Preoperative Optimisation - Columbia Asia Hospital Workshop

Pain Management in Pancreatic Cancer

• Why pain? Inflammatory changes (NGF, CGRP) Ductal and parenchymal hypertension Changes in local neuroanatomy Destruction of nerve fibres Earlier and greater pain - Ca of Pancreatic head than tail

1

Modalities to Manage pain

Medical Management.Exocrine enzyme supplementation, antioxidantsDrainage

Surgical ManagementWhipple’s , others

Use of Medications.Acetaminophen, NSAIDS,Opioids

Interventional.Neurolysis , Nerve block

2

Equipment

• 22G needle , 13 cms long• LA agents-1%xylocaine, 0.5% Bupivacaine +/- Methyl

prednisolone 80 mg• Neurolytic Solution: Alcohol 50:50 or 6% acqueous

Phenol.

• Guidance: USG or CT or Fluroscopy• POSITION: Depending upon technique used.

3

Splanchnic Nerves and Coeliac Plexus

4

Coeliac Plexus Block

5

Important Considerations

• ?Blind/Fluroscopy /CT / USG• Indications and Contraindications• Patient Preparation. Consent, Coagulation Status, Hydration.

• Complications Orthostatic hypotension

6

Classical Approach

7

Where to put in a needle?

8

9

10

Anterior Approach to Celiac Plexus

11

USG and CT Guidance

12

Newer modalities

• Endoscopic/laparoscopic USG aided CPB.• Videoscopic thoracoscopy for surgical

splanchiectomy.

• Resistant/Failed Cases• Intrathecal pump to deliver Opioids+/- LA• Spinal Cord Stimulator.

13