Treatment of "obstructive" pain by endoscopic drainage in patients with pancreatic head carcinoma

Efficacy and safety of early pancreatic duct stenting for unresectable pancreatic cancer: A randomized controlled trial

BACKGROUND

Palliative care for unresectable pancreatic cancer (PC) focuses mainly on the symptoms of the disease, including abdominal pain, obstructive jaundice, and malnutrition. Biliary stent placement using endoscopic retrograde cholangiopancreatography (ERCP) to relieve biliary obstruction has become an internationally recognized treatment. Although a few studies have evaluated the efficacy of endoscopic pancreatic duct stenting in advanced PC, no consensus exists on the use of endoscopic treatment to relieve pain and improve nutritional status.

AIM

To evaluate the efficacy and safety of early pancreatic duct stenting in patients with unresectable PC.

METHODS

Patients with unresectable PC were recruited. The participants were randomized into two groups: The double-stent group underwent ERCP with a fully-covered self-expandable metallic biliary stent (FCSEMS) and a pancreatic duct stent, while the single-stent group underwent ERCP with an FCSEMS only. Abdominal pain, nutritional status, and incidence of adverse events were compared between the two groups using the SPSS software.

RESULTS

Seventy-eight patients with unresectable PC were included in the analysis (40 and 38 in the double- and single-stent groups, respectively). The median pain scores of patients in the double-stent group were lower than those in the single-stent group at 1 (0 vs 2.5, P = 0.002), 2 (0 vs 3, P < 0.001), 3 (0 vs 4, P < 0.001), and 6 months (0 vs 4, P < 0.001) after ERCP. Total serum protein levels in patients in the double-stent group were higher than those in the single-stent group (66.6 ± 8.4 g/L vs 60.4 ± 4.0 g/L, P = 0.046) 6 months postoperatively. The body mass index (BMI) of patients in both groups decreased at six months. However, the BMI in the single-stent group was higher than that in the double-stent group (P < 0.001).

CONCLUSION

Early pancreatic duct stenting reduces abdominal pain and improves nutritional status in patients with unresectable PC without reducing the technical success rate or increasing the incidence of adverse events.

Pancreatic duct stents

Pancreatic duct stenting using endoscopy or surgery is widely used for the management of benign and malignant pancreatic diseases. Endoscopic pancreatic stents are mainly used to relieve pain caused by chronic pancreatitis and pancreas divisum, and to treat pancreatic duct disruption and stenotic pancreaticointestinal anastomosis after surgery. They are also used to prevent postendoscopic retrograde cholangiopancreatography pancreatitis and postoperative pancreatic fistula, treat pancreatic cancer, and locate radiolucent stones. Recent advances in endoscopic techniques, such as endoscopic ultrasonography and balloon enteroscopy, and newly designed stents have broadened the indications for pancreatic duct stenting. In this review we outlined the types, insertion procedures, efficacy, and complications of endoscopic pancreatic duct stent placement, and summarized the applications of pancreatic duct stents in surgery.

[Relief of Obstruction in the Management of Pancreatic Cancer]

Pancreatic cancer is a major cause of cancer-related mortality and morbidity, and its incidence is increasing as the population is aging. On the other hand, significant improvement in the prognosis has not occurred. The absence of early diagnosis means that many patients are diagnosed only when they develop symptoms, such as jaundice, due to a biliary obstruction. The role of endoscopy in multidisciplinary care for patients with pancreatic cancer continues to evolve. Controversy remains regarding the best preoperative biliary drainage in patients with surgically resectable pancreatic head cancer. In general, patients undergoing a surgical resection usually do not require preoperative biliary drainage unless they have cholangitis or receive neoadjuvant chemotherapy. If biliary drainage is performed prior to surgery, the patient's condition and a multidisciplinary approach should be considered. With the increasing life expectancy of patients with pancreatic cancer, the need for more long-time biliary drainage or pre-operative biliary drainage is also increasing. Strong evidence of endoscopic retrograde cholangiopancreatography (ERCP) as a first-line and essential treatment for biliary decompression has been provided. On the other hand, the use of endoscopic ultrasound-guided biliary drainage as well as percutaneous biliary drainage has been also recommended. During ERCP, self-expandable metal stent could be recommended instead of a plastic stent for the purpose of long stent patency and minimizing stent-induced complications. In this review, several points of view regarding the relief of obstruction in patients with pancreatic cancer, and optimal techniques are being discussed.

