Evidence
This page contains a snapshot of featured content which highlights evidence addressing key clinical questions including areas of uncertainty. Please see the main topic reference list for details of all sources underpinning this topic.
BMJ Best Practice evidence tables
Evidence tables provide easily navigated layers of evidence in the context of specific clinical questions, using GRADE and a BMJ Best Practice Effectiveness rating. Follow the links at the bottom of the table, which go to the related evidence score in the main topic text, providing additional context for the clinical question. Find out more about our evidence tables.
This table is a summary of the analysis reported in a guideline (underpinned by a systematic review) that focuses on the above important clinical question.
Confidence in the evidence is very low or low where GRADE has been performed and there is a trade off between benefits and harms of the intervention.
Population: Patients with pancreatic cancer
Intervention: Neurolytic celiac plexus blockade (NCPB) or splanchnicectomy
Comparison: Each other or other methods of pain management
| Outcome | Effectiveness (BMJ rating)? | Confidence in evidence (GRADE)? |
|---|---|---|
NCPB versus medical management alone | ||
Overall survival (follow-up: 6 months) | No statistically significant difference | Moderate |
Pain: reduction in opioid medication ᵃ; pain relief/improved analgesia (pain scores at 4 weeks); absolute change in pain score at 1 and 3 months | Favors intervention | Moderate to Low ᵇ |
Pain: reduction in opioid medication (absolute change in morphine use at 1 and 3 months); pain relief/improved analgesia (pain scores at 2 and 8 weeks); patients reporting effective pain management at 2 and 8 weeks | No statistically significant difference | Low to Very Low ᵇ |
Adverse effects (constipation) | Occurs more commonly with medical management alone compared with NCPB (favors intervention) | Moderate |
Adverse effects (diarrhea) | No statistically significant difference | Low |
Quality of life (QOL): QOL scores at 1 and 3 months (for appetite, sleep, and communication); QOL scores at 3 months (functional scales: role; cognitive; social); QOL scores - symptoms at 3 months (nausea/vomiting; dyspnea; constipation; financial difficulties; diarrhea) | No statistically significant difference | Low to Very Low ᵇ |
QOL scores at 3 months: functional scales: physical/emotional; global quality; symptoms (pain, insomnia, appetite) | Favors intervention | Moderate to Very Low ᵇ |
QOL scores: Digestive Disease Questionnaire-15 (DDQ-15) (at 1 month) | Favors intervention | Low |
QOL scores: DDQ-15 (at 3 months) | No statistically significant difference | Low |
QOL scores: symptoms at 3 months (fatigue) | Favors comparison | Low |
Early NCPB (NCPB followed by medication for controlling pain) versus late NCPB (medication followed by NCPB when pain visual analog score <40) | ||
Reduction in opioid medication (oral morphine; oral tramadol) at both 16 and 24 weeks | Favors late NCPB | Moderate to Low ᶜ |
Pain relief/improved analgesia: pain scores at 16 and 24 weeks | Favors late NCPB | Moderate |
Adverse effects (nausea; constipation) | Occurs more commonly with early NCPB compared with late NCPB (favors comparison) | Low |
Adverse effects (pruritus) | No statistically significant difference | Very Low |
NCPB plus medical management versus thoracic splanchnicectomy plus medical management | ||
Pain relief/improved analgesia: pain scores at 2 and 8 weeks | No statistically significant difference | Very Low |
Patients reporting effective pain management at 2 weeks and 2 months | No statistically significant difference | Very Low |
Thoracic splanchnicectomy plus medical management versus medical management alone | ||
Pain relief/improved analgesia: pain scores at 2 weeks and 8 weeks | No statistically significant difference | Very Low |
Patients reporting effective pain management at 2 weeks and 2 months | No statistically significant difference | Very Low |
Recommendations as stated in the source guideline Consider endoscopic ultrasound-guided or image-guided percutaneous NCPB to manage pain for people with pancreatic cancer who: Have uncontrolled pancreatic pain OR Are experiencing unacceptable opioid adverse effects OR Are receiving escalating doses of analgesics. Do not offer thoracic splanchnicectomy to people with pancreatic cancer.
Note Due to the limited evidence on adverse events, the guideline committee recommends NCPB in people who have had a suboptimal response to conventional analgesia. The guideline committee noted that thoracic splanchnicectomy is invasive, requires general anesthetic, and is not widely used in the UK, resulting in a lack of evidence demonstrating its effectiveness, especially for pain relief. Therefore, they recommended that the procedure should not be performed. ᵃ Includes opioid use at 2 and 4 weeks' follow-up, opioid use the day before to death, and percentage change in analgesic use at 3 months. ᵇ There was a range of GRADE as shown for the outcomes listed here. See guideline for more information. ᶜ Moderate-quality evidence favors late NCPB for the reduction of oral morphine at both 16 and 24 weeks and the reduction of oral tramadol at 16 weeks, whereas low-quality evidence favors late NCPB for the reduction of oral tramadol at 24 weeks.
This evidence table is related to the following section/s:
Cochrane Clinical Answers
Cochrane Clinical Answers (CCAs) provide a readable, digestible, clinically focused entry point to rigorous research from Cochrane systematic reviews. They are designed to be actionable and to inform decision making at the point of care and have been added to relevant sections of the main Best Practice text.
- How do pylorus-preserving and classic pancreaticoduodenectomy compare in people undergoing surgical treatment of periampullary and pancreatic carcinoma?
- In people with pancreatic cancer, how does laparoscopic pancreatectomy compare with open distal pancreatectomy at improving outcomes?
- In people with locally advanced pancreatic cancer, is there randomized controlled trial evidence to support the use of resection instead of palliative treatment?
- How does gemcitabine compare with non‐gemcitabine‐containing regimens for people with advanced pancreatic cancer?
- How do gemcitabine‐containing dual chemotherapy regimens compare with gemcitabine alone for people with advanced pancreatic cancer?
- How does celiac plexus block affect compare with other analgesics in adults with pancreatic cancer pain?
- In patients undergoing pancreatic surgery, what are the benefits and harms of post-operative administration of somatostatin analogues?
- After pancreaticoduodenectomy, how does anastomosis between the pancreatic stump and the jejunum compare with anastomosis between the pancreatic stump and the stomach?
- What are the benefits and harms of using fibrin sealants for prevention of postoperative pancreatic fistula following pancreatic surgery?
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