Iyengaran, H (2015) CT guided celiac plexus neurolysis. Masters thesis, Madras Medical College, Chennai.
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Abstract
A prospective study involving 30 patients, diagnosed to have intractable upper abdomen pain due to malignancies/ pathologies of inoperable status at BARNARD INSTITUTE OF RADIOLOGY, MADRAS MEDICAL COLLEGE & RAJIV GANDHI GOVT GENERAL HOSPITAL, CHENNAI by Dr. H. Iyengaran, III year M.D.R.D. resident, as the principal investigator under the guidance of Professor S. Kalpana, M.D., D.M.R.D,. These patients were referred from the Institute of Anesthesiology and Critical care and from Department of Gastroenterology. AIMS AND OBJECTIVES: • To perform CT guided neurolysis of the CELIAC PLEXUS, through anterior approach in patients with intractable upper abdominal pain due to intraabdominal malignancies/pathologies of inoperable status. • To assess treatment success by evaluating pain relief using Visual Analog Scale (VAS) before and after the procedure. • To assess minor/major complications associated with the procedure. The procedure was done through anterior approach with Absolute alcohol as the neurolytic agent. Pain assessment was done using Visual Analog scale. INDICATIONS: • Patients with persistent and intractable upper abdominal pain due to malignancies / Chronic Pancreatitis of inoperable status • Patients with severe nausea and hyperemesis due to Pancreatic cancer • In visceral neuropathy in patients with diabetes, Inflammatory bowel disease (Crohn’s disease) and sclerosing cholangitis of AIDS. CONTRAINDICATIONS: • Coagulopathies • Hypovolemic status • Ascites • Abdominal aorta aneurysm • Intraabdominal sepsis • Bowel obstruction / Tumors With proper preparation of the patient, with everything in place, procedure done under local anesthesia which involves the following steps: PROCEDURE: · Pre procedure VAS is obtained. · Premedication with Inj.Pentazocine and Inj.Atropine · Patient is positioned supine. · A surface marker is placed over the patient abdomen at T12 to L2 level. · A NECT abdomen is performed. · Celiac artery and celiac plexus are localized and the best axial slice selected. · The puncture sites are then selected. The surface marker gives the long axis and the CT machine lazer beam of the axial slice gives the horizontal axis. · From the point of entry, the trajectory is planned (which is the third axis) on the console and depth measured. · Patient abdomen is painted with povidone iodine and draped. · Skin and the anterior abdominal wall infiltrated with 2% lignocaine on both sides. · Puncture site incision is made with 11 surgical blade. · 20G Chiba or Spinal needle is passed from the puncture site along the trajectory up to the target site, the antecrural space, bilaterally. · The needle tip is first located with the tip artefact. A negative suction helps to rule out intra arterial placement of needle tip. · Then a mixture of 3 ml of 2% lignocaine with 1ml of contrast is injected on each side. In this mixture, lignocaine serves two purposes. First, it assesses the needle tip by evaluating the spread. Second, the injected lignocaine, if produces mild reduction in pain, warrants a successful outcome. · Contrast is added to the mixture, to facilitate the spread of the injected liquid in the target space. As the HU of ethyl alcohol is -210 units, like that of surrounding Fat, its spread cannot be assessed, if it is injected separately. · Once this is confirmed, a mixture of 15 ml of neurolytic agent (Absolute alcohol) and 5 ml of 2% lignocaine is injected on each side. It is important to rule out intra arterial injection by applying negative suction. As the HU of alcohol is - 210 units, its spread can be appreciated only by means of hydrodissection. Lignocaine is added to alleviate any transient pain, associated with alcohol injection and for immediate neurolytic effect. · The needles are then removed (Before withdrawing, the needles are flushed with saline to prevent spillage of alcohol in the trajectory which is painful) and hemostasis secured with manual pressure if needed and adhesives applied. · Immediate post procedure pain evaluation with VAS is obtained on the table. POST PROCEDURE CARE: · Patient is shifted to the ward and advised strict bed rest for 12 hours · Regular monitoring of vitals is done. · Proper hydration with intravenous fluids. · Patient can resume normal diet immediately after the procedure. · A complete neurological examination done at 24 hours post procedure. · A post procedure pain score – VAS score is obtained at 24 hours. · Follow up VAS score obtained at 1 week, 1 month and 2 months. CONCLUSION: 1) Mean percentage reduction of pain intensity between preprocedure VAS score and Immediate post procedure VAS score, immediate post procedure and 24 hours score, 24 hours and 1 week score and preprocedure and 2 months score are 55%, 32%, 31% and 80% respectively, all of which were statistically significant. 2) The pain intensity score remained static from 1 week to 2 months post procedure. 3) Gender does not have any statistical significance in the VAS scores or in the response to procedure. 4) For preprocedure VAS score, the mean difference in within subject analysis is statistically significant for preprocedure VAS and immediate post procedure score. 5) There is difference in the Variances of differences between all possible pairs of groups with statistical significance indicating, there is a true reduction in pain intensity post procedure. 6) Procedure was more effective for malignancies than inflammatory condition. 7) Maximum percentage reduction in pain, of 88% was seen with pancreatic carcinoma. 8) Least percentage reduction in pain, of 74% was seen with Chronic pancreatitis. 9) Hypotension was the commonest complication seen in 18 patients (9 males and 9 females). All these patients settled with intravenous fluids. 10) Back pain was the second most common complication, seen in 14 patients (6 males and 8 females). 11) Shoulder pain was seen in 12 patients (6 males and 6 females). 12) Absence of pain relief was not reported in this study. 13) Complications were independent of Gender and Difference VAS score. 14) Complications were dependent on Age with statistical significance. LIMITATIONS: 1) Sample size is only 30. 2) Number of patients in each disease type are not equal and also too small in the third and fourth type and hence the results cannot be generalised. 3) Follow up is done only up to 2 months. Hence the long term benefits or worsening of pain beyond 2 months is not known.
| Item Type: | Thesis (Masters) |
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| Uncontrolled Keywords: | Celiac Plexus; Intractable Pain; Anterior Approach; Neurolytic Agent; Absolute Alcohol; Visual Analog Scale |
| Subjects: | MEDICAL > Radio Diagnosis |
| Depositing User: | Punitha K |
| Date Deposited: | 26 Mar 2018 06:26 |
| Last Modified: | 26 Mar 2018 06:26 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/6600 |
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