Palliative therapy in pancreatic cancer-interventional treatment with stents

Interventional treatment with stents in pancreatic cancer is a topic that developed during recent years and new fields of palliative stent therapy have evolved. The increasing life expectancy of patients with unresectable pancreatic cancer increases the need for clinical and cost effective therapeutic interventions. Current literature, guidelines, practice and evidence were reviewed. Besides the most obvious biliary stenting via endoscopic retrograde cholangiopancreatography (ERCP), pancreatic and gastroduodenal stenting as well as percutaneous transhepatic cholangiography (PTC) and the rapidly growing field of endosonographic stent implantation in the palliative care of patients with pancreatic cancer are being discussed from several points of view in this review.

Triple bypass for advanced pancreatic head cancer associated with biliary stricture, duodenal stenosis, and recurrent obstructive pancreatitis

Bypass surgery for cancer of the pancreatic head is usually done to palliate the obstructive symptoms in the biliary and/or digestive system. However, it is uncommon for patients to require pancreatic duct drainage for recurrent obstructive pancreatitis. In this article, we report a surgical technique of triple bypass consisting of Roux-en-Y hepaticojejunostomy, gastrojejunostomy, and pancreaticojejunostomy for advanced pancreatic cancer. A 76-year-old male patient with locally advanced and metastatic pancreatic head cancer was referred to our department for biliary stricture, duodenal stenosis, and recurrent obstructive pancreatitis associated with persistent pancreatic pseudocyst. In an attempt to resolve all these problems simultaneously, a triple bypass was performed. The patient survived and continued to receive chemotherapy for almost 1 year after surgery without any serious complications. Thus, triple bypass is a useful surgical technique that could relief symptoms and offer better quality of life to patients with advanced pancreatic cancer presenting with biliary stricture, duodenal stenosis, and severe obstructive pancreatitis difficult to treat by medication or endoscopic procedures.

Palliation of pancreatic ductal obstruction in pancreatic cancer

Pancreatic stenting for patients with obstructive pain secondary to a malignant pancreatic duct stricture is safe and effective, and should be considered a therapeutic option. Although pancreatic stenting does not seem to be effective for patients with chronic pain, it may be beneficial in those with obstructive type pains, pancreatic duct disruption, or smoldering pancreatitis. Fully covered metal stents may be an option, but data on their use are limited. Further studies, including prospective randomized studies comparing plastic and metal stents in these indications, are needed to further validate and confirm these results.

Pancreatic and biliary stents

Biliary and pancreatic stents are used in a variety of benign and malignant conditions including strictures and leaks and in the prevention of post-ERCP pancreatitis.Both plastic and metal stents are safe, effective, and easy to use. SEMSs have traditionally been used for inoperable malignant disease. Covered SEMSs are now being evaluated for use in benign disease. Increasing the duration of patency of both plastic and metal stents remains an important area for future research.

Pancreatic stents

Use of stents in the pancreas has been confined and limited to referral centers that specialize in the treatment of patients with severe pancreatitis and acute relapsing pancreatitis. With therapeutic development in endoscopic treatment of pancreatic diseases and a better understanding of the cause and prevention of ERCP related complications, the use of stents has been extended to transmural drainage of pancreatic fluid collection or of pancreatic ducts has well as to prophylaxis of post-ERCP pancreatitis. As a result, indication for pancreatic stenting and the kind of stents to be used as well as the followup after placement varies. This article reviews the major indication for pancreatic stent placement and focuses on the choice of stent, technique of implantation and followup.

