Therapeutic Endoscopy in the Management of Pancreatic Cancer

Living reference work entry


Endoscopic retrograde cholangiopancreatography (ERCP) is a safe and reliable method for the diagnosis, treatment, and palliation of pancreaticobiliary malignancy. In 2015, the estimated new cases of pancreatic cancer were about 48,960. The 5-year survival of pancreatic cancer is dismal at approximately 5% Siegel et al. (CA: Cancer J Clin 65(1):5–29, 2015). ERCP provides less invasive approaches to diagnosis with examination of the biliary and pancreatic ducts. The procedure also allows for therapeutic relief of biliary obstruction. Advanced endoscopic techniques offer palliation of symptoms related to advanced pancreatic cancer and improvement in quality of life. This chapter addresses the use of therapeutic endoscopy in the diagnosis and management of pancreatic adenocarcinoma.


ERCP FISH Cholangioscopy Intraductal stricture biopsy Self-expandable metal stent Fiducial Celiac plexus neurolysis 


  1. 1.
    Eloubeidi MA, et al. The role of endoscopy in the evaluation and management of patients with solid pancreatic neoplasia. Gastrointest Endosc. 2016;83(1):17–28.CrossRefPubMedGoogle Scholar
  2. 2.
    Kalady MF, et al. Pancreatic duct strictures: identifying risk of malignancy. Ann Surg Oncol. 2004;11(6):581–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Hartmann D, et al. ERCP and MRCP in the differentiation of pancreatic tumors. Dig Dis. 2004;22(1):18–25.CrossRefPubMedGoogle Scholar
  4. 4.
    Andersson R, Vagianos CE, Williamson RCN. Preoperative staging and evaluation of resectability in pancreatic ductal adenocarcinoma. HPB. 2004;6(1):5–12.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Shah SA, Movson J, Ransil BJ, Waxman I. Pancreatic duct stricture length at ERCP predicts tumor size and pathological stage of pancreatic cancer. Am J Gastroenterol. 1997;92(6):964–7.PubMedGoogle Scholar
  6. 6.
    Asbun HJ, et al. When to perform a pancreatoduodenectomy in the absence of positive histology? A consensus statement by the International Study Group of Pancreatic Surgery. Surgery. 2014;155(5):887–92.CrossRefPubMedGoogle Scholar
  7. 7.
    Kim YS, et al. The significance of p53 and K-ras immunocytochemical staining in the diagnosis of malignant biliary obstruction by Brush Cytology during ERCP. Gut Liver. 2010;4(2):219–25.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Wight CO, et al. Improving diagnostic yield of biliary brushings cytology for pancreatic cancer and cholangiocarcinoma. Cytopathology. 2004;15(2):87–92.CrossRefPubMedGoogle Scholar
  9. 9.
    Kipp BR, et al. A comparison of routine cytology and fluorescence in situ hybridization for the detection of malignant bile duct strictures. Am J Gastroenterol. 2004;99(9):1675–81.CrossRefPubMedGoogle Scholar
  10. 10.
    Gonda TA, et al. Polysomy and p16 deletion by fluorescence in situ hybridization in the diagnosis of indeterminate biliary strictures. Gastrointest Endosc. 2012;75(1):74–9.CrossRefPubMedGoogle Scholar
  11. 11.
    Naitoh I, et al. Predictive factors for positive diagnosis of malignant biliary strictures by transpapillary brush cytology and forceps biopsy. J Dig Dis. 2016;17(1):44–51.CrossRefPubMedGoogle Scholar
  12. 12.
    Navaneethan U, et al. Comparative effectiveness of biliary brush cytology and intraductal biopsy for detection of malignant biliary strictures: a systematic review and meta-analysis. Gastrointest Endosc. 2015;81(1):168–76.CrossRefPubMedGoogle Scholar
  13. 13.
    Yang J, et al. K-ras mutational status in cytohistological tissue as a molecular marker for the diagnosis of pancreatic cancer: a systematic review and meta-analysis. Dis Markers. 2014;2014:573783.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Mikata R, et al. Clinical usefulness of repeated pancreatic juice cytology via endoscopic naso-pancreatic drainage tube in patients with pancreatic cancer. J Gastroenterol. 2013;48(7):866–73.CrossRefPubMedGoogle Scholar
  15. 15.
    Tada M, et al. Analysis of K-ras gene mutation in hyperplastic duct cells of the pancreas without pancreatic disease. Gastroenterology. 1996;110(1):227–31.CrossRefPubMedGoogle Scholar
  16. 16.
    Gress TM. Molecular diagnosis of pancreatobiliary malignancies in brush cytologies of biliary strictures. Gut. 2004;53(12):1727–9.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Fukuda Y, et al. Diagnostic utility of peroral cholangioscopy for various bile-duct lesions. Gastrointest Endosc. 2005;62(3):374–82.CrossRefPubMedGoogle Scholar
  18. 18.
    Chen YK, et al. Single-operator cholangioscopy in patients requiring evaluation of bile duct disease or therapy of biliary stones (with videos). Gastrointest Endosc. 2011;74(4):805–14.CrossRefPubMedGoogle Scholar
  19. 19.
    Parsi MA, et al. Diagnostic and therapeutic cholangiopancreatoscopy: performance of a new digital cholangioscope. Gastrointest Endosc. 2014;79(6):936–42.CrossRefPubMedGoogle Scholar
  20. 20.
    Kurihara T, et al. Diagnostic and therapeutic single-operator cholangiopancreatoscopy in biliopancreatic diseases: prospective multicenter study in Japan. World J Gastroenterol. 2016;22(5):1891–901.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Smith AC, et al. Randomised trial of endoscopic steriting versus surgical bypass in malignant low bile duct obstruction. Lancet. 1994;344(8938):1655–60.CrossRefPubMedGoogle Scholar
