Journal of the Pancreas Open Access

Keywords

Celiac Plexus; Ganglia, Sympathetic; Hepatic Artery; Pain, Intractable ; Pancreatic Neoplasms; Surgery

Abbreviations

PS: performance status

INTRODUCTION

Carcinoma of the body of the pancreas is often discovered at an advanced stage after the patient has developed abdominal and/or back pain, or a palpable abdominal mass. This can be explained by the fact that carcinoma in the pancreatic body does not cause jaundice, which could indicate the presence of a relatively early tumor of the head of the pancreas. Pancreatic body carcinomas are considered unresectable when associated with intractable abdominal and/or back pain because the celiac and hepatic arteries are involved in most of these patients [1]. Intractable pain is always progressive and resistant to various modalities of pain control. Consequently, intractable pain results in a poor quality of life in the short survival period.

Distal pancreatectomy with en bloc resection of the celiac and common hepatic arteries and the surrounding nerve tissues such as the celiac plexus and ganglions has recently been advocated as a radical resection for advanced carcinoma of the body of the pancreas [2, 3, 4]. In this operation, the arterial supply to the liver and stomach is maintained via the pancreatoduodenal arcades from the superior mesenteric artery [5]. This procedure has made complicated arterial reconstruction unnecessary. Furthermore, the whole gastrointestinal tract is preserved, unlike the original Appleby procedure involving total gastrectomy for gastric cancer [5]. It is associated with low morbidity and mortality, and has resulted in long-term survival in selected patients [2, 3]. However, there has been only one case report of the use of this procedure in a patient with intractable pain [4]. The purpose of this study was to report the effect of this radical resection on the intractable pain associated with advanced cancer of the pancreatic body. In addition, the mechanism of the intractable pain was examined histologically.

METHODS

Between 1997 and 2000, five patients with carcinoma of the body of the pancreas causing intractable abdominal and/or back pain underwent the radical resection intended to cure the cancer. No radiotherapy or chemotherapy was employed. The tumors had a median diameter of 55 mm (ranging from 45 to 70 mm). Retroperitoneal invasion was noted on preoperative computed tomography in all patients (Figure 1) and one of them (Case 1) had a finding of adrenal involvement. Encasement of the celiac, common hepatic and/or splenic arteries was found in all patients on preoperative arteriography. However, they had no hepatic, peritoneal, or para-aortic metastasis and no involvement of the superior mesenteric artery.

All five patients complained of continuous, severe preoperative abdominal pain. Two patients (Cases 4 and 5) also had back pain. A weight loss of more than 10 kg was noted in two patients (Cases 1 and 2). Diclofenac sodium was used for pain control by all of the patients. One of the patients (Case 1) also used oral morphine. However, there was not enough time left before surgery to increase the dosage or to change the analgesics. The pain was poorly controlled in three patients (Table 1).

In all patients, complete macroscopic tumor removal was achieved by distal pancreatectomy with en bloc resection of the celiac artery, common hepatic artery, left gastric artery, celiac plexus, bilateral celiac ganglions, ventral half of the nerve plexus around the superior mesenteric artery, paraaortic lymph nodes, diaphragmatic crus, and left adrenal gland (Figure 2). Combined resection of the major vessels such as the portal vein, left renal vein, and inferior mesenteric vein was required. The whole alimentary tract including the stomach was preserved.

A retrospective analysis was performed regarding the surgical magnitude, postoperative pain control, postoperative outcome, and histopathologic findings.

ETHICS

Informed consent was obtained from each patient.

STATISTICS

Descriptive statistics were used. Data are reported as median and range values.

