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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 36  |  Issue : 2  |  Page : 100-102

Celiac plexus chemical neurolysis for refractory pain associated with superior mesenteric artery syndrome


1 Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand, India
2 Senior Resident, Department of Anatomy, Aiims, Jodhpur, India

Date of Submission15-Mar-2022
Date of Decision22-Apr-2022
Date of Acceptance23-Apr-2022
Date of Web Publication25-Aug-2022

Correspondence Address:
Dr. Girish Kumar Singh
Department of Anaesthesiology, AIIMS, Rishikesh - 249 203, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_25_22

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  Abstract 


Superior mesenteric artery (SMA) syndrome is caused by the compression of a part of the intestine between the aorta and SMA. It may lead to severe epigastric pain that is even refractory to conservative and surgical forms of therapy. Celiac plexus chemical neurolysis has been used in the past for debilitating pain associated with upper gastrointestinal malignancies and chronic pancreatitis. However, to date, this intervention has never been described in the literature for managing pain in SMA syndrome patients. Here, we describe the case of SMA syndrome whose pain was successfully managed with celiac plexus chemical neurolysis.

Keywords: Aorta, celiac plexus chemical neurolysis, chronic pancreatitis, epigastric pain, gastrointestinal malignancies, intervention, superior mesenteric artery syndrome


How to cite this article:
Sharma RS, Kumar A, Singh GK, Goyal S, Sharma S. Celiac plexus chemical neurolysis for refractory pain associated with superior mesenteric artery syndrome. Indian J Pain 2022;36:100-2

How to cite this URL:
Sharma RS, Kumar A, Singh GK, Goyal S, Sharma S. Celiac plexus chemical neurolysis for refractory pain associated with superior mesenteric artery syndrome. Indian J Pain [serial online] 2022 [cited 2022 Sep 29];36:100-2. Available from: https://www.indianjpain.org/text.asp?2022/36/2/100/354720




  Introduction Top


Superior mesenteric artery (SMA) syndrome, also known as Wilkie's syndrome or cast syndrome, was first described in 1861 by Shiu.[1] Here, part of the small intestine is compressed between the aorta and SMA, leading to intestinal obstruction. This may lead to severe debilitating pain that is refractory to conservative management. This is commonly due to the loss of retroperitoneal fatty tissue as a result of a variety of debilitating conditions.[2] Initial treatment of SMA syndrome is usually conservative, nonoperative medical management. Pain management in these patients is very challenging, and most of the patient's pain is even refractory to surgical intervention. Celiac plexus interventions have been used in the past to manage pain associated with upper gastrointestinal (GI) malignancy and pain associated with chronic pancreatitis.[3]

However, till now, there are no reports of celiac plexus intervention for managing pain in this group of patients. Thus, here, we describe a case of SMA syndrome in a young female patient whose pain was successfully managed with celiac plexus chemical neurolysis.


  Case Report Top


A 17-year-old female patient was referred from the department of surgical gastroenterology to the pain medicine outpatient department with dull aching epigastric pain. She complained of gradual onset of severe pain with a score of 7/10 on the Numerical Rating Scale (NRS). Her sleep was also disturbed due to pain. Her pain was refractory to conservative therapy including paracetamol and tramadol. In the past, she had similar complaints for which she was admitted to the department of surgical gastroenterology, and a diagnosis of SMA syndrome was made. For this pathology, she underwent open median arcuate ligament release surgery under general anesthesia. However, even after 3 months following surgical intervention, her pain persisted.

