Surgical Endoscopy

, Volume 28, Issue 2, pp 405–412 | Cite as

Preoperative opioid use and the outcome of thoracoscopic splanchnicectomy in chronic pancreatitis: a systematic review

  • Yama IssaEmail author
  • Usama Ahmed Ali
  • Stefan A. W. Bouwense
  • Hjalmar C. van Santvoort
  • Harry van Goor



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.


Chronic 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.


  1. 1.
    Ammann RW, Muellhaupt B (1999) The natural history of pain in alcoholic chronic pancreatitis. Gastroenterology 116:1132–1140PubMedCrossRefGoogle Scholar
  2. 2.
    Gardner TB, Kennedy AT, Gelrud A, Banks PA, Vege SS, Gordon SR, Lacy BE (2010) Chronic pancreatitis and its effect on employment and health care experience: results of a prospective American multicenter study. Pancreas 39:498–501PubMedCrossRefGoogle Scholar
  3. 3.
    Ammann RW, Akovbiantz A, Largiader F, Schueler G (1984) Course and outcome of chronic pancreatitis. Longitudinal study of a mixed medical-surgical series of 245 patients. Gastroenterology 86:820–828PubMedGoogle Scholar
  4. 4.
    Nealon WH, Matin S (2001) Analysis of surgical success in preventing recurrent acute exacerbations in chronic pancreatitis. Ann Surg 233:793–800PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Cuschieri A, Shimi SM, Crosthwaite G, Joypaul V (1994) Bilateral endoscopic splanchnicectomy through a posterior thoracoscopic approach. J R Coll Surg Edinb 39:44–47PubMedGoogle Scholar
  6. 6.
    Buscher HC, Schipper EE, Wilder-Smith OH, Jansen JB, van Goor H (2008) Limited effect of thoracoscopic splanchnicectomy in the treatment of severe chronic pancreatitis pain: a prospective long-term analysis of 75 cases. Surgery 143:715–722PubMedCrossRefGoogle Scholar
  7. 7.
    Howard TJ, Swofford JB, Wagner DL, Sherman S, Lehman GA (2002) Quality of life after bilateral thoracoscopic splanchnicectomy: long-term evaluation in patients with chronic pancreatitis. J Gastrointest Surg 6:845–852PubMedCrossRefGoogle Scholar
  8. 8.
    Stefaniak T, Vingerhoets A, Makarewicz W, Kaska L, Kobiela J, Kwiecinska B, Stanek A, Lachinski AJ, Sledzinski Z (2008) Opioid use determines success of videothoracoscopic splanchnicectomy in chronic pancreatic pain patients. Langenbecks Arch Surg 393:213–218PubMedCrossRefGoogle Scholar
  9. 9.
    Lieb JG, Forsmark CE (2009) Review article: pain and chronic pancreatitis. Aliment Pharmacol Ther 29:706–719PubMedCrossRefGoogle Scholar
  10. 10.
    Drewes AM, Krarup AL, Detlefsen S, Malmstrom ML, Dimcevski G, Funch-Jensen P (2008) Pain in chronic pancreatitis: the role of neuropathic pain mechanisms. Gut 57:1616–1627PubMedCrossRefGoogle Scholar
  11. 11.
    Buscher HC, van Goor H, Wilder-Smith OH (2007) Effect of thoracoscopic splanchnic denervation on pain processing in chronic pancreatitis patients. Eur J Pain 11:437–443PubMedCrossRefGoogle Scholar
  12. 12.
    Baghdadi S, Abbas MH, Albouz F, Ammori BJ (2008) Systematic review of the role of thoracoscopic splanchnicectomy in palliating the pain of patients with chronic pancreatitis. Surg Endosc 22:580–588PubMedCrossRefGoogle Scholar
  13. 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. 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
  15. 15.
    Kuriansky J, Saenz A, Fernandez-Cruz L (1999) Thoracoscopic splanchnicectomy for intractable pancreatic pain. Harefuah 137:513–515PubMedGoogle Scholar
  16. 16.
    Olak J, Gore D (1996) Thoracoscopic splanchnicectomy: technique and case report. Surg Laparosc Endosc 6:228–230PubMedCrossRefGoogle Scholar
  17. 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
  18. 18.
    Suchy T, Bernardova M, Etflais L (1995) Video thoracoscopic splanchnicectomy in persistent epigastric pain. Rozhl Chir 74:277–279PubMedGoogle Scholar
  19. 19.
    Buscher HC, Jansen JJ, van Goor H (1999) Bilateral thoracoscopic splanchnicectomy in patients with chronic pancreatitis. Scand J Gastroenterol Suppl 230:29–34PubMedCrossRefGoogle Scholar
  20. 20.
    Leksowski K (2001) Thoracoscopic splanchnicectomy for the relief of pain due to chronic pancreatitis. Surg Endosc 15:592–596PubMedCrossRefGoogle Scholar
