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

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.