Bilateral Thoracoscopic Splanchnicectomy: Effects on Pancreatic Pain and Function

Abstract

ObjectiveTo evaluate prospectively the effect of bilateral thoracoscopic splanchnicectomy on pancreatic pain and function. Summary Background DataSevere pain is often the dominant symptom in pancreatic disease, despite a wide variety of methods used for symptom relief. Refinement of thoracoscopic technique has led to the introduction of thoracoscopic splanchnicectomy in the treatment of pancreatic pain. MethodsForty-four patients, 23 with pancreatic cancer and 21 with chronic pancreatitis, were included in the study and underwent bilateral thoracoscopic splanchnicectomy. Effects on pain (visual analogue scale) and pancreatic function (standard secretin test, basal serum glucose, plasma insulin, and Cpeptide) were measured. ResultsFour patients (9%) required thoracotomy because of bleeding. There were no procedure-related deaths. The mean duration of follow-up was 3 months for cancer and 43 months for pancreatitis. Pain relief was evident in the first postoperative week and was sustained during follow-up, the average pain score being reduced by 50%. All patients showed a decrease in consumption of analgesics. Neither endocrine nor exocrine function was adversely affected by the procedure. ConclusionsBilateral thoracoscopic splanchnicectomy is beneficial in the treatment of pancreatic pain and is not associated with deterioration of pancreatic function.Chronic pancreatitis and pancreatic cancer are both associated with severe pain and impaired pancreatic function. Ideal treatment options would have a limited risk of drug addiction and would leave the functional capacity of the gland unaffected. Recent advances in laparoscopic technique also include developments in the field of thoracoscopy. The first report on successful thoracoscopic splanchnicectomy for pancreatic pain was published as recently as 1993.1 The rationale for neurotomy in this symptom is based on the fact that sensory nerves from the pancreas run along the hepatic, splenic, and superior mesenteric arteries to the semilunar ganglion, where they become incorporated in the greater and lesser splanchnic nerves, which arise from the 5th to the 11th thoracic ganglia on both sides of the vertebrae. Afferent sympathetic fibers follow the same route, whereas extrinsic parasympathetic innervation is supplied by the vagus. Thoracoscopic splanchnicectomy has targeted the greater splanchnic nerve. 1It is well established that exocrine pancreatic secretion is under neurohormonal control.2 Neurotransmitters and hormones interact in a complex manner, so it is difficult to differentiate the relative influence of each factor. Truncal vagotomy and the administration of atropine dramatically decrease the pancreatic bicarbonate and enzyme responses to hormonal stimulation and to intraduodenal fat, protein, or acid.3 There are suggestions that the sympathetic nervous system inhibits pancreatic exocrine secretion. 4,5 Splanchnicectomy by retroperitoneal, intraperitoneal, and transhiatal approaches, transthoracic left splanchnicectomy combined with truncal vagotomy, and pe...

An Open Randomized Comparison of Clinical Effectiveness of Protocol-Driven Opioid Analgesia, Celiac Plexus Block or Thoracoscopic Splanchnicectomy for Pain Management in Patients with Pancreatic and Other Abdominal Malignancies

“…There was information about the percentage with effective pain relief at 2 weeks but not 2 months. Our initial sample size calculation was therefore based on the observations that opioid treatment had achieved good pain relief in the first 2 weeks in an estimated 70% of patients [1], and CPB or TS gives good pain relief immediately in 90% of patients [14,16]. A Bonferroni correction was included for 3 pairwise comparisons (α = 0.016).…”

“…TS has not been studied as extensively as CPB, but on theoretical grounds it is likely that the complications of transient hypotension and diarrhoea would be as frequent as with CPB. Other side effects reported from thoracoscopy include arterial bleeding requiring thoracotomy [14], chylothorax [15] and lung injury causing pneumothorax-requiring drainage.…”

Videothoracoscopic Simultaneous Bilateral Posterior Splanchnicectomy - Initial Report

“…The operations were performed according to the procedure initially presented by Cuschieri and Ihse (12,14). The primary disease was diagnosed during a preceding laparotomy with pathological confirmation of cancer.…”

Surgical and interventional treatment of chronic pancreatitis

“…In one study that included only patients with nonalcoholic pancreatitis, those who have had prior surgical or endoscopic interventions had a poorer response in pain relief compared to patients without prior intervention [113]. On the contrary, two other studies involving mostly patients with alcoholic pancreatitis, found no correlation between the success rate of splanchnicectomy and the incidence of prior interventions directed at pain control [111,112]. Although bilateral thoracoscopic splanchnicectomy is safe, involves a minimal access approach, and may provide improved quality of life in patients with small-duct pancreatitis, further studies are needed to identify clearly the appropriate candidates for this procedure [113].…”

“…A prospective, randomized study comparing the efficacy of EUS-guided versus CT-guided celiac plexus block failed to show any advantage of either approach [110]. Bilateral thoracoscopic splanchnicectomy has been suggested to be the best surgical approach to splanchnic nerve ablation in patients with intractable pain from chronic pancreatitis [111][112][113][114]. In a prospective, semirandomized, case-control study, videothoracoscopic splanchnicectomy significantly decreased intensity of pain and improved the quality of life [114].…”