Unfortunately, only a minority of patients with AC of the pancreas are suitable for resection and potential cure at presentation. Optimal palliation of symptoms to maximize remaining quality of life is of primary importance to most patients. Nonoperative palliation is generally readily available in most centers. The three main components of palliation of unresectable periampullary ACs include (1) drainage of the biliary tree, (2) relief of gastric outlet obstruction, and (3) pain control. The biliary tree may be drained internally or externally with endoprostheses, as well as metallic wall stents that can be inserted endoscopically or percutaneously. Some patients require percutaneous access to the biliary tree and may be best palliated via a percutaneous transhepatic drain that can be externalized when obstructed. There is a chapter on biliary tract endoscopy (see Chapter 134, "Endoscopic Management of Bile Duct Obstruction and Sphincter of Oddi Dysfunction"). New approaches for palliative endostenting of gastric outlet obstruction are now being tried with variable results. Chemical celiac splanchnicectomy may be performed via a transcutaneous approach and is sometimes quite effective at relieving the pain of locally invasive pancreatic cancer.

Some centers also rely on surgical palliation. Surgical palliation offers the only chance for long term palliation of the three major symptoms of periampullary AC. Biliary bypass can be performed with hepaticojejunostomy. Unlike endoscopic and percutaneous approaches, biliary bypass may be more durable. In a series reported from Johns Hopkins, recurrent jaundice developed in only 2% of patients receiving a palliative biliary bypass prior to death. (Lillemore et al, 1993) A second reason that some favor surgical palliation is that nonoperative palliation is frequently associated with late complications of gastric outlet obstruction. In a prospective randomized trial of performing a prophylactic gastrojejunostomy in patients with unre-sectable periampullary AC, 19% of patients not undergoing gastrojejunostomy developed late duodenal obstruction requiring intervention (Lillemore et al, 1999). The final major advantage of operative palliation is the management of pain. A prospective randomized study has demonstrated that intraoperative celiac axis injection with 50% alcohol can both successfully relieve pain in patients with pain and prevent the development of pain in patients without pain at the time of exploration (Lillemore et al, 1993).

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

Get My Free Ebook

Post a comment