Endoscopic Palliation of Pancreatic Cancer

Abstract

In the past the diagnosis of carcinoma of the pancreas, particularly in the presence of jaundice, was often made at exploratory laparotomy and in most patients a biliary and/or gastric bypass would then be performed unless it was possible to perform a radical resection. With the advent of diagnostic endoscopic retrograde cholangiopancreatography (ERCP), ultrasound and CT, the surgeon can achieve a preoperative diagnosis and proceed to planned surgery. In the vast majority of cases this has still meant a surgical biliary bypass and even in the best centres this still carries a substantial 30-day mortality which in various publications has been reported between 5% and 25% (Feduska et al. 1971; Sarr and Cameron 1982). In an attempt to lower the operative mortality of bypass surgery, external transhepatic biliary drainage was performed to lower the serum bilirubin prior to surgery. Controlled trials have shown that there was no difference in the postoperative mortality after surgery whether or not the patients underwent preoperative percutaneous biliary drainage (Hatfield et al. 1982). Transhepatic techniques were developed to allow for internal biliary stenting via the percutaneous route as an alternative to surgery. Such techniques were not without complication and endoscopic endoprosthesis insertion for the palliation of malignant obstructive jaundice was shown to be less dangerous than stenting via the transhepatic route (Speer et al. 1987). Endoscopic stenting has now been widely accepted as the major non-operative technique to palliate obstructive jaundice secondary to carcinoma of the pancreas. It is still not certain whether a period of internal biliary drainage obtained by temporary endoscopic stenting prior to radical pancreatic resection will alter the results of such surgery.