RESULTS

The median operative time was 458 min (range: 405 to 545 min). The median blood loss was 821 mL (range: 532 to 985 mL) (Table 2). No blood transfusions were administered. There was no postoperative mortality. Postoperative complications were noted in four of five patients. All were managed medically (Table 2). Postoperative diarrhea was well controlled in four patients with loperamide hydrochloride (2-6 mg/day). Only one patient (Case 5) required opium. Glucose tolerance was not affected in any of the patients. The median postoperative hospital stay was 52 days (range: 45 to 70 days). Intractable abdominal and/or back pain was completely relieved immediately after surgery in all patients. None of the patients required analgesics at the time of discharge from the hospital. Excellent pain control continued until death in the three patients (Cases 1, 2, and 3) who died of tumor recurrence 8 to 15 months after surgery and in the patient (Case 4) who died of ileus. In the patient who is still alive (Case 5), it also continued until the last follow-up which was carried out 11 months after surgery. The postoperative performance status (PS) was also maintained at 0-1 in all patients.

Histopathologic examination of the surgical specimens revealed all surgical margins including the retroperitoneum were negative. According to the UICC/AJCC staging system, all patients had stage IVA tumors: 3 patients had G2 (moderately differentiated) and 2 patients had G3 (poorly differentiated) carcinoma, respectively. Lymphatic permeation of cancer cells was found in all patients and venous invasion in 3 patients. Notable perineural infiltration extending to the celiac plexus was shown in all patients. In the patient with the most severe pain (Case 1), neural invasion extended into the celiac ganglion.

DISCUSSION

Intractable abdominal and/or back pain due to advanced pancreatic carcinoma severely compromises the quality of life during the short survival period. Medical treatment with antiinflammatory agents and narcotics is often unsuccessful. Celiac plexus block has been used where medical treatment has failed [6, 7]. New techniques including intrathecal morphine administration via a subcutaneous pump [8] and thoracoscopic splanchnicectomy [9, 10, 11] have been used with more success. However, complete pain relief is difficult to achieve. In our patients, complete and continued pain relief was achieved following radical distal pancreatectomy with en bloc resection of the celiac artery for advanced cancer of the pancreatic body.

Pancreatic adenocarcinoma frequently involves nervous tissue and spreads along nerve fibers [12, 13]. We confirmed this showing nervous tissue involvement extending in an extrapancreatic direction from the primary lesion to the celiac plexus and celiac ganglions in patients with intractable abdominal and/or back pain. This strongly suggests that cancer involvement of the celiac plexus or celiac ganglions results in intractable pain. Because radical distal pancreatectomy with en bloc resection of the celiac artery includes complete removal of the celiac plexus and celiac ganglions as well as the retroperitoneal tissues, it is understandable that the operative procedure results in excellent pain control. Although the rate of cure of pancreatic body cancer after this operation has not been determined, some longterm survivors have been reported [2, 3].

The extensiveness of this operative procedure is significant. However, all patients who underwent the procedure survived. Complicated resections of great vessels were required, but arterial reconstruction was not necessary. Although the operative time was long, the low blood loss obviated the need for blood transfusions. Preservation of the entire stomach made gastrointestinal reconstruction unnecessary. Arterial supply to the stomach was maintained by the right gastroepiploic and the right gastric arteries via the pancreatoduodenal arcades from the superior mesenteric artery. Gastric preservation reduced the organ deficit to only the distal pancreas, spleen, and left adrenal gland. Postoperative complications were common, but were controllable with medical treatment. Acceptable surgical magnitude, minimal organ deficit and excellent pain control support the use of this procedure as a radical resection in patients with advanced cancer of the pancreatic body. In fact, Kimura [4] has reported successful social rehabilitation with the disappearance of back pain in a patient who underwent this procedure. However, the long postoperative hospital stay must be shortened by reducing the morbidity, particularly in light of the short survival period. In conclusion, radical distal pancreatectomy with en bloc resection of the celiac artery, celiac plexus, and celiac ganglions can provide patients having locally advanced cancer of the pancreatic body with complete and enduring pain relief. Long-term studies of large numbers of patients will be necessary to define the survival benefit of this procedure.

Tables at a glance

Table 1 Table 2

Figures at a glance

Figure 1 Figure 2

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