  21. 21.
    Maher JW, Johlin FC, Pearson D (1996) Thoracoscopic splanchnicectomy for chronic pancreatitis pain. Surgery 120:603–609PubMedCrossRefGoogle Scholar
  22. 22.
    Maher JW, Johlin FC, Heitshusen D (2001) Long-term follow-up of thoracoscopic splanchnicectomy for chronic pancreatitis pain. Surg Endosc 15:706–709PubMedCrossRefGoogle Scholar
  23. 23.
    Makarewicz W, Stefaniak T, Stanek A, Basinski A, Kossakowska M, Gruca Z (2002) Factors determining morbidity and effectiveness in videothoracoscopic splanchnicectomy. Zentralbl Chir 127:950–955PubMedCrossRefGoogle Scholar
  24. 24.
    Andrievskikh IA, Fokin AA (2004) Multiyear experience in endoscopic thoracic sympathectomy. Angiol Sosud Khir 10:99–104PubMedGoogle Scholar
  25. 25.
    McHale A, Buechter KJ, Cohn I Jr, O’Leary JP (1997) Surgical management of chronic pain from chronic pancreatitis. Am Surg 63:1119–1123PubMedGoogle Scholar
  26. 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
  27. 27.
    Trunin MA (1965) Postganglionic neurotomy in the treatment of some forms of chronic pancreatitis. Vestn Khir Im I I Grek 94:63–71PubMedGoogle Scholar
  28. 28.
    Trunin MA, Krutikova IF (1967) Marginal neurotomy in certain forms of chronic pancreatitis. Vestn Khir Im I I Grek 98:47–53PubMedGoogle Scholar
  29. 29.
    Voboril Z, Jon B (1994) Splanchnicectomy in pancreatic diseases. Rozhl Chir 73:154–156PubMedGoogle Scholar
  30. 30.
    Mallet-Guy P, Jaubert De Beaujeu M (1950) Treatment of chronic pancreatitis by unilateral splanchnicectomy. Arch Surg 60:233–241PubMedCrossRefGoogle Scholar
  31. 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
  32. 32.
    Mallet-Guy P, Feroldi J (1953) Pathological, experimental and clinical bases for left splanchnicectomy in treatment of relapsing chronic pancreatitis. Presse Med 61:99–101PubMedGoogle Scholar
  33. 33.
    Mallet-Guy P (1956) Sphincterotomy and splanchnicectomy in the treatment of chronic relapsing pancreatitis. AMA Arch Surg 72:366–370PubMedCrossRefGoogle Scholar
  34. 34.
    Mallet-Guy P (1965) Treatment of chronic pancreatitis. Am J Surg 109:756–759PubMedCrossRefGoogle Scholar
  35. 35.
    Mallet-Guy P (1976) Principles and results of surgery of chronic and recurrent pancreatitis. Zentralbl Chir 101:518–519PubMedGoogle Scholar
  36. 36.
    Mallet-Guy PA (1983) Late and very late results of resections of the nervous system in the treatment of chronic relapsing pancreatitis. Am J Surg 145:234–238PubMedCrossRefGoogle Scholar
  37. 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
  38. 38.
    Bali B, Deixonne B, Rzal K (1995) Bilateral splanchnicectomy by transhiatal approach in pain of pancreatic origin: 37 cases. Presse Med 24:928–932PubMedGoogle Scholar
  39. 39.
    Forni E, Borri AM, Zadra F, Bordoni P, Spelzini P (1984) Bilateral splanchnicectomy according to the Dubois method in pain caused by chronic pancreatitis and by inoperable neoplasms of the pancreas. Chir Ital 36:827–830PubMedGoogle Scholar
  40. 40.
    Merdzhanov A (1980) Transabdominal splanchnicectomy. Khirurgiia (Sofiia) 33:258–259Google Scholar
  41. 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. 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
  43. 43.
    Shimada S, Okamoto M, Hirota M, Tashima S, Yamaguchi K, Ogawa M (1999) Clinical evaluation of transhiatal bilateral splanchnicotomy for patients with intractable supramesenteric pain. Surg Today 29:1136–1140PubMedCrossRefGoogle Scholar
  44. 44.
    Budd K, Trewby PN (1991) Chronic pancreatitis. Prescr J 31:260–261Google Scholar
  45. 45.
    Delassus P, Deshayes JP, Segol P, Fournier L (1989) The celiac block test under x-ray computed tomography before possible surgical splanchnicectomy. Presse Med 18:1123PubMedGoogle Scholar
  46. 46.
    Hirata K, Higa K, Shono S, Hirota K, Shinokuma T (2003) Splanchnic neurolysis using carbon dioxide as the contrast agent. Reg Anesth Pain Med 28:68–69PubMedGoogle Scholar
  47. 47.
    Pecora DV, Woody DJ (1982) Chronic pancreatitis and splanchnicectomy. Arch Surg 117:983PubMedGoogle Scholar
  48. 48.
