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Ann Thorac Surg 1998;65:810-813
© 1998 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Thoracoscopic Splanchnicectomy for Control of Intractable Pain in Pancreatic Cancer

Service de Chirurgie Thoracique, Hôpital Laennec, Paris, France;
Service de Chirurgie Thoracique, Hôpital de Percy, Clamart, France;
Clinique Chirurgicale, Hôpital Charles Nicolles, Rouen, France;
Chirurgie Abdominale et Thoracique, Hôpital Pasteur, Nice, France;
Service de Chirurgie, Centre Hospitalier des Croix Rouges, Lausanne, Switzerland

Accepted for publication September 16, 1997.

Dr Riquet, Service de Chirurgie Thoracique, Hôpital Laennec, 42 rue de Sèvres, 75007 Paris, France.

	Abstract

Top Abstract Introduction Patients and Methods Results Comment References

 
Background. Pain is the most distressing feature of pancreatic cancer. Thoracoscopic splanchnicectomy, first performed in 1993, has caused a resurgence of interest in surgical treatment of such excruciating pain.

Methods. Twenty patients underwent splanchnicectomy for pancreatic cancer pain over a period of 50 months. All were opiate dependent and unable to pursue normal daily life activities. We evaluated the type of splanchnicectomy performed and the long-term results procured.

Results. The number of splanchnicectomies was 24: unilateral videothoracoscopic splanchnicectomy, n = 11; unilateral videothoracoscopic splanchnicectomy with associated vagotomy, n = 5; and bilateral videosplanchnicectomy, n = 4. There was no postoperative complication. Pain was totally relieved and drug addiction stopped in 16 patients: 10 with unilateral videothoracoscopic splanchnicectomy, 2 with unilateral videothoracoscopic splanchnicectomy and associated vagotomy, and 4 with bilateral videosplanchnicectomy. Pain was not relieved after 4 unilateral videothoracoscopic splanchnicectomies, but bilateralization was not attempted in that subgroup.

Conclusions. Unilateral videothoracoscopic splanchnicectomy is the treatment of choice of intractable pancreatic pain, affording drug cessation and recovery of daily activity in most patients. Failure may be treated secondarily by bilateralization with excellent results. Bilateral videosplanchnicectomy need not be performed by first intention.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment References

 
Pain is the most distressing feature of pancreatic cancer. Many methods have been advocated for its control, ranging from the use of narcotic analgesics to celiac plexus block [1] and operation. Surgical procedures encompass pancreatic duct, biliary or duodenal decompression, partial or complete pancreatic resection, and splanchnicectomy. Most of these operations are performed via an abdominal approach, but splanchnicectomy is also feasible via thoracotomy because of the direct access thoracotomy provides to the nerves at their origin [2][3]. Morbidity and inconsistent results obtained by both abdominal and thoracic procedures prompted most surgeons to discontinue them until 1993, when thoracoscopic performance of surgical splanchnicectomy [4][5] caused a resurgence of interest in this nearly abandoned method. Melki and associates [4] and Worsey and colleagues [5] reported in 1993 left videothoracoscopic splanchnicectomy (LVS) to relieve pain with the addition of vagotomy (PV) to reduce acid stimulation of pancreatic secretion, but only 1 patient was followed up to 1 month. In 1994 Lin and associates [6] and Cuschieri and coworkers [7] reported bilateral videothoracoscopic splanchnicectomy (BVS) with good results, but follow-up did not exceed 3 days in the first article [6] and the number of patients suffering pancreatic cancer pain was only 3 in the second [7]. Takahashi and associates [8] in 1996 advocated LVS alone with good long-term results in 3 cases. The purpose of our study was to evaluate long-term results of thoracoscopic splanchnicectomy for pain control in pancreatic cancer according to different types of techniques and to determine how to proceed in managing such challenging cases with videothoracoscopy.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
We reviewed 20 patients who had been operated on by five different thoracic surgeons. We started performing this procedure in November 1992, and it was done for 20 consecutive patients until February 1997. All patients were at an advanced stage of pancreatic cancer. There were 13 men and 7 women. Their ages ranged from 42 to 76 years, with a mean of 55 years.

