Thoracoscopic bilateral splanchnicotomy for pain control in unresectable pancreatic cancer.

Abdominal pain is the most common symptom of unresectable pancreatic carcinoma. The pancreas receives sympathetic and parasympathetic nerve fibers. The latter, which are the sensitive ones, reach the pancreas through the greater and lesser splanchnic nerve and the celiac ganglion. The greater splanchnic nerve originates from the thoracic ganglia T5-T8 and the lesser splanchnic nerve from T9-T11. The splanchnic nerves are composed of white nerve branches which stem from the ganglia, situated in the intercostal spaces, in the dorsal subpleural region, so they are easily visible through the pleura. The surgical treatment of pain in unresectable pancreatic carcinomas includes abdominal resection of splanchnic nerves, abdominal celiac and superior mesenteric ganglionectomy or thoracic resection of post-ganglionic splanchnic branches. Only recently monolateral thoracoscopic splanchnicotomy in association with vagotomy has been recommended. Because only the bilateral resection of splanchnic nerves ensures total control of pancreatic pain, the Authors have tried an original technique of bilateral thoracoscopic splanchnicotomy. The operation is performed in sequence on the two sides, with the patient lying, on the contralateral side. The lung is excluded and three 10 mm thoracic trocars are inserted: one in the 7th space on the median axillary line (for the optic), one in the 6th space on the posterior axillary line and one in the 5th space on the anterior axillary line. The pleura is opened medially to the sympathetic trunk, at the level of the 5th intercostal space and splanchnicotomy is performed downward up to the 11th intercostal space. The drains, placed through the previously-prepared opening at the level of the 7th intercostal space, are removed on 1 post-operative day. A bilateral thoracoscopic splanchnicotomy should be recommended as treatment of choice of pancreatic pain in unresectable pancreatic carcinoma, because is well tolerated by patients and ensures excellent results in terms of pain control.