Skip to main content
SpringerLink
Log in

Palliative Endoscopic Therapy in Pancreatic Cancer

  • Chapter
  • First Online:
Textbook of Pancreatic Cancer

  • 2613 Accesses

Abstract

Endoscopic palliation in pancreatic cancer patients is an evolving topic due to the rising incidence and longer survival rates of patients diagnosed in a metastasized stadium. The expansive growth of malignant tumors of the pancreas causes secondary problems that often can be addressed via endoscopic procedures. The diagnostic value of ERCP imaging has been decreasing quickly, while interventional possibilities and procedures are evolving quickly. With increasing interventional possibilities, the right choice of intervention method, timing and sequence become more important to ensure maximal benefit with the least amount of interventional sessions and costs. In this article, palliative endoscopic interventions are discussed addressing biliary, pancreatic and luminal obstruction as well as EUS guided placement of therapeutic agents and their sequence and timing.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 129.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 199.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Change history

  • 26 September 2021

    Chapter 79 was inadvertently published with the following

References

  1. Ducreux M, Seufferlein T, Van Laethem JL, Laurent-Puig P, Smolenschi C, Malka D, et al. Systemic treatment of pancreatic cancer revisited. Semin Oncol. 2019;46(1):28–38.

    Article  CAS  PubMed  Google Scholar 

  2. Yachimski PS, Ross A. The future of endoscopic retrograde cholangiopancreatography. Gastroenterology. 2017;153(2):338–44.

    Article  PubMed  Google Scholar 

  3. Dumonceau JM, Tringali A, Papanikolaou IS, Blero D, Mangiavillano B, Schmidt A, et al. Endoscopic biliary stenting: indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline – updated October 2017. Endoscopy. 2018;50(9):910–30.

    Article  PubMed  Google Scholar 

  4. Glomsaker T, Hoff G, Kvaloy JT, Soreide K, Aabakken L, Soreide JA. Patterns and predictive factors of complications after endoscopic retrograde cholangiopancreatography. Br J Surg. 2013;100(3):373–80.

    Article  CAS  PubMed  Google Scholar 

  5. Cotton PB, Garrow DA, Gallagher J, Romagnuolo J. Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years. Gastrointest Endosc. 2009;70(1):80–8.

    Article  PubMed  Google Scholar 

  6. Eloubeidi MA, Decker GA, Chandrasekhara V, Chathadi KV, Early DS, Evans JA, et al. The role of endoscopy in the evaluation and management of patients with solid pancreatic neoplasia. Gastrointest Endosc. 2016;83(1):17–28.

    Article  PubMed  Google Scholar 

  7. Daroczi T, Bor R, Fabian A, Szabo E, Farkas K, Balint A, et al. Cost-effectiveness trial of self-expandable metal stents and plastic biliary stents in malignant biliary obstruction. Orv Hetil. 2016;157(7):268–74.

    PubMed  Google Scholar 

  8. Martinez JM, Anene A, Bentley TG, Cangelosi MJ, Meckley LM, Ortendahl JD, et al. Cost effectiveness of metal stents in relieving obstructive jaundice in patients with pancreatic cancer. J Gastrointest Cancer. 2017;48(1):58–65.

    Article  CAS  PubMed  Google Scholar 

  9. Springfeld C, Jager D, Buchler MW, Strobel O, Hackert T, Palmer DH, et al. Chemotherapy for pancreatic cancer. Presse Med. 2019;48(3 Pt 2):e159–74.

    Article  PubMed  Google Scholar 

  10. Kaassis M, Boyer J, Dumas R, Ponchon T, Coumaros D, Delcenserie R, et al. Plastic or metal stents for malignant stricture of the common bile duct? Results of a randomized prospective study. Gastrointest Endosc. 2003;57(2):178–82.

    Article  PubMed  Google Scholar 

  11. Wang AY. Is plastic stenting for pancreatic cancer still relevant or obsolete in 2015? Gastrointest Endosc. 2015;81(2):367–9.

    Article  PubMed  Google Scholar 

  12. Yoon WJ, Lee JK, Lee KH, Lee WJ, Ryu JK, Kim YT, et al. A comparison of covered and uncovered Wallstents for the management of distal malignant biliary obstruction. Gastrointest Endosc. 2006;63(7):996–1000.