Five patients had intraabdominal metastases (of peritoneal carcinosis [PC] in 1) and 8 patients had unresectable pancreatic cancer that did not necessitate a decompression operation. Seven patients had undergone one previous operative procedure: choledocoenterostomy (n = 1), gastroenterostomy (n = 1), both gastroenterostomy and choledocoenterostomy (n = 1), and cephalad duodenopancreatectomy (n = 4). In the latter case, pain was due to local recurrence and was associated with PC in 1 patient.

Duration of pain at the time of splanchnicectomy ranged from 1.5 to 8 months (mean, 4 months). Pain was periumbilical and epigastric in all patients, with radiation to the flank in 12 patients (right, 4; left, 4; both, 4) and to the back in 15 patients (left, 7; bilateral, 8). In 6 patients radiation to the back was isolated. Pain was limited to the epigastric region without any radiations in only 2 patients.

Pain was excruciating and debilitating in all patients. All 20 patients received narcotic analgesic injections, became opiate dependent, and were unable to pursue normal daily life activities. Seven patients had experimented local anesthetic splanchnic blocks with immediate good results on the pain but transient relief. We studied the type of splanchnicectomy performed, the immediate results of the pain according to the need for narcotics and opiates and using a visual analogue pain scale, and the duration of benefit obtained. In cases of failure we tried to explain the reason behind the failure to determine how to manage such fragile patients.

	Results

Top Abstract Introduction Patients and Methods Results Comment References

 
The total number of splanchnicectomies was 24: 10 LVS, 5 LVS with associated PV, 2 LVS followed shortly after by right videothoracoscopic splanchnicectomy (RVS), 2 BVS, and 1 RVS. This RVS was performed because of previous left pleurodesis.

All procedures were performed with the patient in the lateral decubitus position. General anesthesia was established with double-lumen endotracheal intubation and single-lung ventilation. Three trocar ports were used in 6 cases and 4 ports in 18 cases (Fig 1). Splanchnicectomy was performed by dividing the roots of the splanchnic nerves in 16 cases (16 patients) (see Fig 1), by dividing the splanchnic nerve itself above the diaphragm in 2 cases (1 patient) because of presence of bilateral fibrohyaline plaques (Fig 2), and by removing the splanchnic nerve and performing a dorsal sympathectomy from T-6 to T-12 in 6 cases (4 patients) (Fig 3). In cases of splanchnicectomy at the level of the roots the procedure was left-sided 14 times and bilateral once. The number of divided roots ranged from 3 (n = 2) to 7 (n = 2), with a mean of 5 roots.

View larger version (99K): [in this window] [in a new window]   Splanchnicectomy is performed by dividing the roots of the greater splanchnic nerve. The lesser splanchnic nerve may be divided as well.

View larger version (96K): [in this window] [in a new window]   The splanchnic nerve itself is divided.

View larger version (99K): [in this window] [in a new window]   The splanchnic nerve and sympathic nerve are divided and both are removed as a whole.

Pain was totally relieved and drug addiction stopped in 16 patients: 11 with LVS (2 with addition of PV), 1 with RVS, and 4 with BVS. Results remained good until death in 6 patients (10 months, 1; 7 months, 1; 6 months, 1; 5 months, 2). Eight patients are still alive with good results (4 months, 1; 3 months, 12; 2 months, 1; 1.5 months, 2; 1 month, 3). One patient was lost to follow-up at 7 months without pain recurrence. Pain disappeared for 3 months in 1 patient (LVS) but recurred with PC. Two patients mentioned abdominal discomfort without pain after LVS, but they had abdominal metastases at the time of the operation.

Partial relief of pain was obtained in 1 patient (LVS + PV) and persisted until death (10 months). The patient had sustained previous gastroenterostomy and choledocoenterostomy.

