Computed Tomography–Guided Percutaneous Transaortic Celiac Plexus Neurolysis: An Infrequently Used but Effective Approach

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).[1] 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.[2]

Fig. 1 Animated image showing relevant anatomy of celiac plexus. Reprinted with permission from Kambadakone et al.[7]

Chemical neurolysis of the celiac plexus is an effective method of controlling pain that originates from these organs.[3] 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.[4] 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.[5]

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.[6] 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.[7]

• References

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• 2 Yi S-Q, Miwa K, Ohta T. , et al. Innervation of the pancreas from the perspective of perineural invasion of pancreatic cancer. Pancreas 2003; 27 (03) 225-229
• 3 Mercadante S, Nicosia F. Celiac plexus block: a reappraisal. Reg Anesth Pain Med 1998; 23 (01) 37-48
• 4 Erdine S. Celiac ganglion block. Agri 2005; 17 (01) 14-22
• 5 Staats PS, Hekmat H, Sauter P, Lillemoe K. The effects of alcohol celiac plexus block, pain, and mood on longevity in patients with unresectable pancreatic cancer: a double-blind, randomized, placebo-controlled study. Pain Med 2001; 2 (01) 28-34
• 6 Zhang XM, Zhao QH, Zeng NL. , et al. The celiac ganglia: anatomic study using MRI in cadavers. AJR Am J Roentgenol 2006; 186 (06) 1520-1523
• 7 Kambadakone A, Thabet A, Gervais DA, Mueller PR, Arellano RS. CT-guided celiac plexus neurolysis: a review of anatomy, indications, technique, and tips for successful treatment. Radiographics 2011; 31 (06) 1599-1621
• 8 Wang PJ, Shang MY, Qian Z, Shao CW, Wang JH, Zhao XH. CT-guided percutaneous neurolytic celiac plexus block technique. Abdom Imaging 2006; 31 (06) 710-718
• 9 Ischia S, Ischia A, Polati E, Finco G. Three posterior percutaneous celiac plexus block techniques. A prospective, randomized study in 61 patients with pancreatic cancer pain. Anesthesiology 1992; 76 (04) 534-540
• 10 Titton RL, Lucey BC, Gervais DA, Boland GW, Mueller PR. Celiac plexus block: a palliative tool underused by radiologists. AJR Am J Roentgenol 2002; 179 (03) 633-636