Percutaneous Radiofrequent Lesioning of the Splanchnic Nerves in Patients with Chronic Pancreatitis

Pain control is the most pressing problem in patients with chronic
pancreatitis. Many methods have been advocated to control this pain.
Unfortunately, these methods fail to control the pain in 20-50% of patients.
Management of patients with intractable pain is difficult, often resulting in
narcotic addiction. Percutaneous alcoholic block of the celiac plexus is,
because of the risks of paralysis resulting from a transverse myelopathy and
catastrophic haemorrhage resulting from injury to major abdominal vasculature,
restricted to patients with intractable, severe pain due to terminal pancreatic
cancer. Splanchnic nerve lesioning is a useful alternative to celiac plexus
block in the management of patients with chronic upper abdominal pain. The
predictable relationship of the splanchnic nerves to other structures allows
for accurate needle placement and hence a low risk of iatrogenic damage.
Radiofrequent lesioning uses a high frequency alternating current to heat
tissues leading to thermal coagulation. It produces predictable and accurate
lesions.

To evaluate the feasibility and efficacy of percutaneous radiofrequent
lesioning of splanchic nerves (PRFLSN) in patients with pain caused by chronic
pancreatitis. The primary goal is to determine if a 50% reduction in pain can
be achieved for at least 6 months. Secondary objectives are reduction of opioid
use and improvement of quality of life.

Single blind, intervention study.

One group receives PRFLSN after a positive trial block with bupivacaine, the
other group receives no extra treatment besides optimal medical treatment.

Agenda
* At inclusion: NRS 4 days 3 times a day, QLC-30, PAN-28, MQS, PD/M, EuroQol-5D
(EQ-5D), BDI
* The intervention: PRFLSN or no intervention
* 1 week after intervention NRS 4 days 3 times a day, GPE, QLC-30, PAN-28, MQS,
* 1 month after intervention NRS 4 days 3 times a day, GPE, QLC-30, PAN-28,
MQS, EQ-5D, BDI
* 2 months after intervention NRS 4 days 3 times a day, GPE, QLC-30, PAN-28, MQS
* 3 months after intervention NRS 4 days 3 times a day, GPE, QLC-30, PAN-28,
MQS, PD/M, EQ-5D, BDI

Risks of PRFLSN
RF lesioning has a definite advantage over phenol and alcohol neurolytic
techniques because the RF lesioning is circumscribed and controlled. The
proximal and distal spread of the lesion beyond the uninsulated tip of the
probe is only 1 mm and the cross sectional diameter of the lesion is 5-6 mm.
There is no possibility of nerve root damage or destructive damage of epidural
and subarachnoid structures assuming that electrode placement can be verified
by fluoroscopy and pretesting with electrical stimulation and impedance
monitoring.
Numbness or motor paralysis occurs very rarely as a consequence of the
lesioning. The tissues can be injured anywhere along the needle if there is a
break in the insulation. Therefore, sensory and motor stimulation is always a
prerequisite for such lesioning.
Pneumothorax and diarrhoea can occur following splanchnic nerve blocks. In a
study by Raj et al. 31 patients underwent PRFLSN after a trial block with a
local anaesthetic. There were no complications.