Current surgical aspects of palliative treatment for unresectable pancreatic cancer

Despite all improvements in both surgical and other conservative therapies, pancreatic cancer is steadily associated with a poor overall prognosis and remains a major cause of cancer mortality. Radical surgical resection has been established as the best chance these patients have for long-term survival. However, in most cases the disease has reached an incurable state at the time of diagnosis, mainly due to the silent clinical course at its early stages. The role of palliative surgery in locally advanced pancreatic cancer mainly involves patients who are found unresectable during open surgical exploration and consists of combined biliary and duodenal bypass procedures. Chemical splanchnicectomy is another modality that should also be applied intraoperatively with good results. There are no randomized controlled trials evaluating the outcomes of palliative pancreatic resection. Nevertheless, data from retrospective reports suggest that this practice, compared with bypass procedures, may lead to improved survival without increasing perioperative morbidity and mortality. All efforts at developing a more effective treatment for unresectable pancreatic cancer have been directed towards neoadjuvant and targeted therapies. The scenario of downstaging tumors in anticipation of a future oncological surgical resection has been advocated by trials combining gemcitabine with radiation therapy or with the tyrosine kinase inhibitor erlotinib, with promising early results.

Preoperative endoscopic pancreatic stenting for prophylaxis of pancreatic duct disruption during extirpation of a pancreatic head tumor

BACKGROUND

Pancreatic fistula is a major problem in minimal invasive surgery of the pancreas. To prevent the disruption of the pancreatic duct, the surgeon must recognize the site of the pancreatic duct exactly.

METHODS

We reviewed the cases of 7 patients who underwent preoperative endoscopic pancreatic stenting for the prophylaxis of pancreatic fistula development after enucleation of a benign pancreatic head tumor.

RESULTS

Preoperative endoscopic pancreatic stenting was successfully performed in all 7 patients. The level of serum amylase increased to 1500 IU/L on postoperative day 1, but levels recovered to normal within 3 days. None of the patients developed a pancreatic fistula.

CONCLUSIONS

Preoperative pancreatic duct stenting is a feasible, effective, and safe technique to prevent pancreatic duct disruption during enucleation of a benign tumor of the pancreatic head.

Endoscopic pancreatic duct stenting for relief of pancreatic cancer pain

INTRODUCTION

Little is known about the effects of endoscopic pancreatic duct (PD) decompression in patients with 'obstructive type' pain from pancreatic carcinoma.

METHODS

Twenty patients with unresectable carcinoma of the pancreas, PD obstruction and postprandial epigastric pain were enrolled. The pain intensity, opioid dose and quality-of-life index were documented pre-treatment and at 4-weekly intervals. PD stenting was attempted in all patients. PD stent change was performed if biliary stents had to be changed or intense pain relapsed.

RESULTS

Endoscopic PD drainage was successful in 19/20 patients by placement of a 7 F (n = 9) or 10 F (n = 10) plastic stent. Median follow-up was 16 weeks. Two patients were alive at the end of follow-up. Eleven patients received gemcitabine chemotherapy. The pre-interventional pain score was 6.7 +/- 0.9 points and decreased to 3.1 +/-1.4 points at 4 weeks (P < 0.001). It remained lowered significantly at 8/12 weeks and at the final visit (4.2 +/- 1.5 points, n = 13). The mean pre-stenting fentanyl dose was 85.5 +/- 34.7 microg/h, and it was decreased to 57.9 +/- 39.1 microg/h after 4 weeks (P < 0.01), 60.5 +/- 38.9 microg/h after 8 weeks and 64.1+/-39.8 microg/h (P < 0.01 versus pre-treatment) after 12 weeks but increased to 82.7 +/- 41.3 microg/h (NS) at the final visit. The quality-of-life index improved 4 weeks after stenting (from 4.8+/-1 to 6.2+/-1.5 points, P < 0.01) but was lowered to 5.5 +/- 2.3 points at 12 weeks (NS). The response was independent of stent diameter and chemotherapy.

CONCLUSION

PD stenting achieved significant pain relief and short-term improvement of the quality of life in the majority of patients with PD obstruction due to pancreatic carcinoma.

