cpn-內(nèi)鏡下腹腔神經(jīng)節(jié)阻滯術

EUS-guidedPlexusBlock/Neurolysis(CPN)INTRODUCTION

Painrelatedtopancreaticcancerandchronicpancreatitisisoftenpoorlycontrolled.Celiacplexusneurolysis(CPN)isachemicalsplanchnicectomyoftheceliacplexus,whichablatestheafferentnervefibersthattransmitpainfromintra-abdominalviscera.CPNismostcommonlyusedtopalliatepainfrompancreaticcancerbuthasalsobeenusedforrelievingpaininchronicpancreatitis.METHODSFORPERFORMINGCPNCPNcanbeperformedpercutaneously,surgically,orunderendosonographicguidance.Itismostcommonlyperformedcomputedtomographicguidanceduringwhichabsolutealcoholisinjectedintotheceliacplexus.

Endosonographic(EUS)guidanceoffersthemostdirectaccesstotheceliacplexusofalltheCPNtechniquesshortofsurgicalintervention.Theceliacgangliaarelocatedattheoriginoftheceliacartery,whichiseasilyidentifiedatendosonography.Therelativeproximityoftheceliacgangliatotheposteriorgastricwallensuresanaccuratepassageoftheinjectingneedleintotheganglia,therebyminimizingtheriskofcomplicationsandpotentiallyincreasingtheeffectivenessoftheblock.

TechniqueEUSCPNperformedforthepalliationofpancreaticcancerpainappearstobeassafeandeffectiveasCPNperformedbyothertechniques.AnadvantageoftheEUSapproachisthatitcanbeperformedwhilestagingandobtainingbiopsiesofthetumor.TECHNIQUE

Patientsarehydratedwithintravenousnormalsaline(500to1000cc)priortotheprocedure.UnderdirectEUSvisualization,aultrasoundaspirationneedleprimedwithnormalsalineisplacedimmediatelyadjacentandanteriortotheaortaattheleveloftheceliactrunk.Afterinjecting3ccofsalinetocleartheneedle,anaspirationtestisperformed.Ifnobloodisobtained,5mLof2percentlidocaineisinjected.Theaspirationtestisrepeatedandifnobloodreturnoccurs,15mLabsolutealcoholisinjected.COMPLICATIONS

TransientdiarrheaandhypotensionarecommonmanifestationsofthesympatheticblockadethatcanoccurpostCPNandmaybeseeninupto40percentofpatients.InfectiouscomplicationsofEUSCPNareuncommon.Inaseriesof90patients,onlyonedevelopedaninfectiouscomplication(aperipancreaticabscess).MajorcomplicationsMajorcomplicationsfrompercutaneousCPNarerare,occurringinapproximately1percentofpatients.Theseincludelowerextremityweaknessandparesthesias,paraplegia,pneumothorax,renalpuncture,andprolongedgastroparesisordiarrhea.SUMMARYANDRECOMMENDATIONEUSCPNappearstobeassafeandeffectiveasothermethodsforperformingCPN.EUSCPNmaythemostcost-effectiveofallCPNtechniquessincetumorscanbestagedandbiopsiedatthetimeofCPN.Painrelieflastingforupto24weekshasbeenobservedinapproximately70percentofpatients.AssessmentofPainIntensity No Mild Moderate Severe Very Worst

pain pain pain pain severe possible

pain painVerbalPainIntensityScale No pain

VisualAnalogScaleFacesScale 0 1 2 3 4 50–10NumericPainIntensityScale No Moderate Worst

pain pain possiblepain 0 1 2 3 4 5 6 7 8 9 10PortenoyRK,KannerRM,eds.PainManagement:TheoryandPractice.FADavis;1996:8-10.

WongDL.Wale