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World J Gastrointest Surg. Oct 27, 2018; 10(7): 75-83
Published online Oct 27, 2018. doi: 10.4240/wjgs.v10.i7.75
Current role of palliative interventions in advanced pancreatic cancer
Chelsey C Ciambella, Rachel E Beard, Thomas J Miner
Chelsey C Ciambella, Rachel E Beard, Thomas J Miner, Department of Surgical Oncology, Warren Alpert Medical School Brown University, Providence, RI 02906, United States
Author contributions: Ciambella CC, Beard RE and Miner TJ worked on the concept, design, manuscript writing and manuscript review.
Conflict-of-interest statement: There is no conflict of interest associated with the senior author or other coauthors that contributed their efforts in this manuscript.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Thomas J Miner, MD, Associate Professor, Doctor, Senior Researcher, Surgeon, Surgical Oncologist, Department of Surgical Oncology, Warren Alpert Medical School Brown University, 2 Dudley Street, Providence, RI 02906, United States. tminer@usasurg.org
Telephone: +1-401-4210245 Fax: +1-401-8682310
Received: July 31, 2018
Peer-review started: July 31, 2018
First decision: August 20, 2018
Revised: September 13, 2018
Accepted: October 10, 2018
Article in press: October 10, 2018
Published online: October 27, 2018
Abstract

Pancreatic adenocarcinoma is the third leading cause of cancer death in the United States. Unfortunately, at diagnosis, most patients are not candidates for curative resection. Surgical palliation, a procedure performed with the intention of relieving symptoms or improving quality of life, comes to the forefront of management. This article reviews the palliative management of unresectable pancreatic cancer, including obstructive jaundice, duodenal obstruction and pain control with celiac plexus block. Although surgical bypasses for both biliary and duodenal obstructions usually achieve good technical success, they result in considerable perioperative morbidity and mortality, even when performed laparoscopically. The effectiveness of self-expanding metal stents for biliary drainage is excellent with low morbidity. Surgical gastrojejunostomy for duodenal obstruction appears to be best for patients with a life expectancy of greater than 2 mo while endoscopic stenting has been shown to be feasible with good symptom relief in those with a shorter life expectancy. Regardless of the palliative procedure performed, all physicians involved must be adequately trained in end of life management to ensure the best possible care for patients.

Keywords: Surgical palliation, Duodenal obstruction, Hepatojejunostomy, Gastrojejunostomy, Endoscopic stenting, Malignant ascites, Celiac block, Palliative triangle, Pancreatic cancer, Obstructive jaundice

Core tip: Unfortunately, at the time of diagnosis most patients with pancreatic cancer are not candidates for curative resection. Surgical palliation, a procedure performed with the intention of relieving symptoms or improving quality of life, comes to the forefront of management. The majority of palliative care focuses on three high burden symptoms: obstructive jaundice, duodenal obstruction and tumor-related pain. There exists a wide range of interventions including both operative and non-operative techniques. Regardless of the palliative procedure, all physicians involved must be adequately trained in end of life management to ensure the best possible care for patients.