Table of Contents  

Al-Kawas: Role of endoscopy in patients with pancreatic cancer

Introduction

Pancreatic cancer is an important cause of cancer mortality around the world and, unfortunately, the majority of patients have advanced disease by the time diagnosis. The role of endoscopy is both diagnostic and therapeutic. Imaging and endoscopic ultrasound (EUS) play an important role in the initial diagnosis and staging of pancreatic cancer. The role of endoscopic retrograde cholangiopancreatography (ERCP) is predominantly therapeutic/palliative. EUS-guided therapies are increasingly used, and in most individuals EUS evaluation precedes ERCP during the initial evaluation for suspected pancreas cancer.1,2 Increasingly effective chemotherapy is allowing patients with pancreas cancer to live longer, despite advanced disease. Endoscopic interventions are increasingly used in such patients to improve their quality of life.

Biliary drainage

Preoperative biliary drainage is indicated in patients with symptomatic jaundice, or evidence of cholangitis or when prompt surgery is not available or is delayed.1,2 In candidates with locally advanced disease who are candidates for neoadjuvant therapy, the use of self-expandable covered metal stents is preferable because of the lower risk of cholangitis and reduced need for stent exchange during therapy.

In non-resectable patients, the use of self-expandable stents is effective in providing biliary drainage for an average of 6 months.1,2 Covered stents are associated with less tumour ingrowth; however, stent migration is higher. Delayed stent clogging can be managed by placing a plastic stent or self-expandable metal stent depending on expected prognosis/survival. Limited data suggest that radiofrequency ablation (RFA) of malignant biliary stricture using intraductal RFA probes during ERCP is associated with increased stent patency duration and patient survival.

Pancreas duct drainage

In 5% of patients with unresectable pancreas cancer, pancreas-type pain resulting from pancreatic duct obstruction can be an issue. In such patients the placement of a plastic pancreas stent can help alleviate symptoms.

Gastric outlet obstruction

Malignant gastric outlet obstruction (MGOO) is seen in 10–20% of patients with pancreatic cancer. Both surgical gastrojejunostomy (GJ) and endoscopically placed self-expandable metal duodenal stents are effective in the management of MGOO.3 Oral intake is resumed earlier after endoscopic stent placement. However, surgical GJ is associated with longer benefit. Most available duodenal stents are uncovered and technical success is very high in expert centres. In most patients, oral intake is improved after stent placement, and stent migration and tumour ingrowth are the most common late complications. Choice of intervention depends on local expertise and predicted survival. Limited data suggest the feasibility of endoscopic GJ using magnets or EUS guidance. However, clinical applications of these techniques are currently limited.

Endoscopic ultrasound

The role of EUS in patient with pancreas cancer has progressively expanded from a purely diagnostic role to an increasingly interventional/therapeutic one1,2 and includes the following:

  1. EUS-guided biliary and pancreatic access allows access to the duct of interest with stent placement using EUS guidance when the ampulla cannot be reached or successful cannulation is not possible;

  2. coeliac block for pain control;

  3. fiducial marker or tattoo placement to help target radiation therapy or surgical resection.

Conclusions

Overall, endoscopic interventions are highly effective in the palliative management of patients with advanced pancreas cancer. Newer endoscopic options will become increasingly available in the future and will make it more effective and safer for patients to receive palliation.

References

1. 

Varadarjulu S, Bang JY. Role of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in the clinical assessment of pancreas neoplasms. Surg Oncol Clin N Am 2016; 25:255–72. http://dx.doi.org/10.1016/j.soc.2015.11.004

2. 

Rosenthal MH, Lee A, Jajoo K. Imaging and endoscopic approaches in pancreas cancer. Hematol Oncol Clin N Am 2015; 29:675–99. http://dx.doi.org/10.1016/j.hoc.2015.04.008

3. 

Jeurnink SM, Steyerberg EW, va Hooft JE, et al. Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignancy gastric outlet obstruction (SUSTENT study). A multicenter randomized trial. Gastrointest Endosc 2010; 71:490–9. http://dx.doi.org/10.1016/j.gie.2009.09.042




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