    Article  PubMed  Google Scholar 

  13. Li J, Li T, Sun P, Yu Q, Wang K, Chang W, et al. Covered versus uncovered self-expandable metal stents for managing malignant distal biliary obstruction: a meta-analysis. PLoS One. 2016;11(2):e0149066.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Yang MJ, Kim JH, Yoo BM, Hwang JC, Yoo JH, Lee KS, et al. Partially covered versus uncovered self-expandable nitinol stents with anti-migration properties for the palliation of malignant distal biliary obstruction: a randomized controlled trial. Scand J Gastroenterol. 2015;50(12):1490–9.

    Article  PubMed  Google Scholar 

  15. Almadi MA, Barkun AN, Martel M. No benefit of covered vs uncovered self-expandable metal stents in patients with malignant distal biliary obstruction: a meta-analysis. Clin Gastroenterol Hepatol. 2013;11(1):27–37.

    Article  PubMed  Google Scholar 

  16. Sogabe Y, Kodama Y, Honjo H, Aoyama I, Muramoto Y, Koga E, et al. Tumor invasion to the arteries feeding the gallbladder as a novel risk factor for cholecystitis after metallic stent placement in distal malignant biliary obstruction. Dig Endosc. 2018;30(3):380–7.

    Article  PubMed  Google Scholar 

  17. Shimizu S, Naitoh I, Nakazawa T, Hayashi K, Miyabe K, Kondo H, et al. Predictive factors for pancreatitis and cholecystitis in endoscopic covered metal stenting for distal malignant biliary obstruction. J Gastroenterol Hepatol. 2013;28(1):68–72.

    Article  PubMed  Google Scholar 

  18. Wolfson D, Barkin JS, Chari ST, Clain JE, Bell RH Jr, Alexakis N, et al. Management of pancreatic masses. Pancreas. 2005;31(3):203–17.

    Article  PubMed  Google Scholar 

  19. Tan DM, Lillemoe KD, Fogel EL. A new technique for endoscopic removal of uncovered biliary self-expandable metal stents: stent-in-stent technique with a fully covered biliary stent. Gastrointest Endosc. 2012;75(4):923–5.

    Article  PubMed  Google Scholar 

  20. Bernon M, Kloppers C, Lindemann J, Krige JEJ, Jonas E. Recalcitrant embedded biliary self-expanding metal stents: a novel technique for endoscopic extraction. VideoGIE. 2019;4(2):72–5.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Vienne A, Hobeika E, Gouya H, Lapidus N, Fritsch J, Choury AD, et al. Prediction of drainage effectiveness during endoscopic stenting of malignant hilar strictures: the role of liver volume assessment. Gastrointest Endosc. 2010;72(4):728–35.

    Article  PubMed  Google Scholar 

  22. Bulajic M, Panic N, Radunovic M, Scepanovic R, Perunovic R, Stevanovic P, et al. Clinical outcome in patients with hilar malignant strictures type II Bismuth-Corlette treated by minimally invasive unilateral versus bilateral endoscopic biliary drainage. Hepatobiliary Pancreat Dis Int. 2012;11(2):209–14.

    Article  PubMed  Google Scholar 

  23. Moole H, Dharmapuri S, Duvvuri A, Dharmapuri S, Boddireddy R, Moole V, et al. Endoscopic versus percutaneous biliary drainage in palliation of advanced malignant hilar obstruction: a meta-analysis and systematic review. Can J Gastroenterol Hepatol. 2016;2016:4726078.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Choi JH, Lee SH, You MS, Shin BS, Choi YH, Kang J, et al. Step-wise endoscopic approach to palliative bilateral biliary drainage for unresectable advanced malignant hilar obstruction. Sci Rep. 2019;9(1):13207.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Ge PS, Hamerski CM, Watson RR, Komanduri S, Cinnor BB, Bidari K, et al. Plastic biliary stent patency in patients with locally advanced pancreatic adenocarcinoma receiving downstaging chemotherapy. Gastrointest Endosc. 2015;81(2):360–6.

    Article  PubMed  Google Scholar 

  26. Rathmayer M, Heinlein W, Reiss C, Albert JG, Akoglu B, Braun M, et al. Cost assessment for endoscopic procedures in the German diagnosis-related-group (DRG) system – 5 year cost data analysis of the German Society of Gastroenterology project. Z Gastroenterol. 2017;55(10):1038–51.

