Short Communication
Intra - Operative Celiac Plexus Block – An Invaluable Tool for Upper Abdominal Surgeries
Amy G Rapsang*
Department of Anesthesiology and Critical Care, North Eastern Indira Gandhi Regional Institute of Health and
Medical Sciences, Shillong, Meghalaya, India
*Corresponding author: Amy G Rapsang, Department of Anesthesiology and Critical Care, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
Published: 10 Oct, 2017
Cite this article as: Rapsang AG. Intra - Operative Celiac
Plexus Block – An Invaluable Tool for
Upper Abdominal Surgeries. Clin Surg.
2017; 2: 1656.
Abstract
There are many regional techniques available to the anesthetists for upper abdominal surgery and intra-operative blockade of the celiac plexus is potentially one of the most effective methods for providing pain relief. However, it is also under-utilized. Not only does this block ensure good pain relief, it also decreases stress response, improves gut motility and post-operative pulmonary function. It is a simple and safe procedure and has the advantage of less discomfort, decrease procedure time, use of smaller volume of local anesthetic, avoids puncture of aorta and ensures proper placement of needle tip.
Introduction
An important aspect of improved post-operative outcome in Upper Abdominal Surgery (UAS)
is good post-operative pain relief and decrease stress response. Various articles have shown that
post-operative pain and neuro-endocrine response are the inevitable consequence and the most
common cause of morbidity in UAS by increasing the incidence of surgical wound infection,
decrease patient satisfaction and increase patient discomfort, risk for cardiovascular complications,
erosion of body mass and tissue reserve and post-operative pulmonary lung dysfunction such as
hypoxemia, atelectasis, hypoxia, hyperventilation, increase pulmonary shunt, splinting of the
accessory muscles of respiration, loss of sighing and a loss of vital capacity between 50% to 75%
[1-8]. There are many regional techniques available to the anesthetists for such surgeries and intraoperative
blockade of the celiac plexus is one of the most valuable tools for providing pain relief
and decreasing stress response, but unfortunately, this block is not fully exploited. Celiac Plexus
Block (CPB) was first started in 1914 by Kappis [9] to block the splanchnic nerves and celiac plexus
with local anesthetic for surgical anesthesia percutaneously. In 1921, Braun [10] performed the
intra-operative approach to block the celiac plexus and the splanchnic nerves by gently retracting
the stomach and placing a digit between the aorta and the inferior venecava to serve as a guide
to the injection of an anesthetic agent over the ventral surface of the first lumbar vertebra. This
technique was further popularized by Bridenbaugh et al. [11] who describe effective pain relief in
98% of their patients receiving CPB for upper abdominal cancer pain. Now, CPB is done to relieve
pain associated with intra-abdominal pathologies using local anesthetics or neurolytic solutions,
with the help of Ultrasound or CT scan. This short article describes the benefits of Intra-operative
Celiac Plexus Block (ICPB) for post-operative analgesia in patients undergoing UAS. ICPB is known
as a simple and safe approach and has the advantage of less discomfort, decrease procedure time,
use of smaller volume of local anesthetic, avoids puncture of aorta and ensures proper placement of
needle tip [10]. CPB is observed to cause significant reduction in blood glucose and serum cortisol
level [12] and a combination of somatic and sympathetic blockade is further more effective in
reducing stress response [13,14]. Complete sympathetic denervation of the GIT allows unopposed
parasympathetic activity and increase peristalsis, thus promoting forward gut motility, which could
be an advantage in preventing post-operative ileus. The good pain relief provided by ICPB leads
to improvement of respiratory functions and thus fewer chances of pulmonary complications
leading to a more favorable outcome. The complications of ICPB are hypotension and diarrhea
(due to unopposed parasympathetic activity and increase peristalsis). Diarrhea is usually selflimiting
and hypotension is orthostatic in nature and can be easily treated with intra-venous fluids
and abdominal binders, and usually resolve within 48 h [10]. Other complications like inadvertent
intravascular injection, neurologic complications and visceral injury has also been described [10].
Addition of a vasoconstrictor such as adrenaline to the local anaesthetic decreases the systemic
absorption of the drug, prolong its effects, and increase the depth and duration of analgesia as well as providing a marker for inadvertent intra-vascular injection [1,15].
Bupivacaine itself exerts anti-microbial activity which would further
allay fears of endangering sterility [16]. Intra-operative Celiac Plexus
Block (ICPB) is easy, fast, and effective but despite its simplicity,
unfortunately most surgeons are unfamiliar with or hesitant to adopt
the technique. A study by Rapsang AG [1] in UAS, in addition to
ICPB the author also gave wound infiltration as the combination of
somatic and visceral nerve blockade provide excellent pain relief and
modifying the stress response effectively. In the study, the author used
10 ml - 15 ml of 0.25% bupivacaine with 1 in 2 lakh adrenaline. The
study confirmed that ICPB with bupivacaine provides excellent postoperative
analgesia. The patients who received the block were also
more alert than the control group because of the less consumption of
post-operative opioids. The study also shows that ICPB significantly
obtunds the surgical stress response, improves gut motility but found
no difference in pulmonary function between the study group and
the control group as post-operative pain relief was good in both the
groups (control group – Patient Control Analgesia morphine pump;
study group – ICPB). The author also noted that there is no incidence
of hypotension or diarrhea or any other complication. In another
study by Hamid SK et al. [12], the effects of continuous ICPB (using
bupivacaine) with wound infiltration was assessed on post-operative
analgesia, stress response and pulmonary function in UAS. They
found that pain relief was poor and they attributed this poor relief of
pain to poor somatic afferent block afforded by wound infiltration by
the local anesthetic. In a study by Okuyama et al. [17], the efficacy of
ICPB was compared with pharmacological therapy in the treatment
of pain caused by un-resectable pancreatic cancer in 21 patients. They
found that the analgesic consumption of the ICPB group was much
lower than the ones with pharmacological therapy alone, and there
was no operative mortality or major complication related to the block.
The incidence of adverse effects related to the analgesic drug therapy
was also lower in the group of patients treated with ICPB, suggesting
that the reduction in analgesic consumption is of real clinical benefit.
In two different studies, Tsuji et al. [13] and Shirasaka et al. [14]
studied the effects of ICPB on endocrine metabolic responses by
assessing levels of adreno-cortico tropic hormone, cortisol, glucose,
free fatty acids and urinary noradrenaline and compared them to
patients receiving general anesthesia and epidural analgesia. Tsuji et
al. [13] found significant decrease in stress response in the epidural
and the ICPB group and Shirasaka et al. [14] found greater reduction
of stress response in the ICPB group.
Conclusion
The results obtained in various studies showed that ICPB provide a good means of analgesia, decreases the post-operative stress response, improve gut motility and improve pulmonary function by providing good pain relief. It is also a simple and safe procedure which ensures an accurately placed local anesthetic solution and avoids the need for another invasive procedure for pain relief. This block is an invaluable tool for emergency procedures, where time constraint is there and hence can be used as an alternative to placing an epidural catheter.
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