Palliative gastroenterology

Continuous improvements in endoscopic imaging and accessories have opened up a field of interventional endoscopy. This highly technical offshoot of gastroenterology uses not just standard endoscopic techniques but also newer endoscopic ultrasound (EUS) imaging or fluoroscopic monitoring to facilitate procedures that were once performed either surgically or percutaneously, if at all. This review will update the role of these novel procedures that can be used to assist in the palliative care of patients whose malignancies involve the gastrointestinal tract. The emphasis will be on those palliative interventions that are used to overcome intestinal obstruction in the gastrointestinal tract and restore luminal patency. The role of EUS-guided celiac plexus neurolysis to assist in pain control, especially in patients with pancreatic malignancies, will also be detailed.

Pancreatic stenting for malignant ductal obstruction

Pain is a major issue of palliative treatment in many patients with advanced pancreatic cancer. 'Obstructive'-type pain identified by correlation with meals, back radiation and dilation of main pancreatic duct upstream the stricture may be treated by endoscopic stent placement into the pancreatic duct in order to by-pass the stricture. The clinical experience reported in the literature shows that pancreatic plastic stenting for 'obstructive' pain may provide complete relief of pain in about 60% of patients and partial relief in 25%.

Placement of self-expanding metallic stents in the pancreatic duct for treatment of obstructive complications of pancreatic cancer

BACKGROUND

Stents have been placed through malignant pancreatic strictures, mainly to alleviate pain of presumed obstructive origin. Self-expanding metallic stents have major advantages over plastic stents when used for treatment of malignant biliary strictures. However, there are few reports of their use in patients with malignant pancreatic duct strictures, especially those with complications related to ductal obstruction.

METHODS

Self-expanding metallic stents were placed in the pancreatic ducts of 3 patients with obstructive complications of pancreatic cancer: smoldering pancreatitis, a disrupted pancreatic duct with pseudocyst caused by open surgical biopsy, and a disrupted pancreatic duct with fistula and resultant liver abscess. All 3 patients had metallic stents placed concomitantly in the biliary tract; one had enteral stents placed as well. Clinical and pathology records and imaging studies were reviewed retrospectively.

OBSERVATIONS

In all cases, there was resolution of the specific clinical problem and reasonable survival (1.5 years in one patient).

CONCLUSIONS

The use of self-expanding metallic stents for treatment of certain obstructive complications of pancreatic tumors is feasible and effective.

Metallic stent placement in the pancreatic duct: an experimental study in the normal dog pancreas

PURPOSE

To evaluate radiologic and histologic changes in the pancreatic duct and parenchyma after placement of metallic stents in normal dog pancreatic ducts.

MATERIALS AND METHODS

Eight dogs underwent duodenotomy and placement of a balloon-expandable metallic stent 1.5 mm in diameter and 1 cm in length in the main pancreatic duct. Two dogs each were killed at 1 day and 1, 3, and 5 months after stent placement. Pancreatic duct injection images were obtained before and immediately after stent placement and just before and after sacrifice. Macroscopic and microscopic examinations were also performed.

RESULTS

Pancreatic duct injection images revealed mild dilation of pancreatic ducts related to the procedure immediately and 1 day after stent placement. Microscopically, denudation of the ductal epithelium and small foci of fat necrosis were observed. At 1 month or later, ductal stricture (n = 4) and occlusion (n = 2) were found at the downstream edge of the initially stent-implanted region associated with dilation of the duct upstream. Epithelial hyperplasia was observed at the sites of ductal stricture and occlusion at 1 and 3 months. Stents remained in the region in which they were initially placed until 1 month. However, stents had moved downstream from their initial positions at 3 and 5 months. One stent had migrated into the duodenum at 5 months. Stone formation was found in the ductal lumen and around the stents at 3 and 5 months. Ducts and parenchyma became fibrotic proportional to the period of stent implantation.

CONCLUSION

Metallic stent placement in the pancreatic duct causes ductal and parenchymal damage related to the procedure and reaction to the stent in the normal dog pancreas.

Supportive care for patients with pancreatic adenocarcinoma: symptom control and nutrition

Pancreatic cancer is most frequently a fatal disease with many associated morbidities. Clinicians skilled in its treatment are adept at management of symptoms caused by local and systemic effects of the malignancy. Patients should be assured that there are many treatments that can be used aggressively to maintain their comfort and independence for as long as possible. Patients should be encouraged to inform their health care providers of any discomfort or medical or psychological problems they are experiencing. At times, referrals to specialists can be beneficial for consideration of specific symptom-improving interventions. Timely referral to a palliative medicine service and hospice can have significant beneficial impact on the total care of the patient and on home caregiver.