    PubMed  Google Scholar 

  27. Walter D, van Boeckel PG, Groenen MJ, Weusten BL, Witteman BJ, Tan G, et al. Cost efficacy of metal stents for palliation of extrahepatic bile duct obstruction in a randomized controlled trial. Gastroenterology. 2015;149(1):130–8.

    Article  PubMed  Google Scholar 

  28. Lamarca A, Rigby C, McNamara MG, Hubner RA, Valle JW. Impact of biliary stent-related events in patients diagnosed with advanced pancreatobiliary tumours receiving palliative chemotherapy. World J Gastroenterol. 2016;22(26):6065–75.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Wadsworth CA, Westaby D, Khan SA. Endoscopic radiofrequency ablation for cholangiocarcinoma. Curr Opin Gastroenterol. 2013;29(3):305–11.

    Article  PubMed  Google Scholar 

  30. Wang K, Zhu J, Xing L, Wang Y, Jin Z, Li Z. Assessment of efficacy and safety of EUS-guided biliary drainage: a systematic review. Gastrointest Endosc. 2016;83(6):1218–27.

    Article  PubMed  Google Scholar 

  31. Oh D, Park DH, Song TJ, Lee SS, Seo DW, Lee SK, et al. Optimal biliary access point and learning curve for endoscopic ultrasound-guided hepaticogastrostomy with transmural stenting. Ther Adv Gastroenterol. 2017;10(1):42–53.

    Article  Google Scholar 

  32. Poincloux L, Rouquette O, Buc E, Privat J, Pezet D, Dapoigny M, et al. Endoscopic ultrasound-guided biliary drainage after failed ERCP: cumulative experience of 101 procedures at a single center. Endoscopy. 2015;47(9):794–801.

    Article  PubMed  Google Scholar 

  33. Bishay K, Boyne D, Yaghoobi M, Khashab MA, Shorr R, Ichkhanian Y, et al. Endoscopic ultrasound-guided transmural approach versus ERCP-guided transpapillary approach for primary decompression of malignant biliary obstruction: a meta-analysis. Endoscopy. 2019;51(10):950–60.

    Article  PubMed  Google Scholar 

  34. Ardengh JC, Lopes CV, Kemp R, Dos Santos JS. Different options of endosonography-guided biliary drainage after endoscopic retrograde cholangio-pancreatography failure. World J Gastrointest Endosc. 2018;10(5):99–108.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Uemura S, Iwashita T, Iwata K, Mukai T, Osada S, Sekino T, et al. Endoscopic duodenal stent versus surgical gastrojejunostomy for gastric outlet obstruction in patients with advanced pancreatic cancer. Pancreatology. 2018; https://doi.org/10.1016/j.pan.2018.04.015.

  36. Stier MW, Waxman I. Lumen-apposing metal stents: which one and why? Gastrointest Endosc Clin N Am. 2018;28(2):207–17.

    Article  PubMed  Google Scholar 

  37. Ogura T, Higuchi K. Technical tips for endoscopic ultrasound-guided hepaticogastrostomy. World J Gastroenterol. 2016;22(15):3945–51.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Shah SL, Perez-Miranda M, Kahaleh M, Tyberg A. Updates in therapeutic endoscopic ultrasonography. J Clin Gastroenterol. 2018;52(9):765–72.

    Article  PubMed  Google Scholar 

  39. Cho DH, Lee SS, Oh D, Song TJ, Park DH, Seo DW, et al. Long-term outcomes of a newly developed hybrid metal stent for EUS-guided biliary drainage (with videos). Gastrointest Endosc. 2017;85(5):1067–75.

    Article  PubMed  Google Scholar 

  40. De Cassan C, Bories E, Pesenti C, Caillol F, Godat S, Ratone JP, et al. Use of partially covered and uncovered metallic prosthesis for endoscopic ultrasound-guided hepaticogastrostomy: results of a retrospective monocentric study. Endosc Ultrasound. 2017;6(5):329–35.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Park JK, Woo YS, Noh DH, Yang JI, Bae SY, Yun HS, et al. Efficacy of EUS-guided and ERCP-guided biliary drainage for malignant biliary obstruction: prospective randomized controlled study. Gastrointest Endosc. 2018;88(2):277–82.

