain management: do we have the answers? Reg Anesth Pain Med 1998;23(6):611–614.

18. TEAMWORK IS ESSENTIAL
GRAZIE PER L’ATTENZIONE