  22. 22.
    Abraham NS, Barkun JS, Barkun AN. Palliation of malignant biliary obstruction: a prospective trial examining impact on quality of life. Gastrointest Endosc. 2002;56(6):835–41.CrossRefPubMedGoogle Scholar
  23. 23.
    Ballinger AB, et al. Symptom relief and quality of life after stenting for malignant bile duct obstruction. Gut. 1994;35(4):467–70.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Pfau PR, et al. Pancreatic and biliary stents. Gastrointest Endosc. 2013;77(3):319–27.CrossRefPubMedGoogle Scholar
  25. 25.
    Boulay BR, Parepally M. Managing malignant biliary obstruction in pancreas cancer: choosing the appropriate strategy. World J Gastroenterol. 2014;20(28):9345–53.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Kullman E, et al. Covered versus uncovered self-expandable nitinol stents in the palliative treatment of malignant distal biliary obstruction: results from a randomized, multicenter study. Gastrointest Endosc. 2010;72(5):915–23.CrossRefPubMedGoogle Scholar
  27. 27.
    Isayama H, et al. Cholecystitis after metallic stent placement in patients with malignant distal biliary obstruction. Clin Gastroenterol Hepatol. 2006;4(9):1148–53.CrossRefPubMedGoogle Scholar
  28. 28.
    Maire F, et al. Long-term outcome of biliary and duodenal stents in palliative treatment of patients with unresectable adenocarcinoma of the head of pancreas. Am J Gastroenterol. 2006;101(4):735–42.CrossRefPubMedGoogle Scholar
  29. 29.
    Soderlund C, Linder S. Covered metal versus plastic stents for malignant common bile duct stenosis: a prospective, randomized, controlled trial. Gastrointest Endosc. 2006;63(7):986–95.CrossRefPubMedGoogle Scholar
  30. 30.
    Cavell LK, et al. Biliary self-expandable metal stents do not adversely affect pancreaticoduodenectomy. Am J Gastroenterol. 2013;108(7):1168–73.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Sasahira N, et al. Multicenter study of endoscopic preoperative biliary drainage for malignant distal biliary obstruction. World J Gastroenterol. 2016;22(14):3793–802.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Fang Y, et al. Pre-operative biliary drainage for obstructive jaundice. Cochrane Database Syst Rev. 2012;9:CD005444.PubMedCentralGoogle Scholar
  33. 33.
    Gavazzi F, et al. Role of preoperative biliary stents, bile contamination and antibiotic prophylaxis in surgical site infections after pancreaticoduodenectomy. BMC Gastroenterol. 2016;16:43.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Aadam AA, et al. Efficacy and safety of self-expandable metal stents for biliary decompression in patients receiving neoadjuvant therapy for pancreatic cancer: a prospective study. Gastrointest Endosc. 2012;76(1):67–75.CrossRefPubMedGoogle Scholar
  35. 35.
    Fathi A, et al. Neoadjuvant therapy for localized pancreatic cancer: guiding principles. J Gastrointest Oncol. 2015;6(4):418–29.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Sanders MK, et al. EUS-guided fiducial placement for stereotactic body radiotherapy in locally advanced and recurrent pancreatic cancer. Gastrointest Endosc. 2010;71(7):1178–84.CrossRefPubMedGoogle Scholar
  37. 37.
    Chavalitdhamrong D, et al. Technical advances in endoscopic ultrasound-guided fiducial placement for the treatment of pancreatic cancer. Endosc Int Open. 2015;3(4):E373–7.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Stark A, Hines OJ. Endoscopic and operative palliation strategies for pancreatic ductal adenocarcinoma. Semin Oncol. 2015;42(1):163–76.CrossRefPubMedGoogle Scholar
  39. 39.
    Maetani I. Self-expandable metallic stent placement for palliation in gastric outlet obstruction. Ann Palliat Med. 2014;3(2):54–64.PubMedGoogle Scholar
  40. 40.
    Sasaki R, et al. Endoscopic management of unresectable malignant gastroduodenal obstruction with a nitinol uncovered metal stent: a prospective Japanese multicenter study. World J Gastroenterol. 2016;22(14):3837–44.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Mehta S, et al. Prospective randomized trial of laparoscopic gastrojejunostomy versus duodenal stenting for malignant gastric outflow obstruction. Surg Endosc Int Tech. 2006;20(2):239–42.CrossRefGoogle Scholar
  42. 42.
    Puli SR, et al. EUS-guided celiac plexus neurolysis for pain due to chronic pancreatitis or pancreatic cancer pain: a meta-analysis and systematic review. Dig Dis Sci. 2009;54(11):2330–7.CrossRefPubMedGoogle Scholar
  43. 43.
    Alvarez-Sánchez MV, et al. Interventional endoscopic ultrasonography: an overview of safety and complications. Surg Endosc. 2014;28(3):712–34.CrossRefPubMedGoogle Scholar
  44. 44.
    Costamagna G, et al. Treatment of “obstructive” pain by endoscopic drainage in patients with pancreatic head carcinoma. Gastrointest Endosc. 1993;39(6):774–7.CrossRefPubMedGoogle Scholar
  45. 45.
    Wehrmann T, et al. Endoscopic pancreatic duct stenting for relief of pancreatic cancer pain. Eur J Gastroenterol Hepatol. 2005;17(12):1395–400.CrossRefPubMedGoogle Scholar
  46. 46.
    Sanders M, et al. Endoscopic palliation of pancreatic cancer. Gastroenterol Clin North Am. 2007;36(2):455–76.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media LLC 2016

Authors and Affiliations

  1. 1.Division of GastroenterologyDuke University Medical CenterDurhamUSA

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