Pain reappeared within 1 month in 3 patients: at 4 days (three-root LVS + PV), 3 weeks (PC at the time of the operation), and 1 month (three-root LVS + PV). Pain relief was deemed insufficient in 2 patients, and contralateral RVS was performed 4 and 10 days after LVS despite improvement. Splanchnicectomy was associated with sympathectomy on both sides. Results were very good thereafter, and both patients are still alive (1 and 4 months) but complain of intermittent diarrhea.

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

 
Videothoracoscopic splanchnicectomy was effective in 80% of all cases and represents the treatment of choice in intractable pancreatic cancer pain.

Local anesthetic splachnic blocks in 7 patients had not proved curative but had been satisfying for a few days in all patients. They were not performed to help select patients for splanchnicectomy. The usefulness of this technique before splanchnicectomy has never been proved experimentally, but this technique has been suggested as a method of screening patients by Strickland and associates [9] and the results of our study incidentally support their proposal. In evaluating the results we used a visual analogue pain scale as suggested by Maher and associates [10], who stressed that in most studies the degree of pain relief has not been quantified in an objective way. This evaluation is useful in studying chronic pancreatitis pain because the results of splanchnicectomy are not constant [7][10] but seem to be of little value in the case of pancreatic cancer pain because the results are most often well defined as we observed.

Unilateral videothoracoscopic splanchnicectomy was effective in 66% of cases. Good results with unilateral videothoracoscopic splanchnicectomy also have been reported by others in case of pancreatic cancer pain, but only in a few cases [5][8][11]. Failure of pain relief was observed in 33% of our patients having unilateral videothoracoscopic splanchnicectomy (n = 6). In 2 patients failure was probably due to insufficient number of divided roots (only three roots in each). In 2 patients a contralateral operation was performed very shortly after because of an imperfect immediate result. In 1 patient an incomplete result was observed; the patient had undergone a previous intraabdominal decompression operation and contralateral splanchnicectomy had not been attempted. In 1 patient failure was due to the presence of PC; PC was also responsible for 1 case of secondary failure and pain recurrence. Peritoneal carcinosis seems to be a dark predictive sign for splanchnicectomy results, which is not the case for other abdominal metastases. It is worth stressing that splanchnicectomy often has been used successfully in the treatment of pain induced by hepatic or celiac metastasis [6].

The mechanism by which unilateral splanchnicectomy performed on the left side relieves pain in pancreatic neoplasia remains poorly explained. White and colleagues [12] observed that left splanchnicectomy was fairly effective in treating pancreatitic pain. They reported an experimental study giving the reason why left rather than bilateral splanchnicectomy was used: only left-sided stimulation of the splanchnic nerves produces pancreatic inflammation; on the right side it produces no effect. This procedure has generally been performed mainly and at first intention on the left side. In the particular case where we performed a right splanchnicectomy—the procedure was not feasible on the left side due to previous pleurectomy—the result was equally satisfying. In addition, in the patients in whom left unilateral videothoracoscopic splanchnicectomy failed to provide pain relief, an adjunctive procedure on the right side proved consistently to be effective. Observing these results, one can wonder if the choice of the left side in the treatment of pancreatic pain is founded on a physiologic basis or just the consequence of surgical habits.

Results obtained by unilateral videothoracoscopic splanchnicectomy were not improved by association of PV (n = 5): poor results were observed in 3 of those 5 patients. It is difficult to evaluate the usefulness of associated PV. Merendino in 1964 reported relief of pain after PV and pyloroplasty in 4 cases of pancreatic carcinoma [13]. Stone and associates [3], in 1990, estimated this additional component to the operation to be worthwhile in the case of pancreatitis, although its role is unclear. They gave as an explanation that it is not certain that all pain fibers pass along the splanchnic nerves and that after bilateral truncal vagotomy, there is a significant decrease in the incidence of recurrent attacks of alcohol-induced pancreatis. According to our study and to what we reviewed in the literature, there is no reason to add PV in the management of pancreatic cancer pain.