    Waldum HL (2010) Editorial: this month in Scandinavian journal of gastroenterology. Scand J Gastroenterol 45:772–774CrossRefGoogle Scholar
  49. 49.
    Bradley EL III, Reynhout JA, Peer GL (1998) Thoracoscopic splanchnicectomy for “small duct” chronic pancreatitis: case selection by differential epidural analgesia. J Gastrointest Surg 2:88–94PubMedCrossRefGoogle Scholar
  50. 50.
    Davis BR, Vitale M, Lecompte M, Vitale D, Vitale GC (2008) An objective study of pain relief in chronic pancreatitis from bilateral thoracoscopic splanchnicectomy. Am Surg 74:510–514PubMedGoogle Scholar
  51. 51.
    Hammond B, Vitale GC, Rangnekar N, Vitale EA, Binford JC (2004) Bilateral thoracoscopic splanchnicectomy for pain control in chronic pancreatitis. Am Surg 70:546–549PubMedGoogle Scholar
  52. 52.
    Ihse I, Zoucas E, Gyllstedt E, Lillo-Gil R, Andrén-Sandberg A (1999) Bilateral thoracoscopic splanchnicectomy: effects on pancreatic pain and function. Ann Surg 230(6):785–790PubMedCentralPubMedCrossRefGoogle Scholar
  53. 53.
    Kusano T, Miyazato H, Shiraishi M, Yamada M, Matsumoto M, Muto Y (1997) Thoracoscopic thoracic splanchnicectomy for chronic pancreatitis with intractable abdominal pain. Surg Laparosc Endosc 7:213–218PubMedCrossRefGoogle Scholar
  54. 54.
    Makarewicz W, Stefaniak T, Kossakowska M, Basiński A, Suchorzewski M, Stanek A, Gruca ZB (2003) Quality of life improvement after videothoracoscopic splanchnicectomy in chronic pancreatitis patients: case control study. World J Surg 27:906–911PubMedCrossRefGoogle Scholar
  55. 55.
    Moodley J, Singh B, Shaik AS, Haffejee A, Rubin J (1999) Thoracoscopic splanchnicectomy: pilot evaluation of a simple alternative for chronic pancreatic pain control. World J Surg 23:688–692PubMedCrossRefGoogle Scholar
  56. 56.
    Noppen M, Meysman M, D’Haese J, Vincken W (1998) Thoracoscopic splanchnicolysis for the relief of chronic pancreatitis pain: experience of a group of pneumologists. Chest 113:528–531PubMedCrossRefGoogle Scholar
  57. 57.
    Buscher HC, Jansen JB, van Dongen R, Bleichrodt RP, van Goor H (2002) Long-term results of bilateral thoracoscopic splanchnicectomy in patients with chronic pancreatitis. Br J Surg 89:158–162PubMedGoogle Scholar
  58. 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
  59. 59.
    Andrén-Sandberg A, Zoucas E, Lillo-Gil R, Gyllstedt E, Ihse I (1996) Thoracoscopic Splanchnicectomy for chronic, severe pancreatic pain. Semin Laparosc Surg 3:29–33PubMedGoogle Scholar
  60. 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
  61. 61.
    Negi S, Singh A, Chaudhary A (2010) Pain relief after Frey’s procedure for chronic pancreatitis. Br J Surg 97:1087–1095PubMedCrossRefGoogle Scholar
  62. 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
  63. 63.
    Alexakis N, Connor S, Ghaneh P, Raraty M, Lombard M, Smart H, Evans J, Hughes M, Garvey CJ, Goulden M, Parker C, Sutton R, Neoptolemos JP (2004) Influence of opioid use on surgical and long-term outcome after resection for chronic pancreatitis. Surgery 136:600–608PubMedCrossRefGoogle Scholar
  64. 64.
    Clarke B, Slivka A, Tomizawa Y, Sanders M, Papachristou GI, Whitcomb DC, Yadav D (2012) Endoscopic therapy is effective for patients with chronic pancreatitis. Clin Gastroenterol Hepatol 10:795–802PubMedCentralPubMedCrossRefGoogle Scholar
  65. 65.
    Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L (2011) A comprehensive review of opioid-induced hyperalgesia. Pain Physician 14:145–161PubMedGoogle Scholar
  66. 66.
    Chu LF, Angst MS, Clark D (2008) Opioid-induced hyperalgesia in humans: molecular mechanisms and clinical considerations. Clin J Pain 24:479–496PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Yama Issa
    • 1
    Email author
  • Usama Ahmed Ali
    • 1
    • 2
  • Stefan A. W. Bouwense
    • 3
  • Hjalmar C. van Santvoort
    • 2
  • Harry van Goor
    • 3
  1. 1.Department of SurgeryAcademic Medical CenterAmsterdamThe Netherlands
  2. 2.Department of SurgeryUniversity Medical Center UtrechtUtrechtThe Netherlands
  3. 3.Department of SurgeryRadboud University Nijmegen Medical CenterNijmegenThe Netherlands

Personalised recommendations