Enhancing Splanchnic Neurolysis with Dexmedetomidine: A Double-Blind Randomized Controlled Trial

Introduction

Upper gastrointestinal (GI) malignancies, including cancers of the oesophagus, stomach, pancreas, liver, and gallbladder, present a substantial burden globally [1], with a particularly higher prevalence in Asia. Chronic abdominal pain is a distressing symptom for individuals with upper GI cancer, significantly affecting their quality of life and potentially contributing to disease progression [5,6]. While pharmacotherapy, mainly opioids, is commonly employed for pain management, it has inherent limitations and potential side effects [10].

Interventional therapies such as sympathetic neurolytic blocks targeting the celiac plexus or the splanchnic plexus of nerves have shown effectiveness in alleviating pain associated with upper GI cancers [18-23]. These procedures involve the injection of local anaesthetic drugs or neurolytic agents to block pain signals. Studies have suggested comparable efficacy between celiac plexus neurolysis and splanchnic neurolysis.

Common neurolytic agents such as alcohol and phenol are used for chemical neurolysis but can induce severe pain during injection, and in the initial period after injection due to degradation of the underlying tissue and nerves. This periprocedural and immediate post-procedural burning pain may last up to 24 hours till the drug gives its full effect [52]. This burning pain may be very distressing for the patient. Generally, a local anaesthetic injection is given before the injection of a neurolytic agent to minimize this burning pain. Dexmedetomidine, an alpha-adrenergic agent, has emerged as a promising adjunct for pain management in neurolysis procedures, showing improvement in pain outcomes and reduced opioid consumption without significant side effects. Additionally, Dexmedetomidine may help alleviate the burning pain associated with alcohol injections.

A recent study [47] suggested that adding Dexmedetomidine to the chemical splanchnic neurolysis process reduced the burning pain due to tissue degradation and thus led to reduced morphine consumption. Nonetheless, this study had limitations, including a small sample size, variable drug dilutions of Lignocaine and Dexmedetomidine injected before alcohol injection and a brief follow-up period, highlighting the need for further investigation.

By elucidating the comparative effectiveness and safety profiles of Dexmedetomidine and Lignocaine as adjuncts to alcohol during chemical neurolysis, we aim to offer clinicians evidence-based insights into selecting the optimal approach for pain relief in alcohol neurolysis procedures. Improved pain control not only positively impacts patient satisfaction and quality of life but also enhances procedural outcomes.