# Palliation in pancreatic cancer: biliary and duodenal stents, coeliac plexus block, enzymes and cachexia

Source: https://onco.cc/terms/pancreatic-palliation-obstruction-pain-nutrition/  
OnCo record `pancreatic-palliation-obstruction-pain-nutrition` (Term). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Most people with pancreatic cancer need treatment for a blocked bile duct, pain, poor digestion or weight loss alongside chemotherapy: a metal stent placed by endoscopy for jaundice, a duodenal stent or bypass for a blocked bowel, an alcohol block of the nerves behind the pancreas for pain, enzyme capsules with every meal, and dietetic support.

## Summary

Biliary obstruction: NICE NG85 recommends going straight to surgery rather than draining the bile duct first in people with resectable cancer who are fit, an endoscopically placed self-expanding metal stent when drainage is needed before surgery, and metal stents for unresectable disease (recommendations 1.7.1 to 1.7.5). Across 20 randomised trials and 1,713 patients, metal stents stayed open 4.45 months longer than plastic stents, halved late complications (odds ratio 0.43) and cholangitis (0.53) and cut re-interventions, without changing survival (Almadi 2017). Endoscopic ultrasound-guided drainage is an alternative to ERCP: in a Korean randomised trial of 125 patients technical success was 93.8 against 90.2 percent with fewer adverse events (6.3 against 19.7 percent) and no post-procedure pancreatitis (Paik 2018), and in the 155-patient DRA-MBO trial choledocho-duodenostomy with a lumen-apposing stent had higher technical success (96.2 against 76.3 percent) with the same one-year patency (Teoh 2023). Duodenal obstruction: the Dutch SUSTENT trial (39 patients) found a stent relieved symptoms faster (5 against 8 days) but gastrojejunostomy gave longer relief with fewer re-interventions, so NG85 suggests bypass for people with a better prognosis (1.7.8).

Pain: NG85 recommends endoscopic or image-guided coeliac plexus block for uncontrolled pain, unacceptable opioid effects or escalating doses (1.5.1) and advises against thoracic splanchnicectomy (1.5.2). In a double-blind randomised trial of 96 patients with newly diagnosed painful inoperable cancer, early endoscopic ultrasound-guided neurolysis reduced pain scores at three months (difference in mean percentage change minus 60.7) without changing survival or quality of life (Wyse 2011); pooled response is 68 percent at two weeks and 53 percent at four (Koulouris 2021). Enzymes and nutrition: NG85 says offer enteric-coated pancreatin to everyone with unresectable disease and consider it around resection, and not to offer fish oils for weight loss (1.6.1 to 1.6.3). Exocrine insufficiency affects about 72 percent of people with advanced disease and observational studies link replacement to 3.8 months longer survival (Iglesia 2020), but the one randomised trial of 88 patients found no change in body mass index at eight weeks (Saito 2018). Cachexia: the GDF-15 antibody ponsegromab increased weight by 1.22 to 2.81 kg over placebo at 12 weeks in 187 patients, a third with pancreatic cancer (NEJM 2024), and a pancreatic-specific trial recruits at seven UK hospitals (NCT06989437). Thrombosis: in the pancreatic subgroup of CASSINI (273 patients) rivaroxaban did not reduce venous thromboembolism over 180 days (9.6 against 13.0 percent) but did during treatment (3.7 against 10.1 percent) without more major bleeding; NG85 points to the NICE venous thromboembolism guideline.

## Fields

- Kind: Term
- Last checked: 2026-09-24
- Also known as: Pancreatic cancer supportive care; Biliary stent in pancreatic cancer; Coeliac plexus neurolysis; Pancreatic enzyme replacement in cancer

## Sources

- NICE NG85: pancreatic cancer in adults, recommendations 1.5 to 1.7 (pain, nutrition, biliary and duodenal obstruction): https://www.nice.org.uk/guidance/ng85/chapter/Recommendations
- Almadi et al., plastic versus self-expandable metal stents for malignant biliary obstruction, meta-analyses (Am J Gastroenterol 2017): https://doi.org/10.1038/ajg.2016.512
- Paik et al., EUS-guided biliary drainage versus ERCP, randomised (Am J Gastroenterol 2018): https://doi.org/10.1038/s41395-018-0122-8
- Teoh et al., DRA-MBO randomised trial (Gastroenterology 2023): https://doi.org/10.1053/j.gastro.2023.04.016
- Jeurnink et al., SUSTENT randomised trial (Gastrointest Endosc 2010): https://doi.org/10.1016/j.gie.2009.09.042
- Wyse et al., early EUS-guided coeliac plexus neurolysis, randomised (JCO 2011): https://doi.org/10.1200/JCO.2010.32.2750
- Koulouris et al., EUS-CPN meta-analysis (Pancreatology 2021): https://doi.org/10.1016/j.pan.2020.12.016
- Saito et al., randomised trial of pancreatic enzyme replacement in unresectable pancreatic cancer (Pancreas 2018): https://doi.org/10.1097/MPA.0000000000001079
- Iglesia et al., exocrine insufficiency and enzyme replacement in advanced pancreatic cancer, meta-analysis (UEG Journal 2020): https://doi.org/10.1177/2050640620938987
- Groarke et al., ponsegromab for cancer cachexia (NEJM 2024): https://doi.org/10.1056/NEJMoa2409515
- Vadhan-Raj et al., CASSINI pancreatic subgroup (Cancer Medicine 2020): https://doi.org/10.1002/cam4.3269

## Connected records

- cancers: [Locally advanced unresectable pancreatic ductal adenocarcinoma](https://onco.cc/cancers/locally-advanced-pdac/), [Metastatic pancreatic ductal adenocarcinoma](https://onco.cc/cancers/metastatic-pdac/), [Pancreatic ductal adenocarcinoma](https://onco.cc/cancers/pancreatic/)
- technologies: [Biliary stenting and drainage](https://onco.cc/technologies/biliary-stenting-drainage/), [Cancer-associated thrombosis prevention and treatment](https://onco.cc/technologies/cancer-associated-thrombosis/), [Early integrated palliative care](https://onco.cc/technologies/palliative-care/), [Endoscopic ultrasound and EBUS systems](https://onco.cc/technologies/endoscopic-ultrasound-systems/), [Nutrition support and cachexia management](https://onco.cc/technologies/oncology-nutrition/)
- drugs: [Pancrelipase (pancreatic enzyme replacement therapy)](https://onco.cc/drugs/pancrelipase/), [Ponsegromab](https://onco.cc/drugs/ponsegromab/)
- terms: [Biliary stent problems: blockage and infection](https://onco.cc/terms/biliary-stent-problems/), [Cancer cachexia](https://onco.cc/terms/cachexia/), [Cholangitis: infection of a blocked bile duct](https://onco.cc/terms/acute-cholangitis/), [Malnutrition screening tools (MUST, NRS-2002, MST, PG-SGA)](https://onco.cc/terms/malnutrition-screening/), [Nutrition impact symptoms](https://onco.cc/terms/nutrition-impact-symptoms/), [Obstructive jaundice and biliary obstruction](https://onco.cc/terms/obstructive-jaundice/), [Stent or bypass for jaundice: the choice](https://onco.cc/terms/stent-or-bypass-for-jaundice/), [Stenting (biliary, oesophageal, airway)](https://onco.cc/terms/biliary-stent/)
- trials: [A Study to Learn About the Medicine Ponsegromab in Adults With Cancer of the Pancreas Which Has Spread and Caused Significant Body Weight Loss and Fatigue](https://onco.cc/trials/nct06989437/)

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