Hence, we planned to perform anultrasound guided celiac plexus intervention to relieve her pain. The patient has explained the procedure in detail, and written informed consent was obtained following fasting for 8 h. Thereafter, the patient was shifted to the operation theater, all standard monitors were applied, and a 22G cannula was secured. The patient was placed in the supine position with the arms resting comfortably by the side. Skin adjoining the umbilical area was disinfected with chlorhexidine-based solutions, and draping was done. A low-frequency curvilinear USG transducer (2–5 MHz) was placed in the transverse plane division over the epigastric area [Figure 1] to define the common celiac trunk at its origin from the aorta and its division into hepatic and splenic branches. Then, under real-time USG visualization and Doppler assistance, the classic “Seagull sign” was identified (celiac trunk division into hepatic and splenic arteries). The target point was identified as the right lateral area of the celiac trunk. Following target identification, the skin was infiltrated with 1% lignocaine, and a 22G 12-cm Chiba needle was advanced from the lateral border of the USG transducer using the in-plane approach in a lateral-to-medial fashion under real-time USG guidance. Finally, the needle tip was placed between the celiac trunk and the origin of the hepatic artery. Following needle placement at the target point, negative aspiration was done to rule out vascular placement thereafter, diagnostic intervention was performed using 7 ml of 1% lignocaine under real-time USG guidance [Figure 2]. The needle was kept in situ for 10 min, and her pain was reassessed. Her NRS was significantly reduced following the diagnostic block. Thereafter, 12 ml 6% phenol was injected at the same place under real-time USG guidance. Two ml of 1% lignocaine was injected before the needle removal. The entire procedure was uneventful with stable hemodynamic. Following the procedure, the patient was shifted to the postoperative area, where vitals were monitored for 45 min. The patient vitals remained stable in the recovery room, so the patient was shifted to the general ward and discharged the next day. The patient remained pain-free during follow-up, which was done telephonically at 7 days, at 1 month, and at 3 months.
Figure 1: Probe position for celiac plexus intervention

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Figure 2: Ultrasound picture of the celiac trunk with hepatic and splenic artery with the final needle position

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  Discussion Top


The celiac plexus is a bundle of nerves that surrounds the aorta, located in the retroperitoneal space immediately anterior to the aorta at L1 vertebrae level, and it is composed of visceral afferents from the abdominal viscera, including the entire small intestine, liver, stomach, pancreas, and ascending and transverse colon.[4] Celiac plexus block is indicated for the management of intractable pain associated with benign and malignant neoplasm involving upper GI, pancreas, biliary tree, retroperitoneal organs, and other abdominal organs as well as chronic pancreatitis.[4] Our patient presented with upper GI pain which was refractory to conservative and surgical management (median arcuate ligament release surgery). Thus, we decided to go with an interventional pain procedure targeting nerves of the upper GI. As SMA is innervated by superior mesenteric plexus which is derived from celiac plexus, so we planned to perform chemical neurolysis of celiac plexus following successful diagnostic intervention with a local anesthetic solution. As local anesthetic yielded more than 50% pain relief, so we performed chemical neurolysis of celiac plexus by 6% phenol which provided near-complete pain relief. Although celiac plexus block has been performed for a variety of painful conditions, this is the first case in the literature of refractory SMA syndrome pain that was successfully managed by celiac plexus chemical neurolysis.

Thus, we can conclude that SMA syndrome pain responds poorly to conservative as well as surgical management,[5] and USG-guided celiac plexus intervention can be performed in these challenging scenarios. Further research is warranted to confirm the observed relationships.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published, and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shiu JR, Chao HC, Luo CC, Lai MW, Kong MS, Chen SY, et al. Clinical and nutritional outcomes in children with idiopathic superior mesenteric artery syndrome. J Pediatr Gastroenterol Nutr 2010;51:177-82.  Back to cited text no. 1
    
2.
Zaraket V, Deeb L. Wilkie's syndrome or superior mesenteric artery syndrome: Fact or fantasy? Case Rep Gastroenterol 2015;9:194-9.  Back to cited text no. 2
    
3.
Doroshenko M, Turkot O, Horn DB. Sympathetic nerve block. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021.  Back to cited text no. 3
    
4.
John RS, Dixon B, Shienbaum R. Celiac plexus block. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021.  Back to cited text no. 4
    
5.
Welsch T, Büchler MW, Kienle P. Recalling superior mesenteric artery syndrome. Dig Surg 2007;24:149-56.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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