Video-assisted thoracoscopic sympathectomy-splanchnicectomy for pancreatic cancer pain

Patients with unresectable pancreatic cancer often suffer severe pain. Various techniques are available for pain control. We present a patient with pancreatic cancer who underwent unilateral video-assisted thoracoscopic sympathectomy-splanchnicectomy and had complete pain relief. This minimally invasive procedure offers promise in carefully selected patients with severe pain from pancreatic cancer and other conditions which are not amenable to conventional interventions.

Gastrointestinal tract cancer in the elderly

Gastrointestinal cancers are common in the elderly. In the 1990s, modest advances in the early diagnosis, staging, and treatment of gastrointestinal cancers were made. Emphasis has been placed on screening for colorectal cancer; development of new diagnostic and staging modalities, particularly endoscopic ultrasound; and introduction of new treatment regimens, such as chemoradiation programs for esophageal, pancreatic, and colorectal cancers as well as endoscopic mucosal resection of early gastrointestinal cancers. New palliative techniques, such as laser and photodynamic therapy and placement of enteral stents, are being used increasingly in patients who have advanced cancer and are not surgical candidates. In the past, attitudes toward the elderly affected the management of cancer. Age should not be the only parameter considered when addressing the treatment of a gastrointestinal malignancy. Management decisions in the elderly should follow the same principles as those in younger patients. A thorough medical evaluation in the elderly is necessary to evaluate the patient's risk and to optimize surgical, chemotherapeutic, and palliative outcomes.

Pancreatic Duct Strictures

The treatment of pancreatic duct strictures is based on an accurate assessment of the etiology of the disease, and then the degree of symptomatology. Our outline for therapy is as follows: Exclude a diagnosis of malignancy by using radiologic, endoscopic, histologic, and molecular biologic modalities. Once a benign stricture has been demonstrated, we favor a trial of endoscopic dilation and stent placement For the unresectable pancreatic neoplasm, in which an obstructive etiology for pain is suspected, a trial of endoscopic dilation and stent placement also should be considered. In benign pancreatic duct strictures complicated by biliary obstruction, and where the most durable treatment modality is sought, surgical intervention merits earlier consideration. Pancreatic duct stent placement should seldom be considered definitive therapy, and the risk of stent-induced duct injury must be weighed against potential therapeutic benefit.

Diagnostic and therapeutic approach to pancreatic cancer

Adenocarcinoma of the pancreas ranks fourth as a cause of cancer death in adults in the United States and is the second most common cause of cancer deaths of all GI-related carcinomas. It usually presents late in its course. The clinical features are discussed, with emphasis on those that allow early detection of the disease, as well as a review of diagnostic methods and pre- and perioperative staging, which will allow the appropriate application of surgical and palliative therapeutic modalities. Despite the significant progress that has been made, further research studies are needed to advance our therapeutic approach to this aggressive cancer.

Pancreatic duct stents for "obstructive type" pain in pancreatic malignancy

OBJECTIVE

Obstruction of the main pancreatic duct from malignancy with secondary ductal hypertension may be an important contributor to pain. The aim of our study was to determine the efficacy and safety of pancreatic stent placement for patients with "obstructive" pain due to pancreatic malignancy.

METHODS

Pancreatic duct stents were placed in 10 consecutive patients with malignant pancreatic duct obstruction and abdominal pain. Seven patients had "obstructive" type pain and three had chronic unremitting pain. Nine had primary pancreatic ductal adenocarcinoma and one had metastatic melanoma. There were eight women and two men. Mean age was 61 yr (range, 47-80 yr). All patients had dominant main pancreatic duct strictures with proximal dilation. Tumors were unresectable. All patients took potent analgesics before endoscopic stent therapy. Polyethylene pancreatic stents, 5- and 7-French, were successfully placed in seven patients, and self-expanding metallic stents were successfully placed in three patients.