Bilateral videothoracoscopic splanchnicectomy was always successful whatever the technique used: root splanchnicectomy once, splanchnic nerve division once, and sympathectomy in addition to BVS twice. Such consistent good results in pancreatic cancer pain also have been mentioned by others [6][7]. However side effects may be observed after BVS, the most frequent being transient orthostatic hypotension. Transient orthostatic hypotension was mentioned by Maher and associates [10] but not reported by Cuschieri and colleagues [7]. The intermittent diarrhea we observed after BVS with associated sympathectomy was not described by others who used a different surgical technique. Such effects after sympathectomy may be correlated with the suppression of the physiologic tonus of sympathic innervation at that level. If such undesirable side effects were again encountered, they would contraindicate bilateral associated sympathectomy in this situation.

In conclusion, unilateral videothoracoscopic left splanchnicectomy is an excellent treatment of intractable pancreatic cancer pain, eliminates the need for addicting drugs, and affords recovery of daily activity in particularly fragile patients. Failures are infrequent and may be secondarily treated by a contralateral videothoracoscopic operation with excellent results. However, BVS need not to be performed by first intention.

	References

Top Abstract Introduction Patients and Methods Results Comment References

 

1. Lebovits AH, Lefkowitz M Pain management of pancreatic carcinoma: a review. Pain 1989;36:1-11.[Medline]
2. Sadar ES, Cooperman AM Bilateral thoracic sympathectomy splanchnicectomy in the treatment of intractable pain due to pancreatic carcinoma. Cleve Clin Q 1974;41:185-188.[Medline]
3. Stone HH, Chauvin EJ Pancreatic denervation for pain relief in chronic alcohol associated pancreatitis. Br J Surg 1990;77:303-305.[Medline]
4. Melki J, Riviere J, Roullee N, Soury P, Peillon C, Testart C Splanchnicectomie thoracique sous videothoracoscopie. Presse Med 1993;22:1095-1097.
5. Worsey J, Ferson PF, Keenan RJ, Julian TB, Landreneau RJ Thoracoscopic pancreatic denervation for pain control in irresectable pancreactic cancer. Br J Surg 1993;80:1051-1052.[Medline]
6. Lin CC, Mo LR, Lin YW, Ya MP Bilateral thoracoscopic lower sympathectic splanchnicectomy for upper abdominal cancer pain. Eur J Surg Suppl 1994;572:59-62.
7. Cuschieri A, Shimi SM, Crosthwaite G, Joypaul V Bilateral endoscopic splanchnicectomy through a posterior thoracoscopic approach. J R Coll Surg Edinb 1994;39:44-47.[Medline]
8. Takahashi T, Kakita A, Izumika H, et al. Thoracoscopic splanchnicectomy for the relief of intractable abdominal pain. Surg Endosc 1996;10:65-68.[Medline]
9. Strickland TC, Ditte TL, Riopple JM Performance of local anesthetic and placebo splanchnic blocks via indwelling catheters to predict benefit from thoracoscopic splanchnicectomy in a patient with intractable pancreatic pain. Anesthesiology 1996;84:980-983.[Medline]
10. Maher JW, Johlin FC, Pearson D Thoracoscopic splanchnicectomy for chronic pancreatitis pain. Surgery 1996;120:603-610.[Medline]
11. Thanakumar JAC, Chintapatla S Thoracoscopic pancreactic denervation for pain control in irresectable pancreatic cancer. Br J Surg 1994;81:149.
12. White TT, Lawincki M, Stacher G, et al. Treatment of pancreatitis by left splanchnicectomy and celiac ganglionectomy. Analysis of 146 cases. Am J Surg 1996;112:195-199.
13. Merendino KA Vagotomy for the relief of pain secondary to pancreatic carcinoma. Am J Surg 1964;108:1-2.[Medline]

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