Celiac plexus block: A reappraisal

Abstract

Neurolytic celiac plexus block alone is capable of providing complete pain relief until death in a few cases and, therefore, should be considered as an adjuvant treatment in the analgesic strategy. Combination palliative therapy is necessary in most cases. Failure of the block may be attributed to tumor metastasizing beyond the nerves that conduct pain via the celiac plexus and the component nerves that form it. Concomitant pain of somatic origin (frequently observed in upper gastrointestinal cancer because of significant peritoneal involvement) requires other therapeutic measures.

Coeliac plexus neurolysis for upper abdominal malignancies using an anterior approach: review of the literature

“…Ethanol causes immediate precipitation of endoneural lipoproteins and mucoproteins within the coeliac plexus, leading to extraction of cholesterol, phospholipid, and cerebroside from the neurilemma. 18,19 Irreversible damage to neurons and nerve fibres occurs at an ethanol concentration of more than 50%; hence, a concentration between 50% and 100% is preferred for coeliac plexus neurolysis. 19 At concentrations above 50%, the degree of destruction depends more on the distribution of ethanol within the coeliac plexus than its concentration.…”

“…19 Few authors recommend adding a longacting local anaesthetic such as bupivacaine to ethanol as its injection may cause severe transient pain. 18,19 Iodinated contrast material is another component that is added to ethanol to help visualise the distribution of neurolytic agent in the pre-aortic space. 18,19 A cocktail of absolute alcohol (95-100%), bupivacaine and contrast material, with a ratio of 6:3:1, is the most frequently used neurolytic mixture.…”

“…18,19 Iodinated contrast material is another component that is added to ethanol to help visualise the distribution of neurolytic agent in the pre-aortic space. 18,19 A cocktail of absolute alcohol (95-100%), bupivacaine and contrast material, with a ratio of 6:3:1, is the most frequently used neurolytic mixture. 20 Phenol has a somewhat slower onset and shorter duration of action and is less effective than ethanol.…”

“…20 Phenol has a somewhat slower onset and shorter duration of action and is less effective than ethanol. 18,19 Phenol is generally injected at a concentration of 3-20%, and large amounts of phenol are toxic and cause irritation. 19 It achieves neurolysis similar to that achieved with ethanol by causing protein coagulation and necrosis of neural structures.…”

“…It is also more viscous than ethanol, a characteristic that limits the use of higher concentrations and makes it unsuitable for mixing with contrast material. 18,19 The needle track should be cleared with normal saline during withdrawal of the needle to avoid tracking of the neurolytic solution along the needle path.…”