What are the mechanical and non-mechanical obstructions caused by carcinoma (cancer) of the head of the pancreas?

From the Guidelines

Mechanical and non-mechanical obstructions caused by cancer of the head of the pancreas should be managed with a multidisciplinary approach, prioritizing endoscopic interventions, pain management, and supportive care to improve quality of life and potentially extend survival. For mechanical obstructions like bile duct blockage, endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is the first-line intervention to relieve jaundice and prevent cholangitis, as recommended by 1. Metal stents are preferred for patients with longer life expectancy, while plastic stents may be used for those with limited prognosis, according to 1. Some key points to consider in management include:

• Endoscopic duodenal stenting or surgical gastrojejunostomy may be necessary to restore gastrointestinal transit in cases of duodenal obstruction, as suggested by 1.
• Non-mechanical obstructions, such as delayed gastric emptying from tumor infiltration of the celiac plexus, can be managed with prokinetic agents like metoclopramide or domperidone.
• Pain management often requires a combination of approaches, including celiac plexus neurolysis for severe pain and opioid analgesics like morphine, as recommended by 1 and 1.
• Pancreatic enzyme insufficiency should be treated with pancreatic enzyme replacement therapy (PERT) to improve nutritional status and reduce symptoms.
• For potentially resectable tumors, surgical intervention with pancreaticoduodenectomy (Whipple procedure) may be considered, while chemotherapy regimens like FOLFIRINOX or gemcitabine plus nab-paclitaxel are standard for locally advanced or metastatic disease, as discussed in 1. The most recent and highest quality study, 1, emphasizes the importance of endoscopic interventions and supportive care in managing mechanical and non-mechanical obstructions caused by cancer of the head of the pancreas.

From the Research

Mechanical and Non-Mechanical Obstruction

Caused by CA head of pancreas can lead to various complications, including:

• Malignant biliary obstruction, which may cause debilitating symptoms and increase the risk of subsequent surgery 2
• Duodenal obstruction, which can occur in patients with pancreatic head adenocarcinoma who do not undergo surgical resection, but receive modern chemoradiation 3

Treatment Options

For patients with malignant biliary obstruction, treatment options include:

• Endoscopic biliary stent placement, with self-expanding metallic stents (SEMS) showing improved patency compared to plastic stents 2, 4
• Percutaneous or surgical treatments, which may be used when endoscopic stent placement fails 4
• New endoscopic techniques, such as photodynamic therapy and radiofrequency ablation, which may extend stent patency and patient survival 2

Management of Inoperable Pancreatic Cancer

For patients with inoperable pancreatic cancer, management goals include:

• Maintaining local control
• Managing tumor-related morbidities
• Improving quality of life 5
• Non-operative management, which may involve pancreaticobiliary physicians and endoscopists, is critical for patients who do not undergo surgical intervention 5