Celiac trunk compression syndrome: a review / Una Revisión del Síndrome de Compresión del Tronco Celíaco

La presente revisión tiene por objetivo conocer tanto los aspectos anatómicos como clínicos y quirúrgicos relacionados con el síndrome de compresión del tronco celíaco causado por el ligamento arqueado mediano del diafragma. Se revisan los principales descubrimeinos del síndrome, tanto en el plano anatómico durante la disecación de cadáveres, como en la clínica-quirúrgica de la estenosis del tronco celíaco. Además, se revisa la relación de esta estenosis con los síntomas del paciente y cura después de la descompresión del tronco celíaco. Por otra parte, se explican los métodos no invasivos e invasivos utilizados en la descompresión; el efecto estenótico de los mecanismos fisiológicos del desplazamiento del ligamento arqueado mediano, aorta y tronco celíaco durante la respiración; anatomía del canal aórtico y plexo celíaco; el ligamento arqueado mediano y el plexo celíaco como agentes constrictores; la esquelotopía del tronco celíaco y del ligamento arqueado mediano y la predisposición para el síndrome. Finalmente, se hace una asociación del síndrome del tronco celíaco con anomalías morfológicas y metabólicas.

The purpose of the present review is to report the anatomic and the clinical-surgical aspects involved in the celiac trunk compression syndrome by the median arcuate ligament of the diaphragm, reviewing the major findings of the syndrome in the anatomic field during dissection of cadavers, followed by clinical-surgical findings of stenosis of the celiac trunk, the relationship of this stenosis with the patient's symptoms and healing after decompression of that artery; invasive and non-invasive methods used to diagnose compression; the stenotic effect of physiologic mechanisms of the median arcuate ligament, aorta and celiac trunk displacement during respiration; anatomy of the aortic channel and celiac plexus; the median arcuate ligament and the celiac plexus as constrict agents; skeletopy of the celiac trunk, the median arcuate ligament and predisposition to syndrome; association of the syndrome with morphological and metabolic aspects.

Sistema nervioso autónomo y páncreas. (Análise da influencia de diversos tipos de denervación outonómica en los fenómenos de regeneración glandular y en las de las interaciones del eje endocrino-exocrino / Autonomic nervous system and pancreas. (Analysis of the influence of different types of autonomic denervation in glandular regeneration phenomena and the interactions of the exocrine-endocrine-Axis)

The present tests, in male Wistar rsts, center around the trophic and functional changes of the pancreatic gland (R G), both exocrine and endocrine, induced by different types of autonomic nervous interruptions. First Group of Tests: Following one year celiac ganglionectomy (CG), nonpancreatectomized (Non-Pt) rats showed, basally, in blood, adrop of glucose (G), without changes of insulin (I). At autpsy, the CG animals showed an increase of the pancreatic we weight, of the total protein, of the RNA but not DNA. In the Pt. 95 per cent rats, superimposing CG triggered, on the one hand, a drop to control values of the raised G blood levels, and on the other, a rise of I Besides, in feces, a rising of chymotrypsin concentration. At autopsy, in the PG, an increase of total protein and of RNA. Second Group of Tests: CG, after 6 months, induced, in blood, both basally and a 2 h glucose tolerance test, significant opposite enzyme activities changes in respect to C. Indeed, as amylase (A) was increased, that of lipase (L) was depressed. When alcohol feeding (AF) was superimposed to CG rats, a reversal of the L values was observed. The latter reached levels significantly higher those of the C. In in-vitro tests, the isolated islets of CG disclosed to release more I to the bath medium than those of the C animals. Third Group of Tests: Analyzing, in conscious animal, the L excretory changes in the basal bile pancreatic secretion (BB-PS) induced by chronic (2 months interruption of the autonomic nervous innervation of the PG, it was found that CG, truncal vagotomy (V), the association of CG + V, peri-Vaterian duodenotomy (PV-D), but not bilateral splachnicectomy (Spl), inhibit, significantly the L output. It was also shown that superimosing AF to the V or CG + V animals reverted to C values the I depressed levels...

CT-guided celiac plexus block for intractable abdominal pain

Treatment of intractable abdominal pain due to inoperable intraabdominal malignancy is important, and the ineffectiveness of pharmacological agents has led many investigators to recommend chemical neurolysis of the celiac ganglions as a treatment. The author describes the technique and results of celiac plexus neurolysis under CT-guidance with various approach routes, including anterior, posterior and transaortic routes. Twenty-eight patients, ranging in age from 36 to 82 years, have been treated with this procedure. All had inoperable or recurred intraabdominal malignancies and suffered from intractable upper abdominal pain and/or back pain. The author performed the procedure using absolute alcohol by an anterior approach (n=18), posterior approach (n=6) and transaortic approach (n=4). Pain was rated according to a visual analog scale before and after the procedure to gauge treatment success. No major complications occurred. Mild hypotension occurred in five patients (18%) and transient diarrhea in six patients (21%). Twenty-one (75%) of the 28 patients had some relief of pain and 17 of these patients (61%) had good relief of pain after the procedure. The results support that CT-guided celiac plexus block with alcohol is a safe and effective means of pain control in patients with intraabdominal malignancy.

Three modalities for control of cancer pain: efficacy and safety

We have studied 60 patients suffering from intractable upper abdominal cancer pain. They were classified into 3 equal groups. Group I [oral morphine]: patients were given oral sustained-release morphine tablets [MST] every 12 hours with short-acting morphine tablets as required for breakthrough pain. The dose was adjusted every week to achieve pain relief without maximal recommended dose. Group II [neurolytic celiac plexus block]: patients were scheduled for neurolytic celiac plexus block, under X-ray screening, using alcohol 100%. Oral MST was given as a supplement if there was any residual pain after the block. Group III [epidural morphine]: patients were scheduled for epidural morphine injection via an epidural catheter, 0.03 - 0.05 mg/kg every 4-6 hours as required. No oral MST supplementation was given. The success of each treatment was evaluated by comparing pre-treatment [baseline] and post-treatment [for 12 weeks] scores: pain intensity using visual analogue scale and functional status using Karnofsky performance scale. Opioid consumption per day and side effects of each treatment were recorded. Our results showed that all modalities produced adequate pain relief. There was gradual and significant [p<0.05] increase in the oral morphine dose from the first to last week [from 48 to 227 mg/day] with gradual deterioration in the patient's functional status. Drug-related side effects were nausea, vomiting and constipation. Neurolytic celiac plexus block was associated with a reduction in analgesic drug administration, drug related side effects and insignificant improvement of the functional status of the patients during the first 2 weeks. Complications related to the block were transient diarrhea and hypotension without any neurological complications. With epidural morphine, all patients had adequate pain relief from 11 mg morphine/day, but the daily epidural morphine requirement showed a three fold increase at the 12[th] week [p<0.05]. The functional status of the patients was significantly [p<0.05] high during the first 2 weeks. Pruritus was the main subjective complaint, in addition to the technical complications, such as dislodgment or occlusion of the epidural catheter, or infection. Respiratory depression was not detected in any of our patients. We conclude that no single modality is capable of providing complete relief of intractable upper abdominal cancer pain. Combination therapy should be the rule rather than the exception as each one offers its own advantages and disadvantages