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482
V. Butano et al.
• We place four interrupted sutures between the pancreatic duct and the jejunotomy, at four quadrants of the pancreatic duct in a 6-, 9-, 3-, and 12-o’clock order.
The sutures are tied on the extra-luminal surface.
• A running 3-0 non-absorbable V-Loc™ suture is then used to form the anteriorouter layer between the pancreatic capsule and substance to the seromuscular
layer of the jejunal limb, in a similar fashion as the posterior layer. The anterior
and posterior outer-layer sutures are then tied together.
• A 10 Fr closed suction drain is placed near the proximal pancreatic stump and
pancreaticojejunostomy. A nal check for hemostasis is performed and the
abdomen is desufated. All port sites larger than 8mm are closed and the operation is complete.
Discussion
Central pancreatectomy brings several advantages when compared to other standard
pancreatic resection techniques (pancreatoduodenectomy and distal pancreatectomy), mainly attributed to the preservation of pancreatic parenchyma. These
include a reduced incidence of postoperative exocrine and endocrine insufciency,
as well as the avoidance of splenectomy-related complications [10–13], while
enabling excision of pancreatic body tumors otherwise could not have been safely
excised via enucleation. The rst reported case of a laparoscopic CP was published
by Baca and Bokan in 2003 for cystadenoma [14]. The rst robotic CP was reported
by Giulianotti etal. from Misericordia Hospital in Grosseto a year later [15]. Since
then, there have been only few reports on minimally invasive CP surgical techniques
and clinical outcomes. In this chapter, we aim to describe surgical steps of central
pancreatectomy and discuss important clinical aspects of this operation.
Relative to distal pancreatectomy, central pancreatectomy has higher rates of
overall and severe morbidity, overall and clinically relevant pancreatic stula, hemorrhage, and longer length of stay, which limits its widespread application and
adoption [2, 16]. Other complications may include issues related to the reconstruction such as enteric leak, bowel obstruction, or internal hernia. The technical demand
of ne suturing skills during the creation of pancreaticojejunostomy anastomosis
further deters surgeons from undertaking laparoscopic CP. The advent of robotic
surgical systems facilitates ne suturing, which ameliorates this technical issue;
however, the availability of the robotic platform is still not universal currently.
In 2018, Xio etal. conducted a systematic review which included 50 studies and
1305 patients undergoing CP.The outcomes of these patients were compared with
those undergoing distal pancreatectomy and pancreaticoduodenectomy. The overall
morbidity, mortality, postoperative pancreatic stula, and reoperation rate was 51%,
0.5%, 35%, and 4%, respectively. Endocrine and exocrine insufciency occurred in
only 4% and 5% of patients, respectively [2]. Further subgroup meta-analysis of CP
versus distal pancreatectomy favored CP with regard of blood loss and lower rate of
postoperative endocrine insufciency (OR = 0.13, p < 0.001) and exocrine
28 Minimally Invasive Central Pancreatectomy
483
insufciency (OR=0.38, p<0.001); however, CP was associated with high pancreatic leak rate. In comparison to pancreatoduodenectomy, CP also had a lower risk of
postoperative endocrine (OR = 0.14, p < 0.001) and exocrine insufciency
(OR=0.14, p<0.001), but higher pancreatic leak rate (OR=1.6, p=0.015). The
authors concluded that CP maintains pancreatic endocrine and exocrine function
better than distal pancreatectomy and pancreatoduodenectomy, but it is associated
with a high pancreatic leak rate.
The most recent systematic review and meta-analysis published by Rompianesi
et al. includes 13 series and 265 patients undergoing robotic central pancreatectomy. In all cases but one, robotic CP was undertaken to excise benign or low-grade
tumors. Clinically relevant postoperative pancreatic stula occurred in 42.3% of
patients. The overall complications were 57.5%; however, only 9.4% were ClavienDindo ≥3 grades [17]. Despite the high rate of pancreatic stula, the incidence of
new-onset diabetes mellitus after the CP was only 0.3% with negligible mortality.
This nding was consistent with long-term endocrinologic benets of pancreatic
parenchymal preservation offered by CP.
