Ann Thorac Surg 2002;73:1290-1292
© 2002 The Society of Thoracic Surgeons
Case report
Videothoracoscopic splanchnicectomy for intractable pain from adrenal metastasis
Loïc Lang-Lazdunski, MD, PhD*a,
Françoise Le Pimpec-Barthes, MDa,
Marc Riquet, MD, PhDa
a Department of Thoracic Surgery, Hôpital Européen Georges Pompidou, Paris, France
Accepted for publication August 6, 2001.
* Address reprint requests to Dr Lang-Lazdunski, Service de Chirurgie Thoracique, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France
e-mail: loic.lang{at}wanadoo.fr
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Abstract
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Splanchnicectomy has been known for years as a treatment for refractory pain in patients with pancreatic cancer or chronic pancreatitis. We report herein the performance of a videothoracoscopic left splanchnicectomy in a patient with a previous right pneumonectomy who suffered intractable pain from an irresectable left adrenal metastasis associated with metastatic retroperitoneal lymph nodes. Immediate pain relief was obtained, but abdominal pain of middle intensity recurred 6 weeks later. Although infrequently required, this procedure might be of value in some patients with refractory pain.
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Introduction
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Videothoracoscopic splanchnicectomy provides safe and effective treatment for pain in patients with irresectable pancreatic cancer or chronic pancreatitis [1–3]. We report herein the performance of a left videothoracoscopic splanchnicectomy in a patient who had undergone right pneumonectomy 27 months before and who suffered refractory pain from irresectable left adrenal metastasis associated with metastatic renal and aorticorenal lymph nodes.
A 58-year-old man was referred to our department for the exploration and treatment of severe abdominal pain. His past medical history included a right pneumonectomy performed on July 1998 for a pT2N0M0 squamous cell carcinoma and a combined right adrenalectomy for an adrenal mass that proved to be benign hyperplasia. On January 2000, the patient started complaining of abdominal and lumbar pain, and a left adrenal mass associated with metastatic renal and aorticorenal lymph nodes was diagnosed on abdominal computed tomography (Figs 1, 2).
Computed tomographic-guided percutaneous needle aspiration biopsy of the adrenal mass revealed a poorly differentiated squamous cell carcinoma. The patient was considered to have metachronous adrenal metastasis. The lesion was considered irresectable due to the associated metastatic renal and aorticorenal lymph nodes and the patient was assigned to receive three cycles of chemotherapy associating cisplatin, vinorelbin, and docetaxel, and to receive palliative radiotherapy on the adrenal gland (16 Gy). Pain disappeared for a few months, but recurred in November 2000 and became rapidly intractable. The patient became unable to pursue normal daily life activities. On admission, the patient was currently receiving oral codeine 270 mg/day associated with a transdermal patch delivering 75 µg/h of fentanyl. Pain was graded 8.5 on a 10-point visual analog pain scale and was described as excruciating. Considering the magnitude of pain and the amount of analgesic drugs used daily, we decided to perform a left splanchnicectomy.
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Fig 1. Abdominal computed tomographic scan showing an 89 x 65-mm left adrenal mass. There are also metastatic lymph nodes in the renal hilum.
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Fig 2. Abdominal computed tomographic scan showing aorticorenal lymph nodes greater than 2 cm in diameter.
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Operation was performed on December 21, 2000. After general anesthesia, the patient was placed in the right lateral decubitus position and ventilated with a single lumen endotracheal tube. We used 3 ports and a 0-degree 10-mm videothoracoscope. The left lung was retracted medially and superiorly with some very brief periods of exclusion. The patient was rolled on the right side and placed in the Trendelenburg position to facilitate exposure of the inferior sympathetic chain. The diaphragm was retracted inferiorly using a palm-type retractor to allow for adequate exposure of the T9 to T12 splanchnic roots. All roots between T6 and T12 were divided using electrocautery. The sympathetic trunk was also divided from T6 to T11 between all ganglia. Operative time was less than 1 hour. Blood loss was minimal.
