Preoperative opioid use and the outcome of thoracoscopic splanchnicectomy in chronic pancreatitis: a systematic review
Thoracoscopic splanchnicectomy (TS) is a minimally invasive intervention to relieve pain in patients with chronic pancreatitis (CP) with equivocal results. Preoperative opioid use seems to impair TS outcome but this has not been investigated in a systematic matter.
We searched PubMed, EMBASE, and The Cochrane Library for studies on the outcome of TS in CP patients. Studies with ≥5 patients and a follow-up of ≥12 months were included. Success was defined as the proportion of patients free of opioids or who had a reduction of ≥4 points on a pain scale. The effect of opioid use on the success rate of TS was analyzed by uni- and multivariate regression.
Sixteen studies with 484 patients were included in our review. The mean (±SD) age of the patients was 44 ± 4.3 years and 66 % were male. Median follow-up period was 21 months (IQR 14–35). Median preoperative opioid use was 85 % (IQR 54–100 %). After TS, a median of 49 % (IQR 22–75 %) of patients were free of opioids at end of follow-up. The median success rate was 62 % (IQR 48–86 %). Mean success rate in studies in which ≤50 % of the patients used opioids preoperatively was 81 % (SD ± 21) compared to 60 % (SD ± 15) for other studies (p = 0.049). Higher age, male gender, and lower rates of preoperative opioid use were associated with a higher success rate (p = 0.003, 0.047, and 0.017, respectively). Multivariate regression, including age, gender, preoperative opioid use, and duration of follow-up, identified age and preoperative opioid use as independent predictors of success after TS (both p = 0.002).
Preoperative opioid use is associated with a worse outcome after TS in CP patients. To optimize outcome, use of TS may be considered at an earlier stage in the treatment of patients with CP before prolonged opioid therapy.
KeywordsChronic pancreatitis Pain Opioid Thoracoscopic splanchnicectomy Review Meta-analysis
Harry van Goor received a European grant for pain treatment using THC in the field of chronic pancreatitis and a speaker’s fee for lecturing at the national symposium on chronic pancreatitis. Yama Issa, Usama Ahmed Ali, Stefan A. W. Bouwense, and Hjalmar C. van Santvoort have no conflicts of interest or financial ties to disclose.
- 13.Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. BMJ 339:2700CrossRefGoogle Scholar
- 14.Galan GG, Tarrazona HV, Morcillo AA, Calvo MV, Martinez CP, Paris RF (1999) The indications for and results of video thoracoscopic surgery. Reflections on 152 procedures. Arch Bronconeumol 35:477–482Google Scholar
- 17.Strekalovskii VP, Grishin NA, Buriev IM, Shishin KV, Subbotin VV, Savvina TV (1999) Thoracoscopic splanchnic sympathectomy in pancreatic diseases. Khirurgiia (Mosk) 11:17–19Google Scholar
- 26.Tomulescu V, Grigoroiu M, Stanescu C, Kosa A, Merlusca G, Vasilescu C, Ionescu M, Popescu I (2005) Thoracoscopic splanchnicectomy: a method of pain palliation in non-resectable pancreatic cancer and chronic pancreatitis. Chirurgia (Bucur) 100:535–540Google Scholar
- 31.Mallet-Guy P, Jaubert De Beaujeu M (1952) Evaluation of left splanchnicectomy in therapy of chronic relapsing pancreatitis; analyzation of 52 personal cases (1942–1951). Lyon Chir 47(5)Google Scholar
- 37.Mallet G, Jacquemet P, Braonnot P, Partensky C (1968) Development of the duodenogram in chronic and recurrent pancreatitis treated by left splanchnicectomy and celiac gangliectomy. Arch Fr Mal App Dig 57:933–948Google Scholar
- 40.Merdzhanov A (1980) Transabdominal splanchnicectomy. Khirurgiia (Sofiia) 33:258–259Google Scholar
- 41.Michotey G, Sastre B, Argeme M, Mannara P, Crespy B (1983) [Splanchnicectomy by Dubois’ transhiatal approach. Technics, indications and results. Apropos of 25 nerve sections for visceral abdominal pain]. J Chir (Paris) 120:487–491Google Scholar
- 42.Relimpio FF, Ferrari Marquez JL, Lopez RA (1988) Splanchnicectomy by the transhiatal route in the treatment of intractable pain in pancreatic pathology (preliminary report). Rev Esp Enferm Apar Dig 73:460–464Google Scholar
- 44.Budd K, Trewby PN (1991) Chronic pancreatitis. Prescr J 31:260–261Google Scholar
- 58.Tarnowski W, Malec-Milewska M, Bielecki K, Ciesielski A, Baczuk L, Michalik E, Jastrzêbski J (2004) Bilateral thoracoscopic splanchnicectomy for pain control in chronic pancreatitis patients: one year prospective observation. Gastroenterol Pol 11:449–452Google Scholar
- 60.Leksowski K, Tomaszewski S, Sokala P, Szyca R, Ostrowski C (2005) The effect of thoracoscopic splanchnicectomy on pain intensity and common daily functions in patients with intractable pancreatic pain. Gastroenterol Pol 12:305–309Google Scholar
- 62.Ahmed Ali U, Nieuwenhuijs VB, van Eijck CH, Gooszen HG, van Dam RM, Busch OR, Dijkgraaf MG, Mauritz FA, Jens S, Mast J, van Goor H, Boermeester MA (2012) Clinical outcome in relation to timing of surgery in chronic pancreatitis: a nomogram to predict pain relief. Arch Surg 147:925–932PubMedGoogle Scholar