Palliative surgery in advanced pancreatic cancer

In patients with pancreatic cancer, a high percentage is not eligible for curative treatment, and therefore palliative care is indicated. Malignant obstructive jaundice, severe pain, and gastric outlet obstruction (GOO) contribute a major compromise to patients' quality of life. To manage these symptoms, different strategies of treatment, either surgical or interventional, are available. Obstructive jaundice can either be treated by hepatico-/choledochojejunostomy or by interventional placement of a biliary stent. Patency of surgical bypasses by hepaticojejunostomy is longer, when compared to interventionally placed biliary stents. However, self-expandable metal stents (SEMS) display better patency rates, expanding the spectrum of biliary stenting also on patients with longer life expectancy. GOO significantly contributes to decreased quality of life (QOL). Patients with an unresectable pancreatic cancer at exploration should receive a gastrojejunostomy. Surgical palliation for GOO should be considered due to superiority to interventional duodenal stenting if life expectancy is longer than 2 months. Pain can sufficiently be treated with neurolytic interventions. Splanchnicectomy provides more sufficient pain relief than neurolysis of the celiac plexus. Prior to neurolytic interventions, a sufficient pharmacological analgesic treatment should be undertaken, and neurolysis should be performed early during workup if irresectability is evident. In light of potent neoadjuvant treatment regimens, today's resection polices are getting more aggressive, and exploration should be performed whenever possible. If irresectability is evident during operation, R2 resections should be avoided due to increased postoperative complications and no survival benefit. In these situations, a double bypass surgery is always a better option.