McGreevy, K., Hurley, R.W., Erdek, M.A., Aner, M.M., Li, S., & Cohen, S.P. (2013). The effectiveness of repeat celiac plexus neurolysis for pancreatic cancer: A pilot study. Pain Practice, 13, 89–95.

To determine the success rate and duration of relief following repeat celiac plexus neurolysis (CPN) for pancreatic cancer pain

CPN was performed using either fluoroscopy or computed tomography (CT). All CPN and neurolytic procedures were performed under sterile conditions with IV sedation provided as needed at the discretion of the attending physician. The decision to use fluoroscopy versus CT was based on several factors, including patient condition, resource availability, and radiologic demonstration of tumor distribution. A diagnostic/prognostic block was performed first; in patients who obtained relief, subsequent neurolysis with 80%–100% ethanol was administered. Volume was variable and dependent on clinical circumstances. All procedures were performed in the prone position using a posterior approach. Patients were kept prone for 30 minutes to avoid spread to posterior nerves.

• N = 24
• MEAN AGE: Participants with negative outcome (defined as less than 50% pain relief in less than one month following repeat CPN procedure) = 52.4 years; those with positive response = 59 years
• MALES: 62.5%, FEMALES: 37.5%
• KEY DISEASE CHARACTERISTICS Pancreatic cancer (unresectable) with moderate-to-severe abdominal and/or back pain poorly controlled with pharmacotherapy
• OTHER KEY SAMPLE CHARACTERISTICS: Severe, persistent pain; end-stage pancreatic cancer pain management
• EXCLUSION CRITERIA: Untreated coagulopathy, unstable medical illness, cognitive impairment that precluded an accurate response assessment

• SITE: Single site 
• SETTING TYPE: Outpatient
• LOCATION: Baltimore, MD

• PHASE OF CARE: Late/end-stage, end-of-life care
• APPLICATIONS: Elder care, palliative care

• Prospective, descriptive

• A successful procedure was defined as 50% or more pain relief for one month or longer after repeat CPN.
• Baseline 0–10 Numeric Rating Scale pain score

Those participants with a successful response to initial CPN were more likely to have pain symptoms in the back and abdomen and have a shorter time interval from diagnosis of pancreatic cancer to initial CPN. The overall success rate decreased from 67% after initial CPN to 29% following repeat CPN (p = 0.13). The mean duration of pain relief also decreased from 3.4 months following initial CPN to 1.7 months after repeat CPN (p = 0.03). The proportion of individuals with successful repeat CPN after unsuccessful initial CPN was 50% (four out of eight), which favorably compared to 19% (3 out of 16) in those who had successful initial CPN (p = 0.13). In multivariate analysis, the presence of metastases was associated with a 90% decrease in success rate. No statistically significant differences were found between repeat CPN success, and failure groups were observed for age, sex, baseline pain score, location of tumor, presence of metastasis, encasement of celiac axis, opioid use, peritoneal tumor involvement, use of repeat diagnostic block, radiologic guidance used for procedure, needle approach or technique used, or the use of sedation for the procedure. Disease progression on imaging and a longer period between blocks were contributors to treatment failure.

This study demonstrated that the magnitude and duration of pain relief following repeat CPN were significantly less than after the initial procedure. Results suggest that a subset of patients may benefit from repeat CPN. Thirty percent of individuals reported positive responses to repeat CPN, which warrants further analysis.

• Small sample (less than 30)
• Measurement/methods not well described
• Other limitations/explanation: Because of the infrequency with which repeat CPN is performed and the patient population involved, a randomized study was deemed impractical. This research did not contain any objective documentation of functional improvement or quality of life.

Evaluation of a repeat procedure may be warranted when pain levels begin to escalate following a successful initial procedure. However, this is a preliminary suggestion warranting more well-controlled studies. As patient advocates and proponents of pain management, nurses are in a position to further research regarding patient responses to pain management interventions and techniques, such as CPN and repeat CPN. In the outpatient setting, oncology nurses focus on pain management at every visit and direct patients to follow up with the appropriate interdisciplinary team member(s) to address as needed. Nurses are involved in every aspect of patient care, including pre-, post-, and during interventions (e.g., the various CPNs described here), and in outpatient, inpatient, hospice, and palliative settings.