Palliation of jaundice in pancreatic cancer: stent or surgery?

Abstract

Pancreatic cancer still remains a lethal disease, and a large proportion of patients present for treatment at an advanced stage. Surgical resection is still the best hope for cure, but is only possible in localized disease. Locally advanced tumors may benefit from en bloc resection of the superior mesenteric vein or adjacent portal vein, and neoadjuvant chemoradiation may help to render some advanced tumors resectable. For the majority of other locally advanced or disseminated pancreatic head cancers, palliation is the only realistic option. Patients may suffer from obstructive jaundice, with or without cholangitis, and disabling pruritus, from vomiting due to obstruction to the gastric outlet, and other symptoms such as anorexia or abdominal pain. What is the optimal approach to palliating patients with obstructive jaundice due to pancreatic cancer? Patients may be classified into two groups: those with obviously unresectable or metastatic disease on preoperative evaluation or with severe comorbid illness which precludes operation or renders it at high risk; and those where preoperative imaging indicates a possibly resectable pancreatic tumor. In patients where evaluation has established that the tumors or patients are unsuitable for surgical resection, the decision to employ nonsurgical palliation is more straightforward. Expandable metallic stent insertion provides effective palliation of jaundice, duodenal stents may be used for gastric outlet obstruction (although these may be difficult to place when the obstruction extends to the third part of the duodenum), and endoscopic ultrasound-guided or percutaneous celiac plexus neurolysis may be employed for relief of intractable pain. In this issue of the Journal, Nikfarjam et al. [1] have compared the outcomes following stent insertion vs. surgical bypass. The “majority” of their patients who underwent surgical bypass were candidates for curative resection which were found to be unresectable on the operation table. Stents were used in older patients and those with poor performance status and deeper jaundice. Overall, survival figures were comparable, though stent insertion was followed by a significantly larger number of reinterventions, and 13 % required subsequent surgical intervention. Forty-one percent of metallic stents blocked over a median follow up of 224 days. The paper highlights a number of interesting observations: (a) patients who underwent stenting were less likely to undergo palliative chemotherapy—presumably their general condition was too poor to allow the use of chemotherapy; (b) the majority of stent blockage could be treated by restenting, and the chief area of failure was the development of duodenal obstruction; and (c) the only factor affecting survival was the presence of metastatic disease. Patients without meta