Pancreatic cancer is a malignant tumour with very poor prognosis and a chance for 5-year survival is approximately 6%. One of the main symptoms of this neoplasm is pain, mostly of neuropathic origin, which significantly decreases the quality of life and impairs the functional activity of patients. The most common treatment of pain in pancreatic cancer is conservative therapy which is based on analgesic ladder rules established by the World Health Organization. Unfortunately, it is not always effective and it has many side effects that also can diminish patients' quality of life. Invasive treatment of pain in pancreatic cancer includes mainly coeliac plexus block and sympathectomy, and both of them significantly reduce levels of pain and help to improve the quality of life. It is postulated that the place of those two invasive methods should not be at the final stage of treatment, but they can provide significantly better improvement of pain once instituted earlier (such as the first or second step of analgesic World Health Organization's ladder). The aim of this article is to review and assess the conservative as well as the invasive therapy in the management of pain in pancreatic cancer. It also presents brief insight into non-medical methods of pain reduction, which can be supplementary to conservative and/or invasive treatment.
BackgroundPancreatic cancer is a malignant neoplasm with a high mortality rate, often associated with a delayed diagnosis, the early occurrence of metastasis and an overall, poor response to chemotherapy and radiotherapy. Pain management in pancreatic cancer consists mainly of pharmacological treatment according to the WHO analgesic ladder. Surgical treatment for pain relief, such as splanchnicectomy, is considered amongst the final step of pain management. It has been proven that splanchnicectomy is a safe procedure with a small percentage of complications, nevertheless, it is often used as a last resort, which can significantly decrease its effectiveness. Performance of thoracoscopic splanchnicectomy along the first step of the analgesic ladder may lead to long-lasting protection against the presence and severity of pain.Methods/DesignA prospective, open label, 1:1 randomized, controlled trial, conducted at a single institution to determine the effectiveness of invasive treatment of pain via splanchnicectomy, in patients with advanced pancreatic cancer. The size of tested group will consist of 26 participants in each arm of the trial, to evaluate the level of pain relief and its impact on quality of life. To evaluate the influence on patients’ rate of overall survival, a sample size of 105 patients is necessary, in each trial arm. Assessments will not only include the usage of analgesic pharmacotherapy throughout the course of disease, and overall patient survival, but also subjective pain perception at rest, in movement, and after meals (measured by NRS score questionnaire), the patient’s quality of life (measured using the QLQ-C30 and FACIT questionnaires), and any pain-related suffering (measured with the PRISM projection test). The primary endpoint will consist of pain intensity. Questionnaires will be obtained upon the initial visit, the day of surgery, the day after surgery, as well as during long-term follow-up visits, held every two weeks thereafter.DiscussionEarlier implementation of invasive treatment, such as thoracoscopic splanchnicectomy, can provide a higher efficacy of pain management, prevent deterioration in the patient’s quality of life, and lengthen their overall survival.Trial registrationClinicalTrials.gov identifier: NCT02424279. Date of registration January 2, 2015.
Thoracic sympathectomy is an efficient method of treatment in palmar hyperhidrosis which significantly increases patients' QOL especially in a functional domain.
Thoracic sympathectomy (TS) is one of the most effective methods of treatment of primary hyperhidrosis. One of the side effects of this procedure is compensatory sweating (CS). The aim of our study was to evaluate the influence of body mass index (BMI) on CS in patients after TS due to palmar hyperhidrosis. Data from 157 patients with palmar hyperhidrosis who underwent TS were collected. The patients were subsequently divided in two groups according to their initial BMI: group A, BMI < 25 kg/m, and group B, BMI ≥ 25 kg/m. Objective (gravimetry) and subjective (VAS) measurements of the intensity of hyperhidrosis were taken from the patients' bodies prior to surgery, as well as 3 and 12 months after TS. Average palmar hyperhidrosis levels before the surgery did not differ significantly between the two groups (238.65 vs. 190.15; = 0.053). A statistically significant decrease in palmar hyperhidrosis was noted in both groups, both 3 and 12 months after surgery (238.65 vs. 11.86 vs. 13.5; < 0.05, and 190.15 vs. 16.67 vs. 11.81; < 0.05, respectively). The intensity of sweating over the abdomino-lumbar area differed significantly between the groups before the surgery, both in subjective (1.71 vs. 3.61; < 0.05) and objective (13.57 vs. 35.95; < 0.05) evaluations. Three months after surgical intervention, an intensification of CS was observed in both the groups; however, no statistically significant differences were observed between the two sets of patients (VAS: 4.58 vs. 5.16; = 0.38; gravimetry: 33.87 vs. 53.89; = 0.12). Twelve months after TS, CS was higher in the group with an initial BMI ≥ 25 kg/m, both in subjective and objective evaluations (3.23 vs. 4.94; = 0.03 and 18.08 vs. 80.21; = 0.026, respectively). Patients with a BMI ≥ 25 kg/m experience more severe CS after TS, both in subjective and objective evaluations.
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