Endoscopic palliation of pancreatic cancer

Abstract

Endoscopy has an increasingly important role in the palliation of patients with pancreatic ductal adenocarcinoma. Endoscopic biliary drainage is still requested in the majority of patients who present with obstructive jaundice, and the increased use of self-expandable metallic stents has reduced the incidence of premature stent occlusion. First-line use of metallic stents is expected to be utilized more frequently as neoadjuvant protocols are improved. The efficacy of endoscopy for palliating gastroduodenal obstruction has advanced with the development of through-the-scope, self-expandable gastroduodenal stents. There have been advances in pain management, with endoscopic ultrasound-guided celiac plexus neurolysis reducing opiate requirements and pain for patients with unresectable malignancy. Future applications of endoscopy in pancreatic cancer may include fine-needle injection of chemotherapeutic and other agents into the lesion itself. This review will summarize the evidence of endoscopy in the management of patients with pancreatic cancer.

Figure 1. Occlusion of a plastic bile duct stent

Due to their limited diameter, plastic stents may occlude after 2–3 months due to the development of a bacterial biofilm and precipitation of bile/sludge along the internal margin of the stent. For this reason, use of a 10Fr stent is preferred in the setting of malignant biliary obstruction when surgery is anticipated in the next three months.

Figure 2A–B. Distal bile duct obstruction: Deployment of a self-expandable metallic stent (SEMS)

Cholangiogram confirms a distal bile duct stricture (A). A self-expandable metallic stent (SEMS) is deployed (note contrast flow immediately following deployment), with the proximal margin of the stent > 2cm below the hepatic bifurcation (B). This permits safe creation of a choledochojejunostomy if surgery is performed at a later date.

Figure 3. Recommended algorithm for biliary drainage in patients with PDAC

PDAC = pancreatic ductal adenocarcinoma; SEMS = self-expandable metallic stents; PDAC ^†SEMS are currently approved by the FDA for use in patients who have an inoperable, malignant bile duct stricture. ^¥Surgical resection without preoperative biliary drainage is reasonable if the procedure can be arranged in a timely fashion and the patient has no significant symptoms related to biliary obstruction (e.g., cholangitis, pruritis refractory to medical therapy).

Figure 4A–E. Endoscopic deployment of a gastroduodenal stent

An obstructing malignant stricture is visualized in the duodenal sweep (A) and demarcated using fluoroscopy (B). A previous biliary metallic stent is only seen on fluoroscopy. A balloon catheter is used to advance a 0.035” stiff guidewire across the stricture, aided by a combination of endoscopy and fluoroscopy (C). The endoscope is withdrawn to the antrum, where the stent catheter is advanced over the guidewire and centered across the stricture (D). The stent is deployed by slowly withdrawing its sheath, allowing its proximal margin to flare in the antrum (E).Reproduced, permission pending, from Cote GA and Edmundowicz SA

Figure 5. EUS-guided celiac neurolysis

A 22 gauge needle is inserted into a celiac ganglion identified by endoscopic ultrasound. Factors associated with a better response include direct injection of celiac ganglia (when visualized) and absence of tumor invasion of the celiac plexus.