P048: CELIAC PLEXUS BLOCK WITH TRANSAORTIC APPROACH
Alexander Hall, MD; Maria Rathore, DO; Evan Peskin, MD, MBA; Dennis Patin, MD; University of Miami/Jackson Memorial Hospital
Pancreatic cancer is a painful malignancy that is often unresponsive to medications. Celiac plexus block and neurolysis can be performed in order to alleviate both the noicioceptive and neurogenic pain cause by pancreatic cancer. The celiac plexus is the largest autonomic plexus located anterolateral to the aorta and posterior to the pancreas. The celiac plexus block has been shown to decrease pain and opioid consumption. In literature, neurolysis of the celiac plexus has been shown to provide as much as 6 months of relief when administered successfully.
A 61 year old female with metastatic pancreatic cancer with mets to the liver and peritoneum came to the pain clinic for abdominal pain. She was using a Fentanyl patch and Oxycodone which did not provide pain relief. There was a discussion about celiac plexus neurolysis and she was interested in the procedure. A CT scan was done prior to the procedure to identify anatomy which showed that the lungs finished at the inferior border of T12. An L1 transaortic approach using fluoroscopy was used due to the location of the lungs. The L1 vertebral body was identified and a spinal needle was advanced through the skin until immediately adjacent to the anterolateral surface of the vertebrae. A loss of resistance syringe was used as punching through posterior and anterior wall of aorta. There was loss of resistance when entering the posterior surface of the aorta with positive blood return, and return of resistance with negative blood return when the needle was advanced through the anterior surface of the aorta. Contrast was inserted and spread was visualized to confirm location. Next, 15mL of concentrated ethyl alcohol was injected to perform neurolysis. The patient experienced cramp-like abdominal pain for approximately 30 seconds after the injection, which resolved. She experienced almost complete pain relief and was able to decrease her opioid requirements the next day.
The most common approach to the celiac plexus block is the posterior paraaortic in which the diaphragm is traversed to enter the antecrural space anterolateral to the aorta between the levels of the superior mesenteric artery and celiac trunk. For our case, the posterior transaortic approach was used. Advantages to a posterior transaortic approach include decreased risk of neurologic injury due to spinal cord injury and more reliable spread of neurolytic agent. Ethanol and phenol are used as the neurolytic agent because they cause irreversible neural damage. The amount of injectate varies with location; the retrocrural space requires less versus antecrural space. The retrocrural space is known to affect the splanchnic nerves whereas the antecrural block aids in the destruction of the celiac plexus. Multiple studies have shown that the celiac plexus neyrolysis provides pain relief in metastatic pancreatic cancer for atleast 6 months and decreases the use of opioids. For this reason it is important to offer the block in early disease and prevent side affects of opioids and provide better quality of life.