From the Guidelines
The next line of action for a patient with pancreatic carcinoma (CA) 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.
Key Considerations
- The preferred treatment for biliary obstruction in patients with pancreatic cancer is endoscopic placement of a permanent self-expanding stent in the bile duct, as it provides relief of jaundice and pruritus, normalization of bilirubin levels, and prevention of other adverse outcomes such as cholangitis and frequent hospitalizations 1.
- Metal stents are generally preferred over plastic stents due to their wider diameter and lower likelihood of blockage, resulting in longer patency times and reduced risk of recurrent biliary obstruction 1.
- The choice of stent depends on patient prognosis and the relative costs of metal stents and repeat endoscopic retrograde cholangiopancreatographies, with plastic stents considered for patients expected to survive less than 3 months 1.
- For patients with jaundice and potentially resectable disease who are found to have unresectable tumors after laparotomy, an open biliary-enteric bypass provides durable palliation of biliary obstruction and can be combined with procedures that palliate symptoms resulting from gastric outlet obstruction and cancer-related pain 1.
- Palliative therapy, including opioids for pain management and potentially hypofractionated radiotherapy, should also be considered for patients with advanced pancreatic adenocarcinoma characterized by biliary or gastric obstruction, severe abdominal pain, or other tumor-associated manifestations of the disease 1.
From the Research
Management of Pancreatic Carcinoma with Biliary Obstruction and Liver Metastasis
- The patient's condition requires a multidisciplinary approach, involving representatives from surgery, medical oncology, gastroenterology, radiology, and palliative care medicine 2, 3.
- The primary goal is to palliate debilitating symptoms, including obstructive jaundice, gastric outlet obstruction, cancer-related pain, pancreatic enzyme insufficiency, and thromboembolic disease 2.
- For patients with unresectable pancreatic cancer, palliative treatment is directed at relieving obstructive jaundice, duodenal obstruction, and cancer-related pain 3.
- Endoscopic biliary stent placement is the first-line therapy for malignant biliary obstruction, with self-expanding metallic stents (SEMS) showing improved patency compared to plastic stents 4, 5.
- The choice of stent depends on the patient's life expectancy, with metallic stents preferred for patients with longer life expectancy 4.
- In cases where endoscopic stent placement fails, percutaneous or surgical treatments may be necessary 4.
- Biliary events, such as obstruction and stent malfunction, can interfere with chemotherapy administration and impact survival in patients with advanced pancreatic ductal adenocarcinoma 6.
- Effective management of biliary events is crucial to ensure completion of planned chemotherapy and improve overall survival 6.