RESULTS

There were no procedure-related complications. One patient required a single repeat examination to replace a migrated stent. Seven patients (75%) experienced a reduction in pain. Analgesia was no longer required in five (50%). Three patients who did not improve had chronic pain rather than "obstructive" pain.

CONCLUSIONS

Pancreatic stent placement for patients with "obstructive" pain secondary to a malignant pancreatic duct stricture appears to be safe and effective. It should be considered as a therapeutic option in these patients. It does not seem to be effective for chronic unremitting pain.

Diagnostic approach to pancreatic cancer

Adenocarcinoma of the pancreas ranks fourth as a cause of cancer death in adults in the United States and is the second most common cause of cancer deaths of all gastrointestinal-related carcinomas. It usually presents late in its course. In this article, the authors discuss the clinical features of pancreatic cancer, with emphasis on those that allow early detection of the disease. They also review diagnostic methods and preoperative and perioperative staging that allows the appropriate application of surgical and palliative therapeutic modalities. Despite the significant progress that has been made, further research studies are needed to advance the therapeutic approach to this aggressive cancer.

Proximal migration of transanastomotic pancreatic stent following pancreaticoduodenectomy and pancreaticojejunostomy

BACKGROUND

The use of catheters to stent the pancreaticojejunal anastomosis following pancreaticoduodenectomy is practiced by some surgeons. Their long-term effects in this setting, however, remain unknown.

METHODS

A 60-yr-old woman underwent a potentially curative pylorus preserving pancreaticoduodenectomy for Stage I ampullary carcinoma. Roux-en-Y pancreaticojejunostomy was constructed over a short stent. She presented 4 yr later with abdominal pain, steatorrhea, and weight loss. Computed tomography revealed a stent within the proximal pancreatic duct, with gross upstream ductal dilatation and parenchymal features of chronic pancreatitis.

RESULTS

Laparotomy revealed no disease recurrence. The stent, removed through a jejunotomy, was occluded. On-table pancreatogram demonstrated a 3-cm proximal duct stricture. Drainage was achieved with a lateral pancreaticojejunostomy (modified Puestow procedure). Recovery was uneventful, with clinical recovery of pancreatic exocrine function at 6 mo follow-up.

CONCLUSION

Proximal migration of transanastomotic pancreatic stent with subsequent development of chronic pancreatitis is a potential complication following pancreaticoduodenectomy. It can be managed effectively with stent removal and a lateral pancreaticojejunostomy.

Ruolo Dell'Endoscopia Nella Palliazione Del Carcinoma Pancreatico

The incidence of pancreatic cancer continues to increase and, although improving of diagnostic techniques, the prognosis is very poor with 5-year survival less than 5% and high mortality cancer rate.

Neural and lymphatic micrometastases appear in early stages and curative resection is possible in few selected cases; in these patients there is a high local recurrence rate and a low median survival.

Most patients with pancreatic cancer need palliative care of the obstructive jaundice (90%), duodenal stenosis and abdominal pain; endoscopic procedures have an important role in the treatment of these patients.

Endoscopic placement of plastic biliary stents is a safe and efficient technique to perfom a biliary drainage with a short hospital stay. The use of metal stent, instead of plastic prosthesis, improve median patency of the prosthesis with a low incidence of cholangitis, but they should be used only in patients with a life expectancy of more than six months, because of their high costs.

Laparoscopic gastro-entero-anastomosis is a valide alternative to laparotomic procedure in the treatment of the duodenal stenosis, with a shorter hospital stay and a lower morbidity rate. The endoscopic treatment of abdominal pain with pancreatic endoprosthesis placement or with endosonography-guided celiac plexus neurolysis is an alternative approach to radiotherapy and analgesic drugs.

