Palliative Management of Advanced Pancreatic Cancer: The Role of Gastroentero-hepatologist

Randy Adiwinata, Andrea Livina, Bradley Jimmy Waleleng, Nelly Tendean, Fandy Gosal, Luciana Rotty, Jeanne Winarta, Andrew Waleleng


Pancreatic cancer commonly diagnosed at late stage due to subtle clinical manifestation and associated with low 5-year survival rate. Only 10-20% of patients were found in resectable or localized stage. Several complications may arise due to advanced pancreatic cancer such as obstructive jaundice, gastric outlet obstruction, pancreatic cancer cachexia, pruritus of cholestasis, and cancer pain. Palliative management should be optimized in order to improve patient’s quality of life. A gastroentero-hepatologist should collaborate with other specialties to give comprehensive palliative care for advanced pancreatic cancer patients.


pancreatic cancer; metastases; palliative; obstructive jaundice


Bilici A. Prognostic factors related with survival in patients with pancreatic adenocarcinoma. World J Gastroenterol. 2014;20(31):10802-12.

McGuigan A, Kelly P, Turkington RC, Jones C, Coleman HG, McCain RS. Pancreatic cancer: A review of clinical diagnosis, epidemiology, treatment and outcomes. World J Gastroenterol. 2018;24(43):4846-61.

Rawla P, Sunkara T, Gaduputi V. Epidemiology of pancreatic cancer: Global trends, etiology and risk factors. World J Oncol. 2019;10(1):10-27.

Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394-424.

Ferlay J, Lam F, Colombet M, et al. Global cancer observatory: cancer today Lyon: International Agency for Research on Cancer; [cited 2020 January 30]. Available from:

Malik NK, May KS, Chandrasekhar R, et al. Treatment of locally advanced unresectable pancreatic cancer: a 10-year experience. J Gastrointest Oncol. 2012;3(4):326-34.

Rome RB, Luminais HH, Bourgeois DA, Blais CM. The role of palliative care at the end of life. Ochsner J. 2011;11(4):348-52.

Shen Z, Tian L, Wang X. Treatment of pancreatic head cancer with obstructive jaundice by endoscopy ultrasonography-guided gastrojejunostomy: A case report and literature review. Medicine (Baltimore). 2018;97(28):e11476.

Boulay BR, Birg A. Malignant biliary obstruction: From palliation to treatment. World J Gastrointest Oncol. 2016;8(6):498-508.

Pu LZ, Singh R, Loong CK, de Moura EG. Malignant biliary obstruction: Evidence for best practice. Gastroenterol Res Pract. 2016;2016:3296801.

Domínguez-Muñoz JE, Lariño-Noia J, Iglesias-Garcia J. Biliary drainage in pancreatic cancer: The endoscopic retrograde cholangiopancreatography perspective. Endosc Ultrasound. 2017;6(Suppl 3):S119-s21.

Dumonceau JM, Tringali A, Papanikolaou IS, et al. Endoscopic biliary stenting: indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline - Updated October 2017. Endoscopy. 2018;50(9):910-30.

Dumonceau JM, Andriulli A, Elmunzer BJ, et al. Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - updated June 2014. Endoscopy. 2014;46(9):799-815.

Lean LL, Samuel M, Koh CJ, Ibrahim I, See KC. Endoscopic versus surgical palliation for malignant distal bile duct obstruction. Cochrane Database Syst Rev. 2017;2017(8):CD012758.

Nam HS, Kang DH. Current status of biliary metal stents. Clin Endosc. 2016;49(2):124-30.

Kwon CI, Lehman GA. Mechanisms of biliary plastic stent occlusion and efforts at prevention. Clin Endosc. 2016;49(2):139-46.

Almadi MA, Barkun A, Martel M. Plastic vs. Self-expandable metal stents for palliation in malignant biliary obstruction: A series of meta-analyses. Am J Gastroenterol. 2017;112(2):260-73.

Tringali A, Hassan C, Rota M, Rossi M, Mutignani M, Aabakken L. Covered vs. uncovered self-expandable metal stents for malignant distal biliary strictures: a systematic review and meta-analysis. Endoscopy. 2018;50(6):631-41.

Fernandez YVM, Arvanitakis M. Early diagnosis And management of malignant distal biliary obstruction: A review on current recommendations and guidelines. Clin Exp Gastroenterol. 2019;12:415-32.

Hatamaru K, Kitano M. EUS-guided biliary drainage for difficult cannulation. Endosc Ultrasound. 2019;8(Suppl 1):S67-s71.

Bapaye A, Dubale N, Aher A. Comparison of endosonography-guided vs. percutaneous biliary stenting when papilla is inaccessible for ERCP. United European Gastroenterol J. 2013;1(4):285-93.

