Neurolytic Sympathectomy in the Management of Cancer Pain-Time Effect: A Prospective, Randomized Multicenter Study

Context. Sympathectomy is currently used as the fourth step of the modified World Health Organization (WHO) analgesic ladder. Sympathectomy can be performed early, before the second step on the ladder. Objectives. We hypothesized that early sympathectomy would reduce pain and opioid consumption and improve quality of life. Methods. One hundred nine patients, with inoperable abdominal or pelvic cancer, reporting visceral pain of 40-70 on a visual analogue scale and taking nonopioid analgesics were allocated randomly into two groups: either blocks were performed before Step 2 of the WHO ladder, then analgesics were managed according to the ladder (Group I) or analgesics were given according to the WHO ladder, and blocks were performed as the fourth step after failure of strong opioids to control pain (Group II). Visual analogue scale scores, responder analysis, daily opioid consumption, related side effects, and quality of life were assessed. Results. Responders were significantly higher in Group I (P < 0.0001), and partial responders and nonresponders significantly increased in Group II (P < 0.0001 and 0.006, respectively). Opioid consumption significantly decreased in Group I (P < 0.0001 during first 12 months and 0.007 at the last assessment time), with concomitant significant reduction in related side effects. The number of patients who had a good analgesic response on tramadol significantly increased in Group I during the first five months (P < 0.05). European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 global quality-of-life subscale scores revealed significant improvement until the fifth month in Group I (P < 0.05). Conclusion. Sympathectomy before Step 2 on the WHO analgesic ladder seems to lead to better pain control, less opioid consumption, and better quality of life in cancer patients.(C) 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.