Systematic review of the role of thoracoscopic splanchnicectomy in palliating the pain of patients with chronic pancreatitis

Abstract

Splanchnicectomy reduces pain and improves quality of life for patients with chronic pancreatitis. Patient selection determines success rates, but the early good results achieved decline with time elapsed after thoracoscopic splanchnicectomy.

Has Central Sensitization Become Independent of Nociceptive Input in Chronic Pancreatitis Patients Who Fail Thoracoscopic Splanchnicectomy?

“…Technical failure due to difficult identification of all the splanchnic branches, variations in morphology, alternative pathways, and localization of the greater and lesser splanchnic nerves have all been described in the literature. 13,15 However, during our procedures, all nerves and branches were visualized in all patients, and all procedures were classified as technically successful. The surgery of itself could have caused further central sensitization due to nerve destruction, resulting in increased central excitation and facilitation via descending pathways, where finally an autonomous state of chronic pain can be present.…”

“…6 Peripheral nociception at the site of the pancreas can be expected to spread via ascending pathways of the spinal cord to supraspinal structures including the cortex. 12,13 Because of ongoing nociceptive input, the dorsal horn of the spinal cord undergoes neuroplastic changes, resulting in an increase in neuronal excitability and synaptic strength and neuronal reorganization, 8 characterized by segmental hyperalgesia at the site of injury. 16 Ultimately, ongoing nociceptive drive on secondary neurons will lead to spreading and generalized hyperalgesia, because of hyperexcitability and firing of supraspinal neurons at lower thresholds.…”

“…11 However, the fact that such deafferentation is not effective in all patients could imply that, in some patients, such neuroplastic changes are independent of peripheral nociceptive input. 12,13 The aim of the present study was to investigate, using QST, whether such independence of neuroplastic central alterations from ongoing peripheral nociceptive input exists. Our hypothesis is that pain in some CP patients is related to alterations in pain processing, explaining the failure of splanchnicectomy in some CP pain patients.…”

Surgery for Chronic Pancreatitis

“…One-third to half of these patients have shown good reduction of pain in a short-term follow-up; however, only 10% of them seem to show a benefit at 24 weeks [64]. Many studies [64][65][66] show that the early good results achieved by neuroablative procedure decline with time elapsed as compared with the durable relief obtained from conventional surgical procedures. Over twothirds of patients would ultimately need surgery again [66].…”

Splanchnicectomy for Pancreatic Cancer Pain

“…The greater, lesser, and least splanchnic nerves carry sympathetic pain innervation to the upper abdominal viscera, including the pancreas, from the 5th to 8th, 9th to 10th, and 11th thoracic ganglia, respectively [5]. Visceral pain arises from the stimulation of a celiac ganglion, which then sends a signal to the splanchnic nerves [6].…”