内镜超声引导下腹腔神经丛放射术与阻滞术治疗晚期胰腺癌腹痛的疗效比较

Comparison on the efficacy of EUS-guided celiac plexus radiation and celiac plexus neurolysis in treating abdominal pain of advanced pancreatic cancer

目的评估内镜超声(EUS)引导下125I粒子腹腔神经丛放射术和无水乙醇腹腔神经丛阻滞术治疗晚期胰腺癌腹痛的疗效。方法回顾性分析第二军医大学长海医院消化内科2017年1月至2018年4月间收治的43例伴有中重度腹痛的晚期胰腺癌患者的临床资料,其中20例接受EUS引导下腹腔神经丛阻滞术(CPN),23例接受EUS引导下腹腔神经丛放射术(CPR),即在腹腔神经丛植入125I粒子。比较CPN组与CPR组患者术后腹痛VAS评分、硫酸吗啡控释片用量及并发症发生情况。结果CPN组与CPR组患者的性别比(男/女,10/10比14/9)、平均年龄[(64±11)岁比(64±12)岁]、病灶部位(头部/体尾部,7/13比8/15)、TNM分期(Ⅲ/Ⅳ,9/11比7/16)的差异均无统计学意义,具有可比性。与术前相比,术后1周CPN组患者VAS评分(3.0分比5.5分)及吗啡用量(30.0mg比52.5mg)显著降低;术后2周CPR组VAS评分(5.0分比6.0分)及吗啡用量(50.0mg比55.0mg)均低于术前,且术后4、8、12周VAS评分均为3.0分,吗啡用量分别降至30.0、25.0、30.0mg,与术前比较差异均具有统计学意义(P值均<0.0001)。与CPR组比较,术后2周CPN组患者VAS评分下降程度(3.0分比2.0分)、吗啡用量减少程度(30.0mg比10.0mg)及腹痛部分缓解率(70.0%比4.3%)均更高(P值分别为0.01、0.005、<0.001);但术后4、8、12周CPR组患者较术前VAS评分下降程度、吗啡用量减少程度及腹痛部分缓解率均显著高于CPN组(P值均<0.05)。CPN组与CPR组患者无1例疼痛完全缓解,未观察到严重并发症的发生,仅有轻度消化道不良反应。结论CPN和CPR均能安全、有效地缓解晚期胰腺癌患者的腹痛。CPR起效时间晚,但疼痛缓解程度及持续时间更具优势。

Objective To evaluate the efficacy of endoscopic ultrasonography-guided celiac plexus radiation with iodine-125(125I) seeds and celiac plexus neurolysis with absolute ethanol for pain relief secondary to advanced pancreatic cancer.MethodsA retrospective analysis of 43 patients of advanced pancreatic cancer with moderate to severe abdominal pain in the Department of Gastroenterology, Shanghai Changhai Hospital from January 2017 to April 2018 was performed. 20 patients underwent EUS-guided celiac plexus neurolysis (CPN), and 23 patients underwent EUS-guided celiac plexus radiation (CPR) with the implantation of 125I seeds around the celiac ganglia. The postoperative VAS score of abdominal pain, mean analgesic (MS Contin [morphine sulfate]) consumption and complications were compared between the two groups.ResultsThere were no statistically significant differences between the two groups in the sex ratio (male/female, 10/10 vs 14/9), average age [(64±11) vs (64±12)], lesion location (head/tail, 7/13 vs 8/15 ] and TNM stage (Ⅲ/Ⅳ, 9/11 vs 7/16), and the two groups were comparable. Compared with preoperative ones, the VAS score (3.0 points vs 5.5 points) and morphine dosage (30 mg vs 52.5 mg ) were significantly lower in the CPN group one week after operation. In the CPR group, the VAS score (5.0 points vs 6.0 points) and morphine dosage ( 50 mg vs 55 mg ) at 2 weeks after the operation were lower than those before the operation;the VAS scores of 4, 8 and 12 weeks after the operation decreased to 3.0 points, and the dosage of morphine decreased to 30 mg, 25 mg and 30 mg, respectively. The differences were statistically significant (P<0.0001). Compared with the CPR group, at 2 weeks postoperatively the CPN group demonstrated a significantly higher decrease of VAS score (3.0 points vs 2.0 points), degree of morphine reduction (30 mg vs 10 mg) and rate of partial pain relief (70.0% vs 4.3%). However, from 4 to 12 weeks postoperatively, the decrease in VAS score, the decrease in the dosage of MS Contin and the rate of partial pain relief in the CPR group were all significantly higher than those in the CPN group (P<0.05). There was no complete relief of pain in the two groups. No procedure-related deaths or serious complications were observed and only mild gastrointestinal adverse reactions occurred.ConclusionsTwo methods can both relieve abdominal pain in patients with advanced pancreatic cancer safely and effectively. CPR takes effect late but has advantages of good extent and long duration of pain relief.