Pain Management in Pancreatic Cancer

• Why pain? Inflammatory changes (NGF, CGRP) Ductal and parenchymal hypertension Changes in local neuroanatomy Destruction of nerve fibres Earlier and greater pain - Ca of Pancreatic head than tail

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Modalities to Manage pain

Medical Management.Exocrine enzyme supplementation, antioxidantsDrainage

Surgical ManagementWhipple’s , others

Use of Medications.Acetaminophen, NSAIDS,Opioids

Interventional.Neurolysis , Nerve block

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Equipment

• 22G needle , 13 cms long• LA agents-1%xylocaine, 0.5% Bupivacaine +/- Methyl

prednisolone 80 mg• Neurolytic Solution: Alcohol 50:50 or 6% acqueous

Phenol.

• Guidance: USG or CT or Fluroscopy• POSITION: Depending upon technique used.

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Splanchnic Nerves and Coeliac Plexus

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Coeliac Plexus Block

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Important Considerations

• ?Blind/Fluroscopy /CT / USG• Indications and Contraindications• Patient Preparation. Consent, Coagulation Status, Hydration.

• Complications Orthostatic hypotension

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Classical Approach

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Where to put in a needle?

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Anterior Approach to Celiac Plexus

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USG and CT Guidance

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Newer modalities

• Endoscopic/laparoscopic USG aided CPB.• Videoscopic thoracoscopy for surgical

splanchiectomy.

• Resistant/Failed Cases• Intrathecal pump to deliver Opioids+/- LA• Spinal Cord Stimulator.

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