    Article  PubMed  Google Scholar 

  42. Costamagna G, Gabbrielli A, Mutignani M, Perri V, Crucitti F. Treatment of “obstructive” pain by endoscopic drainage in patients with pancreatic head carcinoma. Gastrointest Endosc. 1993;39(6):774–7.

    Article  CAS  PubMed  Google Scholar 

  43. Tham TC, Lichtenstein DR, Vandervoort J, Wong RC, Slivka A, Banks PA, et al. Pancreatic duct stents for “obstructive type” pain in pancreatic malignancy. Am J Gastroenterol. 2000;95(4):956–60.

    CAS  PubMed  Google Scholar 

  44. Costamagna G, Mutignani M. Pancreatic stenting for malignant ductal obstruction. Dig Liver Dis. 2004;36(9):635–8.

    Article  CAS  PubMed  Google Scholar 

  45. Wehrmann T, Riphaus A, Frenz MB, Martchenko K, Stergiou N. Endoscopic pancreatic duct stenting for relief of pancreatic cancer pain. Eur J Gastroenterol Hepatol. 2005;17(12):1395–400.

    Article  PubMed  Google Scholar 

  46. Fasanella KE, Davis B, Lyons J, Chen Z, Lee KK, Slivka A, et al. Pain in chronic pancreatitis and pancreatic cancer. Gastroenterol Clin N Am. 2007;36(2):335–64. ix

    Article  Google Scholar 

  47. Ceyhan GO, Demir IE, Rauch U, Bergmann F, Muller MW, Buchler MW, et al. Pancreatic neuropathy results in “neural remodeling” and altered pancreatic innervation in chronic pancreatitis and pancreatic cancer. Am J Gastroenterol. 2009;104(10):2555–65.

    Article  PubMed  Google Scholar 

  48. Dawod E, Kahaleh M. Management of benign and malignant pancreatic duct strictures. Clin Endosc. 2018;51(2):156–60.

    Article  PubMed  Google Scholar 

  49. Kamata K, Takenaka M, Minaga K, Sakurai T, Watanabe T, Nishida N, et al. EUS-guided pancreatic duct drainage for repeat pancreatitis in a patient with pancreatic cancer. Oncology. 2017;93(Suppl 1):87–8.

    Article  PubMed  Google Scholar 

  50. Singh SM, Longmire WP Jr, Reber HA. Surgical palliation for pancreatic cancer. The UCLA experience. Ann Surg. 1990;212(2):132–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  51. Tsauo J, Yoo MW, Song HY, Hwang DW, Park JH, Ryu MH, et al. Partially-covered stent placement versus surgical gastrojejunostomy for the palliation of malignant gastroduodenal obstruction secondary to pancreatic cancer. Abdom Radiol (NY). 2016;41(11):2233–40.

    Article  Google Scholar 

  52. Yoshida Y, Fukutomi A, Tanaka M, Sugiura T, Kawata N, Kawai S, et al. Gastrojejunostomy versus duodenal stent placement for gastric outlet obstruction in patients with unresectable pancreatic cancer. Pancreatology. 2017;17(6):983–9.

    Article  PubMed  Google Scholar 

  53. Yamao K, Kitano M, Takenaka M, Minaga K, Sakurai T, Watanabe T, et al. Outcomes of endoscopic biliary drainage in pancreatic cancer patients with an indwelling gastroduodenal stent: a multicenter cohort study in West Japan. Gastrointest Endosc. 2018;88(1):66–75.

    Article  PubMed  Google Scholar 

  54. Staub J, Siddiqui A, Taylor LJ, Loren D, Kowalski T, Adler DG. ERCP performed through previously placed duodenal stents: a multicenter retrospective study of outcomes and adverse events. Gastrointest Endosc. 2018;87(6):1499–504.

    Article  PubMed  Google Scholar 

  55. Rimbas M, Larghi A, Costamagna G. Endoscopic ultrasound-guided gastroenterostomy: are we ready for prime time? Endosc Ultrasound. 2017;6(4):235–40.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Itoi T, Baron TH, Khashab MA, Tsuchiya T, Irani S, Dhir V, et al. Technical review of endoscopic ultrasonography-guided gastroenterostomy in 2017. Dig Endosc. 2017;29(4):495–502.