The conclusion is minimally invasive central pancreatectomy is safe and feasible
as an alternative option to distal pancreatectomy and pancreatoduodenectomy for
benign or low malignant potential pancreatic neck/body tumors. The ultimate benet of CP is preservation of pancreatic endocrine and exocrine function, despite a
higher incidence of postoperative pancreatic leak.
Acknowledgments Kaitlyn Crespo, BS; Cameron Syblis, BS; and Jacob Lambdin, MD for contributions of the images and preparation of the manuscript.
References
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2. Xiao W, Zhu J, Peng L, Hong L, Sun G, Li Y.The role of central pancreatectomy in pancreatic
surgery: a systematic review and meta-analysis. HPB (Oxford). 2018;20:896–904. https://doi.
org/10.1016/j.hpb.2018.05.001.
3. Ambiru S, Kato A, Kimura F, Shimizu H, Yoshidome H, Otsuka M, et al. Poor postoperative blood glucose control increases surgical site infections after surgery for hepato-biliarypancreatic cancer: a prospective study in a high-volume institute in Japan. J Hosp Infect.
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4. Sadowski SM, Millo C, Cottle-Delisle C, Merkel R, Yang LA, Herscovitch P, etal. Results of
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5. Werba G, Napolitano MA, Sparks AD, Lin PP, Johnson LB, Vaziri K.Impact of preoperative
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6. Ross S, Rayman S, Sucandy I, Syblis C, Rosemurgy A.Whipple’s operation and distal pancreatectomy. In: Costello T, editor. Principles and practice of robotic surgery. Philadelphia:
Elsevier; 2024.
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7. Ross S, Rosemurgy A, Wecowski J, Bourdeau T, Sucandy I.Robotic pylorus-preserving pancreaticoduodenectomy and cholecystectomy. In: Atlas of robotic general surgery. Elsevier;
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8. Ross SB, Downs D, Sucandy I, Rosemurgy AS.Robotic pylorus-preserving pancreaticoduodenectomy. In: Fong Y, Woo Y, Hyung W, Lau C, Strong V, editors. The SAGES atlas of robotic
surgery. Cham: Springer; 2018. p.319–34.
9. Rosemurgy A, Ross S, Bourdeau T, Craigg D, Spence J, Alvior J, etal. Robotic pancreaticoduodenectomy is the future: here and now. J Am Coll Surg. 2019;228:613–24.
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11. Iacono C, Verlato G, Ruzzenente A, Campagnaro T, Bacchelli C, Valdegamberi A, Bortolasi L,
Guglielmi A.Systematic review of central pancreatectomy and meta-analysis of central versus
distal pancreatectomy. Br J Surg. 2013;100(7):873–85. https://doi.org/10.1002/bjs.9136.
12. Xu SB, Zhu YP, Zhou W, Xie K, Mou YP. Patients get more long-term benet from central
pancreatectomy than distal resection: a meta-analysis. Eur J Surg Oncol. 2013;39(6):567–74.
https://doi.org/10.1016/j.ejso.2013.02.003. Epub 2013 Mar 7.
13. Santangelo M, Esposito A, Tammaro V, Calogero A, Criscitiello C, Roberti G, Candida M,
Rupealta N, Pisani A, Carlomagno N.What indication, morbidity and mortality for central
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14. Baca I, Bokan I. Laparoskopische Pankreassegmentresektion bei Pankreaszystadenom
[Laparoscopic segmental pancreas resection and pancreatic cystadenoma]. Chirurg.
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15. Giulianotti PC, Sbrana F, Bianco FM, Addeo P, Caravaglios G. Robot-assisted laparoscopic
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V. Butano et al.
Chapter 29
Palliation ofPancreatic Cancer
ImadElkhatib andMarcMesleh
Key Points
• Increasing number of patients with pancreatic cancer will require palliation of
symptoms as more effective chemotherapeutic options became available.
• Endoscopically placed metal stents are the preferred method of palliating malig-
nant biliary obstruction.
• Biliary metal stents have varying durations of patency and will require varying
types of maintenance.
• Surgical gastrojejunostomy is an effective method of palliation.
• Palliation of duodenal obstruction via duodenal metal stent placement vs surgical
bypass based on the expected prognosis.
• Cancer-related abdominal pain most often responds to narcotics, but may be pal-
liated with EUS-guided celiac plexus neurolysis.
