From the Guidelines
Pancreatic head cancer can cause both mechanical and non-mechanical obstructions, and management typically involves a multidisciplinary approach with surgical intervention, biliary stenting, pancreatic enzyme replacement therapy, and diabetes management as needed. Mechanical obstructions occur when the tumor physically blocks anatomical structures, including:
- Bile duct obstruction leading to jaundice, which can be managed with endoscopic stent placement, as it is associated with lower frequency of complications than percutaneous insertion and has a shorter hospital stay 1
- Duodenal obstruction causing gastric outlet syndrome
- Pancreatic duct obstruction resulting in pancreatitis Non-mechanical obstructions involve functional impairments without direct blockage, such as:
- Pancreatic exocrine insufficiency due to reduced enzyme production
- Endocrine dysfunction causing diabetes
- Vascular compromise affecting blood flow to surrounding organs
- Neural invasion leading to pain and motility disorders Pain control often requires a combination of analgesics, including opioids and adjuvant medications like gabapentin, with morphine being the drug of choice, and parenteral routes of administration considered for patients with impaired swallowing or gastrointestinal obstruction 1. The choice of stent depends on patient prognosis, with metal stents preferred for patients with a life expectancy of >3 months, as they present fewer complications than plastic endoprostheses 1. Early nutritional support is essential, as these obstructions can significantly impact digestion and nutrient absorption, potentially accelerating cancer cachexia, and routine parenteral nutrition is not recommended in non-surgical well-nourished oncologic patients, but may be required in patients with acute gastrointestinal complications or radiation enteropathy 1. Some key points to consider in management include:
- Endoscopic stenting is the preferred procedure for unresectable patients with jaundice
- Metal prostheses should be preferred for patients with a life expectancy of >3 months
- Pancreatic enzyme replacement therapy should be started with a typical dose of 25,000-40,000 units of lipase per meal
- Diabetes management should be individualized, with insulin or oral hypoglycemics as needed
- Pain control should be prioritized, with a combination of analgesics and adjuvant medications as needed.
From the Research
Mechanical Obstruction Causes by CA Head of Pancreas
- Mechanical obstruction of the bile duct is a common complication of pancreatic cancer, particularly when the tumor is located in the head of the pancreas 2, 3, 4, 5, 6
- The obstruction can cause jaundice, pruritis, and malaise, and can lead to poor general conditions and acute cholangitis 4, 5
- Endoscopic retrograde cholangiopancreatography (ERCP)-guided interventions, such as pancreatobiliary decompression, can play a crucial role in the management of pancreatic cancer 4
- Self-expanding metal stents (SEMSs) are commonly used for biliary drainage in unresectable tumors, and are classified into uncovered and covered SEMSs 5
Non-Mechanical Obstruction Causes by CA Head of Pancreas
- Non-mechanical obstruction of the bile duct can also occur in pancreatic cancer, due to tumor infiltration or compression of the bile duct 3
- Preoperative biliary drainage (PBD) has been developed to improve surgical outcomes in patients with resectable pancreatic cancer, but its role is being reassessed due to potential adverse events 6
- Current indications for PBD include cholangitis, delayed surgery, and relief of jaundice in patients planned to receive neoadjuvant therapy (NAT) 6
- Endoscopic ultrasound-assisted biliary drainage is a viable option for PBD, and self-expanding metal stents have been shown to be cost-effective in this setting 6