Current Surgical Aspects of Palliative Treatment for Unresectable Pancreatic Cancer

Abstract

Despite all improvements in both surgical and other conservative therapies, pancreatic cancer is steadily associated with a poor overall prognosis and remains a major cause of cancer mortality. Radical surgical resection has been established as the best chance these patients have for long-term survival. However, in most cases the disease has reached an incurable state at the time of diagnosis, mainly due to the silent clinical course at its early stages. The role of palliative surgery in locally advanced pancreatic cancer mainly involves patients who are found unresectable during open surgical exploration and consists of combined biliary and duodenal bypass procedures. Chemical splanchnicectomy is another modality that should also be applied intraoperatively with good results. There are no randomized controlled trials evaluating the outcomes of palliative pancreatic resection. Nevertheless, data from retrospective reports suggest that this practice, compared with bypass procedures, may lead to improved survival without increasing perioperative morbidity and mortality. All efforts at developing a more effective treatment for unresectable pancreatic cancer have been directed towards neoadjuvant and targeted therapies. The scenario of downstaging tumors in anticipation of a future oncological surgical resection has been advocated by trials combining gemcitabine with radiation therapy or with the tyrosine kinase inhibitor erlotinib, with promising early results.

National trends in pancreatic cancer outcomes and pattern of care among Medicare beneficiaries, 2000 through 2010

“…[6][7][8][9][10][11] The last decade has brought a multitude of changes that affect pancreatic cancer care, including increased use of abdominal imaging, a general shift toward outpatient oncology care, a renewed emphasis on end-of-life care, and increased scrutiny of the quality and cost-effectiveness of cancer care. [12][13][14][15][16] The effects of these changes on clinical and economic outcomes in pancreatic cancer remain largely unknown.…”

The Choice of Palliative Treatment for Biliary and Duodenal Obstruction in Patients With Unresectable Pancreatic Cancer: Is Surgery Bypass Better?

“…9 Relief of obstructive jaundice should always be a major therapeutic goal, because jaundice is harmful for the liver and other organs. Therefore, the best palliative treatment for obstructive jaundice should be simple, have less trauma, have a low mortality and recurrence rate, produce a better quality of life for patients, and offer a shorter time in the perioperative period of overall survival time.…”

Pain in pancreatic cancer: review of medical and surgical remedies

“…Its aetiology appears to be complex, including secondary to pancreatic duct blockage, increased parenchymal pressure and superimposed pancreatic inflammation in the area of the tumour. At the level of nociception, the most important mechanism here is, however, neuropathic pain associated with infiltration of the nerves by cancer cells, and the incidence of perineural invasion is estimated at 70–90% . It has been proven that pancreatic cancer shows neurotropism.…”

“…An important component of the therapy is therefore palliative treatment which covers the treatment of obstructive jaundice, mechanical obstruction, weight loss and pain. Already at the time of diagnosis, 40–80% of patients report pain as one of their main symptoms, while almost all of them will eventually at some stage of the disease suffer from moderate to severe pain, which is strongly associated with poorer quality of life, impaired functional activity and greater depression . Pain treatment methods in those patients are often insufficient, and analgesic effect does not persist long enough.…”