Introduction
Each year more than 62,000 patients in the United States develop cancer of the
pancreas, and of these patients, only 11% are expected to survive 5years from diagnosis [1]. Pancreatic cancer portends a poor prognosis regardless of stage, with an
estimated 3–6-month survival for those patients presenting with metastatic disease
and a 9–12-month survival for those with locally advanced, unresectable disease
I. Elkhatib
Advanced/Therapeutic Endoscopy, Advocate Christ Medical Center, Oak Lawn, IL, USA
M. Mesleh (
Department of Surgery, University of Illinois Chicago (UIC), Chicago, IL, USA
Advocate Christ Medical Center, Oak Lawn, IL, USA
e-mail: marc.mesleh@aah.org
Switzerland AG 2025
E. P. Ceppa et al. (eds.), The SAGES Manual of Evolving Techniques in
Pancreatic Surgery, https://doi.org/10.1007/978-3-031-78409-5_29
*)
485© The Author(s), under exclusive license to Springer Nature
486
Table 29.1 Categories of cancer-related symptoms and endoscopic palliation options
Cancer-related
problem Symptoms Role of endoscopic treatment
Biliary obstruction
Duodenal
obstruction
Neural invasion – Abdominal
– Jaundice
– Pruritis
– Cholangitis
– Nausea/emesis
– Anorexia
– Esophagitis
pain
– Biliary stenting
– EUS-guided
choledocoduodenostomy
– Endoluminal stenting
– Venting PEG
– EUS-guided
gastrojejunostomy
– Celiac plexus neurolysis – Celiac plexus block
I. Elkhatib and M. Mesleh
Role of surgical
treatment
– Hepaticojejunostomy
– Gastrojejunostomy
[2]. Resection offers the only potential for cure, but even after pancreaticoduodenectomy for curative intent, the 5-year survival remains low at 27%. Therefore, the
management of many patients with pancreatic cancer will involve palliation of
cancer- related symptoms. Due to patients surviving longer with newer chemotherapy and radiation treatments, the prevalence of these symptoms continues to
increase. The role of palliative therapy is becoming increasingly important to offer
an acceptable quality of life.
The approach to palliating cancer-related symptoms in patients with pancreatic
cancer is a multidisciplinary one and involves the combination of medical oncologists, radiation oncologists, surgical oncologists, interventional gastrointestinal
endoscopists, interventional radiologists, pain management physicians, and medical
palliative care teams. The focus of this chapter will be on the options for endoscopic
and surgical techniques in palliation of cancer-related symptoms.
The most common cancer-related symptoms from pancreatic adenocarcinoma
which requires intervention include biliary obstruction, duodenal obstruction, and
pain from neural involvement of locally advanced disease (Table29.1). Deciding on
the best intervention for each patient depends on several factors and should be discussed in a multidisciplinary team.
Biliary Obstruction
Given the intra-pancreatic course of the common bile duct, biliary obstruction due
to tumor invasion is the most common cancer-related complication of pancreatic
cancer. In fact, given that 75–85% of new diagnoses of pancreatic cancer involve the
head of the pancreas, up to 70% of patients will develop some degree of biliary
obstruction, which is commonly symptomatic, causing jaundice and pruritus [3].
Severe biliary obstruction can lead to liver dysfunction and coagulopathy. This
coagulopathy must be diagnosed and treated before invasive procedures can be
safely performed.
29 Palliation ofPancreatic Cancer
While there are multiple pharmacologic options for the treatment of pruritis
including hydroxyzine, diphenhydramine, benzodiazepines, cholestyramine, and
ursodeoxycholic acid [4], these are seldom effective given the progressive obstructive nature of the jaundice. Therefore, it is reserved for patients who are not able to
receive endoscopic or surgical interventions.
487
Endoscopic Interventions
Endoscopic biliary stenting provides an effective means of palliating jaundice and
pruritis due to malignant biliary obstruction from pancreatic cancer. It is the most
common therapy for this indication. Biliary stenting can be performed via endoscopic or percutaneous routes. There are mixed data regarding the benets of the
endoscopic route as compared to the percutaneous route [5–7]. An early randomized trial showed an 81% success rate of endoscopic decompression versus a rate of
61% via the percutaneous route, with a higher mortality in the percutaneous group
which was mainly attributed to complications such as bile leaks and liver hematomas [5]. Another important consideration is that with percutaneous stenting the
patient will require an external drain, at least initially, which in addition to inconvenience, pain, and leaking may also lead to infection, nutrient deciencies, malnutrition, dehydration, and electrolyte imbalance.