The postoperative course was uneventful with immediate back pain, flank pain, and abdominal pain relief. The patient had the chest tube removed after 2 days, and he was discharged home after 4 days with oral hydrocortisone, paracetamol, and dextropropoxyphene. He returned to normal daily life activities.
Eight months later, he is still alive and living at home. Neither diarrhea, nor hypotension have been noted by the referring physician. Abdominal pain has recurred after 6 weeks, but has been graded less intense by the patient (5 on a 10-point visual analog pain scale) and did not irradiate to the back and left flank. The patient has received additional radiotherapy (35 Gy) and has been put on a regimen of oral codeine (180 mg/day) and transdermal fentanyl (25 µg/h) with adequate pain control. He can pursue normal daily life activities.
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Comment
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The occurrence of adrenal metastasis has been reported in 1.62 to 3.5% of patients with operable non-small cell lung cancer [4]. Although long-term survival has been observed in a few patients with adrenal resection, median survival has been reported to be less than 12 months in the vast majority of patients [4]. As others, our policy is to resect all solitary adrenal metastases, either synchronous or metachronous, if they are unique and if the surgical act is performed with a curative intent [4, 5].
Both chemotherapy and radiotherapy have been reported as palliative therapy for patients whose adrenal metastasis cannot be resected [5–8], with median survival being 3 to 8.5 months [5–8]. Soffen and colleagues [6] showed that the overall response rate was 75% in patients receiving palliative radiotherapy for painful adrenal metastasis. However, pain may rapidly become extremely intense from invasion of celiac plexus, aorticorenal ganglia, renal ganglia, and other surrounding nervous structures. Thus, large amounts of analgesic drugs may be required for pain relief in those patients.
Nervous inputs from the adrenal glands reach the spinal cord through the celiac plexus and ganglia, aorticorenal ganglia and renal ganglia, and greater and lesser splanchnic nerves. Therefore, extended splanchnicectomy, dividing both the greater and lesser splanchnic nerves, may logically suppress all sensory inputs from the adrenal gland.
Videothoracoscopic splanchnicectomy has been stressed as an effective procedure for pain relief in patients with irresectable pancreatic cancer, chronic pancreatitis, and celiac metastasis [1–3]. Bilateral procedures have been associated with side effects such as orthostatic hypotension and diarrhea due to the suppression of the physiologic sympathetic tonus [1]. Because unilateral left splanchnicectomy has been reported effective in most patients [1], we did consider this surgical option the most appropriate for our patient. In our experience, total pain relief could be obtained in most patients with unilateral left splanchnicectomy performed for refractory pain from irresectable pancreatic cancer [1]. However, some had only partial relief of pain and required right splanchnicectomy shortly after in order to obtain total pain relief [1].
In the present case, we did not consider right splanchnicectomy appropriate due to the previous performance of a right pneumonectomy. Because the performance of a right splanchnicectomy was not anticipated in this patient, we decided to perform a radical sympatho-splanchnicectomy by dividing both splanchnic roots and sympathetic trunk to prevent pain recurrence from potential left-sided accessory nervous pathways. Although abdominal pain of middle intensity had recurred in our patient, it was appropriately controlled by major analgesics. Perhaps we should have performed a posterior vagotomy to prevent pain recurrence from celiac plexus invasion in this patient.
Although the surgical procedure was technically more difficult in our patient who could not tolerate left lung exclusion due to the previous performance of a right pneumonectomy, videothoracoscopy did appear the most appropriate approach in this fragile patient with a life expectancy of less than 12 months.
This short report illustrates the feasibility of performing an extended splanchnicectomy in patients who cannot tolerate single-lung ventilation, and suggests a potentially useful new indication of splanchnicectomy in patients with painful adrenal metastasis that cannot be resected and who fail to respond to chemotherapy and radiotherapy. Although this procedure would be infrequently required, it might be of value for some patients with refractory pain.
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References
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Abstract
Introduction
