From the Guidelines
The next line of action for a patient with pancreatic carcinoma and biliary obstruction and liver metastasis is to undergo endoscopic placement of a permanent self-expanding metal stent in the bile duct to re-establish drainage and relieve jaundice and pruritus, as this is the preferred treatment for palliating biliary obstruction in patients with unresectable disease 1.
Key Considerations
- Metal stents are preferred over plastic stents due to their wider diameter and lower likelihood of blockage, resulting in fewer complications and longer patency times 1.
- Endoscopic stent placement is the preferred procedure for unresectable patients, as it is associated with lower frequency of complications and shorter hospital stay compared to percutaneous insertion or surgical procedures 1.
- Palliative therapy should also include management of pain, with opioids such as morphine being the drug of choice, and consideration of hypofractionated radiotherapy or percutaneous celiacoplexus blockade for patients with severe pain 1.
Treatment Approach
- For patients with a life expectancy of >3 months, metal prostheses should be preferred due to their fewer complications and longer patency times 1.
- Percutaneous biliary drainage with subsequent internalization may be necessary if a biliary stent cannot be placed endoscopically 1.
- Open biliary-enteric bypass may be considered for patients with jaundice and potentially resectable disease who are found to have unresectable tumors after laparotomy 1.
From the Research
Management of Pancreatic Carcinoma with Biliary Obstruction and Liver Metastasis
The management of pancreatic carcinoma with biliary obstruction and liver metastasis involves a multidisciplinary approach to palliate symptoms and improve quality of life.
- The primary goal is to relieve obstructive jaundice, duodenal obstruction, and cancer-related pain 2.
- A multidisciplinary team consisting of representatives from surgery, medical oncology, gastroenterology, radiology, and palliative care medicine is essential for optimal palliation of symptoms 3.
- First-line therapy for malignant biliary obstruction consists of endoscopic biliary stent placement, with self-expanding metallic stents (SEMS) showing improved patency compared to plastic stents 4.
- For patients with advanced disease, the choice of metallic or plastic stent depends on life expectancy, and percutaneous or surgical treatments may be considered when endoscopic stent placement fails 4.
- Brachytherapy drainage catheter (BDC)-combined chemotherapy may be an effective treatment option for unresectable pancreatic carcinoma combined with obstructive jaundice, with improved stent patency and survival rates compared to conventional drainage catheter (CDC) intervention with chemotherapy 5.
- Nonoperative techniques such as biopsy and internal biliary drainage may be suitable for patients with metastatic disease and biliary obstruction, while bypass procedures may be considered for patients who undergo exploration and are found to be candidates 6.