Computed Tomography–Guided Percutaneous Transaortic Celiac Plexus Neurolysis: An Infrequently Used but Effective Approach
25 March 2017
21 July 2017
24 November 2017 (eFirst)
Celiac plexus/ganglion block is used for palliation of severe upper abdominal pain caused by chronic pancreatitis or tumors of the pancreas.
Celiac ganglia are located at T12–L1 level in relation to the celiac axis and superior mesenteric artery (SMA). It is predominantly composed of sympathetic and parasympathetic efferent fibers and visceral sensory afferent fibers. The preganglionic sympathetic efferent supply stems from greater splanchnic (T5–T9), lesser splanchnic (T10–T11), and least splanchnic (T12) nerves. This supply is derived from posterior cord of the vagus nerve ([Fig. 1]). Visceral afferent nociceptive fibers are received from the liver, pancreas, gallbladder, spleen, adrenals, kidneys, and bowel (distal esophagus till transverse colon). Topographically, the innervation of the uncinate process of the pancreas originates from the superior mesenteric plexus (SMPlx) along the inferior pancreaticoduodenal artery (IPDA), whereas most nerve fibers going to body and tail of the pancreas originate from the celiac plexus.
Chemical neurolysis of the celiac plexus is an effective method of controlling pain that originates from these organs. It has also been reported to be beneficial in managing severe nausea and vomiting in patients with pancreatic cancer. This has been attributed to sympathetic blockade causing parasympathetic predominance causing increased gastric motility and peristalsis. Some authors have also reported that celiac plexus neurolysis improves survival in patients with cancer by reducing opiate requirements, diminishing drug-induced sedation, and enhancing the ability of patients to perform day-to-day activities that are necessary to extend life, such as feeding and ambulation.
The block can be guided by anatomical bony landmarks, fluoroscopy, sonography, or computed tomography (CT). Cross-sectional imaging such as CT and magnetic resonance imaging (MRI) can reveal soft tissue, especially the celiac plexus. CT is the preferred route due to its wide availability, high contrast, and spatial resolution. It clearly depicts retroperitoneal structures, and celiac plexus may sometimes be directly identified. It depicts the exact needle tract and shows diffusion of contrast mixed neurolytic agents. CT fluoroscopy allows real-time monitoring of the procedure.
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