    Article  PubMed  Google Scholar 

  57. Perez-Miranda M, Tyberg A, Poletto D, Toscano E, Gaidhane M, Desai AP, et al. EUS-guided gastrojejunostomy versus laparoscopic gastrojejunostomy: an international collaborative study. J Clin Gastroenterol. 2017;51(10):896–9.

    Article  PubMed  Google Scholar 

  58. Khashab MA, Bukhari M, Baron TH, Nieto J, El Zein M, Chen YI, et al. International multicenter comparative trial of endoscopic ultrasonography-guided gastroenterostomy versus surgical gastrojejunostomy for the treatment of malignant gastric outlet obstruction. Endosc Int Open. 2017;5(4):E275–81.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Krafft MR, Hsueh W, James TW, Runge TM, Baron TH, Khashab MA, et al. The EDGI new take on EDGE: EUS-directed transgastric intervention (EDGI), other than ERCP, for Roux-en-Y gastric bypass anatomy: a multicenter study. Endosc Int Open. 2019;7(10):E1231–40.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Kedia P, Tyberg A, Kumta NA, Gaidhane M, Karia K, Sharaiha RZ, et al. EUS-directed transgastric ERCP for Roux-en-Y gastric bypass anatomy: a minimally invasive approach. Gastrointest Endosc. 2015;82(3):560–5.

    Article  PubMed  Google Scholar 

  61. Wang BC, Furnback W. Modelling the long-term outcomes of bariatric surgery: a review of cost-effectiveness studies. Best Pract Res Clin Gastroenterol. 2013;27(6):987–95.

    Article  PubMed  Google Scholar 

  62. Kedia P, Tarnasky PR, Nieto J, Steele SL, Siddiqui A, Xu MM, et al. EUS-directed transgastric ERCP (EDGE) versus laparoscopy-assisted ERCP (LA-ERCP) for Roux-en-Y gastric bypass (RYGB) anatomy: a multicenter early comparative experience of clinical outcomes. J Clin Gastroenterol. 2019;53(4):304–8.

    Article  PubMed  Google Scholar 

  63. Irani S, Yang J, Khashab MA. Mitigating lumen-apposing metal stent dislodgment and allowing safe, single-stage EUS-directed transgastric ERCP. VideoGIE. 2018;3(10):322–4.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Yasuda I, Wang HP. Endoscopic ultrasound-guided celiac plexus block and neurolysis. Dig Endosc. 2017;29(4):455–62.

    Article  PubMed  Google Scholar 

  65. Michaels AJ, Draganov PV. Endoscopic ultrasonography guided celiac plexus neurolysis and celiac plexus block in the management of pain due to pancreatic cancer and chronic pancreatitis. World J Gastroenterol. 2007;13(26):3575–80.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Bang JY, Sutton B, Hawes RH, Varadarajulu S. EUS-guided celiac ganglion radiofrequency ablation versus celiac plexus neurolysis for palliation of pain in pancreatic cancer: a randomized controlled trial (with videos). Gastrointest Endosc. 2019;89(1):58–66.

    Article  PubMed  Google Scholar 

  67. Han J, Chang KJ. Endoscopic ultrasound-guided direct intervention for solid pancreatic tumors. Clin Endosc. 2017;50(2):126–37.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Upper Abdominal Diseases, Karolinska University Hospital, Solna, Sweden

    Alexander Waldthaler, Wiktor Rutkowski & J.-Matthias Löhr

  2. Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden

    Alexander Waldthaler, Wiktor Rutkowski & J.-Matthias Löhr

Authors
  1. Alexander Waldthaler
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Wiktor Rutkowski
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. J.-Matthias Löhr
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Alexander Waldthaler .

Editor information

Editors and Affiliations

  1. Stavanger University Hospital, The University of Bergen, Bergen, Norway

    Kjetil Søreide

  2. Chirurgie (VTT), Innsbruck Medical University, Innsbruck, Tirol, Austria

    Stefan Stättner

Rights and permissions

Reprints and permissions

Copyright information

© 2021 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Waldthaler, A., Rutkowski, W., Löhr, JM. (2021). Palliative Endoscopic Therapy in Pancreatic Cancer. In: Søreide, K., Stättner, S. (eds) Textbook of Pancreatic Cancer. Springer, Cham. https://doi.org/10.1007/978-3-030-53786-9_79

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-53786-9_79

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-53785-2

  • Online ISBN: 978-3-030-53786-9

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation