The majority of patients with pancreatic cancer are not candidates for surgical resection. Palliative therapy remains the cornerstone of management of this population.
Methods
We reviewed recent clinical and experimental studies on endoscopic palliative therapy of inoperable pancreatic cancer.
Results
Endoscopic placement of a biliary stent is the preferred mode of palliation of obstructive jaundice in patients with pancreatic cancer. The techniques of endoscopic stent insertion are briefly described. Episodic recurrence of jaundice and cholangitis due to stent occlusion is a major drawback of biliary polyethylene stents. Self-expandable metal stents with large diameters have lower rates of stent occlusion and are cost effective in patients who are expected to survive beyond 3 months. Palliation of duodenal obstruction with self-expandable enteral stents and endosonography-guided celiac plexus neurolysis are emerging options for the treatment of patients with advanced pancreatic cancer.
Conclusions
Endoscopic therapy offers safe and effective management options for palliation of major symptoms associated with inoperable pancreatic cancer.
References
1.
GreenleeR.T., MurrayT., BoldenS.. Cancer statistics, 2000.CA Cancer J Clin.2000; 50: 7–33.
2.
CameronJ.L., CristD.W., SitzmannJ.V.. Factors influencing survival after pancreatoduodenectomy for pancreatic cancer.Am J Surg.1991; 161: 120–125.
3.
SarrM.G., CameronJ.L.. Surgical management of unresectable carcinoma of the pancreas.Surgery.1982; 91: 123–133.
4.
BallingerA.B., McHughM., CatnachS.M.. Symptom relief and quality of life after stenting for malignant bile duct obstruction.Gut.1994; 35: 467–470.
5.
McLeanG.K., BurkeD.R.. Role of endoprostheses in the management of malignant biliary obstruction.Radiology.1989; 170: 961–967.
6.
WatanapaP., WilliamsonR.C.. Surgical palliation for pancreatic cancer: developments during the past two decades.Br J Surg.1992; 79: 8–20.
7.
ShepherdH.A., RoyleG., RossA.P.. Endoscopic biliary endoprosthesis in the palliation of malignant obstruction of the distal common bile duct: a randomized trial.Br J Surg.1988; 75: 1166–1168.
8.
AndersenJ.R., SorensenS.M., KruseA.. Randomised trial of endoscopic endoprosthesis versus operative bypass in malignant obstructive jaundice.Gut.1989; 30: 1132–1135.
9.
DowsettJ.F., RussellR.C.G., HatfieldA.R.W.. Malignant obstructive jaundice: a prospective randomized trial of surgery vs. endoscopic stenting.Gastroenterology.1989; 96: A128.
10.
SmithA.C., DowsettJ.F., RussellR.C.. Randomised trial of endoscopic stenting versus surgical bypass in malignant low bile duct obstruction.Lancet.1994; 344: 1655–1660.
11.
CottonP.B.. Diagnosis and management of malignant biliary obstruction. In: SivakMVJr, SchleutermannD.S., eds. Gastroenterologic Endoscopy.2nd ed.Philadelphia, Pa: WB Saunders;1999.
12.
LawrieB.W., PughS., WaturaR.. Bile duct stenting: a comparison of the One-Action Stent Introduction System with the conventional delivery system.Endoscopy.1996; 28: 299–301.
TarnaskyP.R., CottonP.B., BaillieJ.. Proximal migration of biliary stents: attempted endoscopic retrieval in forty-one patients.Gastrointest Endosc.1995; 42: 513–520.
15.
SungJ.Y., LeungJ.W., ShafferE.A.. Ascending infection of the biliary tract after surgical sphincterotomy and biliary stenting.J Gastroenterol Hepatol.1992; 7: 240–245.
16.
GroenA.K., OutT., HuibregtseK.. Characterization of the content of occluded biliary endoprostheses.Endoscopy.1987; 19: 57–59.
17.
DowidarN., KolmosH.J., LyonH.. Clogging of biliary endoprostheses: a morphologic and bacteriologic study.Scand J Gastroenterol.1991; 26: 1137–1144.
18.
SmitJ.M., OutM.M., GroenA.K.. A placebo-controlled study on the efficacy of aspirin and doxycycline in preventing clogging of biliary endoprostheses.Gastrointest Endosc.1989; 35: 485–489.
19.
GhoshS., PalmerK.R.. Prevention of biliary stent occlusion using cyclical antibiotics and ursodeoxycholic acid.Gut.1994; 35: 1757–1759.
20.
BarriozT., IngrandP., BessonI.. Randomised trial of prevention of biliary stent occlusion by ursodeoxycholic acid plus norfloxacin.Lancet.1994; 344: 581–582.
21.
GeogheganJ.G., BranchM.S., CostertonJ.W.. Biliary stents occlude earlier if the distal tip is in the duodenum in dogs.Gastrointest Endosc.1991; 37: 257.
22.
McAllisterE.W., CareyL.C., BradyP.G.. The role of polymeric surface smoothness of biliary stents in bacterial adherence, biofilm deposition, and stent occlusion.Gastrointest Endosc.1993; 39: 422–425.
HoffmanB.J., CunninghamJ.T., MarshW.H.. An in vitro comparison of biofilm formation on various biliary stent materials.Gastrointest Endosc.1994; 40: 581–583.
25.
LeungJ.W., LauG.T., SungJ.J.. Decreased bacterial adherence to silver-coated stent material: an in vitro study.Gastrointest Endosc.1992; 38: 338–340
26.
SungJ.J., ChungS.C., TsuiC.P.. Omitting side-holes in biliary stents does not improve drainage of the obstructed biliary system: a prospective randomized trial.Gastrointest Endosc.1994; 40: 321–325.
O'BrienS., HatfieldA.R., CraigP.I.. A three year follow up of self expanding metal stents in the endoscopic palliation of longterm survivors with malignant biliary obstruction.Gut.1995; 36: 618–621.
29.
van BerkelA.M., BergmanJ.J., WaxmanI.. Wallstents for metastatic biliary obstruction.Endoscopy.1996; 28: 418–421.
30.
DavidsP.H., GroenA.K., RauwsE.A.. Randomised trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction.Lancet.1992; 340: 1488–1492.
31.
Carr-LockeD.L., BallT.J., ConnorsP.J.. Multicenter randomized trial of Wallstent biliary endoprosthesis versus plastic stents.Gastrointest Endosc.1993; 39: 310–316
32.
KnyrimK., WagnerH.J., PauschJ.. A prospective, randomized, controlled trial of metal stents for malignant obstruction of the common bile duct.Endoscopy.1993; 25: 207–212.
33.
FeretisC., BenakisP., DimpoulosC.. Duodenal obstruction caused by pancreatic head carcinoma: palliation with self-expandable endoprostheses.Gastrointest Endosc.1997; 46: 161–165.
