[Surgical options in the palliative treatment of pancreatic cancer]

Pancreatic carcinoma is an aggressive disease and its prognosis is dismal. Patients present with an advanced stage of disease and only a small number of patients undergo resection with a curative intent; thus the 5 years survival rate is very low. Several improvements have been made in the surgical approach with a decrease in perioperative morbidity and mortality. Results offered by chemotherapy and radiotherapy remain unsatisfactory despite a number of new drugs and considerable advancements in irradiation techniques. Jaundice, pain and gastrointestinal obstruction are the main clinical problems to be dealt with in advanced patients. Surgical palliation still represents a widely preferred option but non surgical approaches appear promising. The Authors analyse the possible options in palliation for pancreatic carcinoma. The various surgical procedures for biliary by-pass are described. Hepaticojejunostomy is the operation of choice and offers the best results in terms of quality of life and time of palliation. A possible role for resective operation also in advanced cases has been proposed by some groups and is gaining wide acceptance in referral centres where low morbidity and mortality are now routine. Percutaneous and endoscopic approaches to jaundice represent a valid alternative in some patients with a low life expectancy and in those centres with a high experience. Gastrointestinal by-pass in symptom-free patients or advanced cases only is an unsolved dilemma. New approaches such as locoregional chemotherapy with curative or neoadjuvant intent are also described in this paper. Many chemotherapic agents have been tested in various settings and appear to offer promising results in palliation and also, in some cases, in downstaging tumors then amenable to resection. Pain control is a major aspect in management of advanced pancreatic carcinoma. Appropriate pain therapy has to be established in all patients in order to obtain a better quality of life. Various options are available such as intraoperative alcohol injection or CT guided percutaneous splanchnicectomy. Palliation in patients with pancreatic carcinoma is a major aspect of management because of the high percentage of non curable cases; multimodality approach is mandatory and all possible problems have to be dealt with in order to increase survival and, more importantly, quality of life.