Review article: current treatment and optimal patient management in pancreatic cancer

This review analyses the current state of knowledge and understanding concerning the optimum treatment and therapeutic management of patients who suffer from pancreatic cancer. It outlines recent advances in scientific understanding and assesses their potential future value to clinicians in confronting this disease. Despite a significant expansion in scientific knowledge relating to factors underlying the early development of pancreatic carcinoma, the clinician continues to be restricted to a severely limited therapeutic armoury for this disease. Local therapies (surgery and radiation) are inevitably of limited value in the face of a disease that is normally encountered at a stage where metastasis is already highly developed. Despite such limitations, however, surgery performed in specialist units may be of value for 10-20% of patients, with a 5-year survival rate in such units of between 10 and 24%. This may be improved even further by appropriate use of adjuvant treatment. The advanced stage of the disease when normally encountered emphasizes the potential value of systemic treatment in this therapeutic area. Unfortunately systemic treatment (chemotherapy) has been found to be ineffective to date in significantly extending survival, with a low rate and duration of remission being identified in most trials. The challenge for both the health service and the pharmaceutical industry is to harness recent and future developments in scientific knowledge to the practical benefit of clinicians. Where cure is possible it should be vigorously pursued; where it is not, in this field above all others, clinicians have a duty of care. To achieve this it is necessary to abandon the therapeutic nihilism that has characterized the attitudes of clinicians towards this disease in the past. It is time that such nihilism was replaced by a recognition of the challenges and the opportunities available to clinicians in enhancing the quantity and quality of life available to patients. The dictum of 'curing whenever possible but caring always' should be the future therapeutic philosophy used to guide clinicians in this important and rapidly changing therapeutic area.

Managing patients with pancreatic cancer

The diagnosis of pancreatic cancer is devastating for patients and family members because of the high morbidity and mortality rates associated with the disease. Regardless of the stages of their illnesses or the treatments they receive, only 3% of patients diagnosed with pancreatic cancer survive five years or more after diagnosis. Compassionate, knowledgeable, supportive nursing care is necessary throughout all stages of pancreatic cancer. This article provides perioperative nurses with information about the diagnosis, treatment, and palliative care for patients diagnosed with pancreatic cancer.

Pain management in patients with pancreatic carcinoma

Pancreatic cancer has a very poor prognosis and is often associated with severe pain. A variety of pain syndromes and pain pathophysiologies can be identified. Information about the analgesic efficacy of available oncological treatments is very limited, but the available data suggest that pharmacological and non-pharmacological approaches can be effective in the majority of cases. Guidelines have been developed for drug administration that emphasize indications, selection of routes, optimal dosing, and side effect treatment. Celiac plexus block can be considered for a subgroup of patients who fail to benefit from drug therapy. Optimally, pain management should be provided within a broader model of palliative care, which can address the many problems associated with this challenging disease.

The role of pancreatic stenting in obstructive ductal disorders other than pancreas divisum

Pancreatic ductal strictures may lead to pancreatitis, with associated pain and nausea. Very little literature is available regarding stent placement for this problem; the efficacy of stenting, expected stent viability, and safety of the procedure require further study. In this series, 21 patients with pancreatic ductal strictures underwent a total of 42 ERCPs with pancreatic stent placement. Eighty-six percent of patients experienced significant improvement in their symptom score after at least 1 session; however, relief was usually not evident until day 7. Stent viability averaged 26.9 days, but it was significantly longer for patients with pancreatic cancer. Overall, pancreatic ductal stenting can relieve symptoms of pain and nausea, but relief is usually short-lived. It may be useful only for short-term therapeutic trials and to provide temporary relief in highly selected cases.

Endoscopic palliation for unresectable pancreatic carcinoma

Endoscopic stenting has revolutionized the palliation of malignant biliary obstruction. Individuals with biliary obstruction due to pancreatic malignancy are best managed by a team approach comprising individuals with expertise in oncology, surgery, endoscopy, and radiology. The clinical value of alleviating jaundice and associated symptoms of anorexia, pruritus, and malaise cannot be overestimated. These quality-of-life factors deserve more attention in future studies to define subgroups of patients most likely to derive benefit from the array of treatment options. Further technical improvements are required to solve the most important clinical problem of late stent occlusion. New developments such as expandable metallic stents and refinements in existing equipment and techniques have already resulted in measurable gains and hold great promise for future expansion of their use in malignant gastric outlet obstruction secondary to tumor infiltration of the duodenum. Corresponding advances are being made in the fields of percutaneous transhepatic intervention and hepatobiliary surgery such that further prospective randomized trials are necessary to define optimal therapy.