Palliation of pain and jaundice: an overview

Between 70 and 90 percent of patients with pancreatic cancer will present with jaundice, and 90% will have pain at some stage of their illness. Resection for cure is possible in less than 5% of patients, thus a palliative approach is of necessity the appropriate management in 95% of patients. A palliative approach demands an attitude of mind which objectively defines relief of symptoms as the end point of treatment. Regional surveys show clearly that the care offered to the pancreatic cancer patient is poor with a high mortality (18%) for both resection and palliative bypass. The evidence that symptoms are managed well is unclear. The approach to pancreatic pain should follow the stepwise progression advocated by the World Health Organisation with a progression from minor to major analgesics and due attention to control of associated symptoms and mood. Surgery for pain relief is limited to thoracoscopic splanchnicectomy--a technique yet to be fully evaluated or a peroperative coeliac plexus block, which appears to be an important part of palliative surgery. Alternative approaches, such as chemotherapy and radiotherapy have been less well evaluated in terms of symptom control. The relief of jaundice may provide dramatic but short-lived remission in the patients' well-being--it is a mandatory part of palliation but must be undertaken with minimal disruption to the patients' life. For the majority, an endoscopic stent achieves this goal, but for the minority with a resectable or possibly resectable tumour a surgical bypass is preferable enabling a biliary and gastric bypass and a coeliac plexus block to be performed during the procedure.