Duan F, Cui L, Bai Y, Li X, Yan J, Liu X. Comparison of efficacy and complications of endoscopic and percutaneous biliary drainage in malignant obstructive jaundice: a systematic review and meta-analysis. Cancer Imaging. 2017;17(1):27.

Li DF, Zhou CH, Wang LS, Yao J, Zou DW. Is ERCP-BD or EUS-BD the preferred decompression modality for malignant distal biliary obstruction? A meta-analysis of randomized controlled trials. Rev Esp Enferm Dig. 2019;111(12):953-60.

Han SY, Kim S-O, So H, Shin E, Kim DU, Park DH. EUS-guided biliary drainage versus ERCP for first-line palliation of malignant distal biliary obstruction: A systematic review and meta-analysis. Scientific Reports. 2019;9(1):16551.

Leung Ki EL, Napoleon B. Endoscopic ultrasound-guided biliary drainage: A change in paradigm? World J Gastrointest Endosc. 2019;11(5):345-53.

McGrath C, Tsang A, Nithianandan H, Nguyen E, Bauer P, Dennis K. Malignant Gastric Outlet Obstruction from Pancreatic Cancer. Case Rep Gastroenterol. 2017;11(3):511-5.

Miyazaki Y, Takiguchi S, Takahashi T, et al. Treatment of gastric outlet obstruction that results from unresectable gastric cancer: Current evidence. World J Gastrointest Endosc. 2016;8(3):165-72.

Tringali A, Giannetti A, Adler DG. Endoscopic management of gastric outlet obstruction disease. Ann Gastroenterol. 2019;32(4):330-7.

Uemura S, Iwashita T, Iwata K, et al. Endoscopic duodenal stent versus surgical gastrojejunostomy for gastric outlet obstruction in patients with advanced pancreatic cancer. Pancreatology. 2018.

Mussetto A, Fugazza A, Fuccio L, Triossi O, Repici A, Anderloni A. Current uses and outcomes of lumen-apposing metal stents. Ann Gastroenterol. 2018;31(5):535-40.

Wang G, Liu X, Wang S, Ge N, Guo J, Sun S. Endoscopic ultrasound-guided gastroenterostomy: A promising alternative to surgery. J Transl Int Med. 2019;7(3):93-9.

Kerdsirichairat T, Irani S, Yang J, et al. Durability and long-term outcomes of direct EUS-guided gastroenterostomy using lumen-apposing metal stents for gastric outlet obstruction. Endosc Int Open. 2019;7(2):E144-e50.

Mueller TC, Burmeister MA, Bachmann J, Martignoni ME. Cachexia and pancreatic cancer: are there treatment options? World J Gastroenterol. 2014;20(28):9361-73.

Hackert T, Schütte K, Malfertheiner P. The pancreas: Causes for malabsorption. Viszeralmedizin. 2014;30(3):190-7.

Gilliland TM, Villafane-Ferriol N, Shah KP, et al. Nutritional and metabolic derangements in pancreatic cancer and pancreatic resection. Nutrients. 2017;9(3).

Tan CR, Yaffee PM, Jamil LH, et al. Pancreatic cancer cachexia: a review of mechanisms and therapeutics. Front Physiol. 2014;5:88.

Mitchell T, Clarke L, Goldberg A, Bishop KS. Pancreatic cancer cachexia: The role of nutritional interventions. Healthcare (Basel). 2019;7(3).

Nitta H, Baba H, Sugimori K, et al. Chemotherapy-induced nausea and vomiting in patients with hepatobiliary and pancreatic cancer treated with chemotherapy: A prospective observational study by the CINV study group of Japan. Anticancer Res. 2016;36(4):1929-35.

Jin XY, Khan TM. Quality of life among patients suffering from cholestatic liver disease-induced pruritus: A systematic review. J Formos Med Assoc. 2016;115(9):689-702.

European Association for the Study of the Liver. EASL Clinical practice guidelines: management of cholestatic liver diseases. J Hepatol. 2009;51(2):237-67.

Beuers U, Kremer AE, Bolier R, Elferink RP. Pruritus in cholestasis: facts and fiction. Hepatology. 2014;60(1):399-407.

Lindor KD, Gershwin ME, Poupon R, Kaplan M, Bergasa NV, Heathcote EJ. Primary biliary cirrhosis. Hepatology. 2009;50(1):291-308.

Scarborough BM, Smith CB. Optimal pain management for patients with cancer in the modern era. CA Cancer J Clin. 2018;68(3):182-96.

Lahoud MJ, Kourie HR, Antoun J, El Osta L, Ghosn M. Road map for pain management in pancreatic cancer: A review. World J Gastrointest Oncol. 2016;8(8):599-606.

Fallon M, Giusti R, Aielli F, et al. Management of cancer pain in adult patients: ESMO Clinical Practice Guidelines. Ann Oncol. 2018;29(Suppl 4):iv166-iv91.

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