Endoscopic biliary decompression is done via the placement of a biliary stent
through the ampulla of Vater using a side viewing duodenoscope during Endoscopic
Retrograde Cholangiopancreatography (ERCP). The procedure can be done with
moderate sedation or general anesthesia and procedure time can vary, with a mean
length of 30 min. Prior to biliary cannulation, the endoscopist must decide on
whether to place a metal or plastic stent, a covered or uncovered stent as well as
decide on the length of stent to be used.
Plastic Versus Metal Stents
Plastic stents are effective and inexpensive (<$20). They can be removed if needed
and they are relatively easy to exchange. Plastic stents eventually develop occlusion
by a combination of bacterial biolm and sludge, with a resultant patency life of
approximately 3months [8]. This necessitates repeated ERCPs with stent exchange,
which can impart a substantial nancial and quality of life burden on the patient.
The effect of stent diameter on time until occlusion was studied, and it appeared that
11.5 Fr stents were non-superior to 10 Fr stents in regard to rate of occlusion [9],
and in practice 11.5 Fr stents are seldom used as they are technically challenging to
place with no additional benet.
Self-expanding metal stents (SEMS) are highly effective, expensive (>$1000)
and come with an increased patency of approximately 6months [8, 10]. Metal stents
488
ab
I. Elkhatib and M. Mesleh
are composed of laser-cut nitinol and are available as uncovered, partially covered,
or fully covered types (Figs.29.1 and 29.2). The uncovered metal stents have an
open mesh or cell conguration that embed in the biliary wall and are therefore not
removable, whereas the fully covered stent is easily removable should the need
arise. SEMS are available in diameter sizes of 6, 8, and 10mm diameter (much
larger than the plastic counterparts), with lengths ranging from 4 to 10cm. They are
deployed via through-the-scope (TTS) delivery systems.
The decision to use a plastic versus metal stent is made after consideration of the
expected length of survival, anticipated treatment plan, costs, and physician expertise. That being said, the majority of endoscopists are now predominately using
SEMS for palliation of malignant biliary obstructions. A systematic review and
meta-analysis showed that metal stents had a lower risk of recurrent obstruction
[10] although success rate and complication rate were not statistically different
between SEMS use and plastic stents. As the majority of patients with pancreatic
cancer at the time of bile duct obstruction are surviving longer than 2–6months,
metal stents are becoming a more desirable option (especially with hopes of
decreased need to hold chemotherapy in event of biliary blockage resulting in cholangitis). Even if the therapeutic plan for the patient is still unclear at the time of
ERCP, placement of a short length (4–6 cm long) SEMS will not interfere with
future surgical resection. A Monte Carlo decision analysis compared multiple
approaches to patients with obstructive jaundice from pancreatic cancer in whom
the surgical plan was undetermined and results showed that placement of a short
length SEMS is the preferred initial treatment for overall cost reduction [11]. In a
high-volume center, there should be a standardized approach to pre-op stenting
based on the endoscopist and surgeon preferences.
Fig. 29.1 Endoscopic appearance of an fully uncovered (a) and fully covered (b) self-expanding
metal biliary stent
29 Palliation ofPancreatic Cancer
Fig. 29.2 Fluoroscopic
image of a fully uncovered
non-laser-cut selfexpanding metal stent
placed across a 3cm long
distal biliary stricture from
pancreas head cancer. Note
the appropriate “waistsign” in the mid-line of the
stent
Covered Versus Uncovered Metal Stents
489
Covered Self-Expanding Metal Stents (CSEMS) were developed with the goal of
increasing patency duration over Uncovered Self-Expanding Metal Stents (USEMS).
Tumor in-growth and overgrowth are examples of reasons SEMS can become
occluded. There have been multiple randomized controlled trials comparing the
two, yet these trials failed to show increased patency rates for CSEMS [12–14]. For
example, in one of the trials evaluated 400 patients that had stent placement for
malignant distal biliary obstruction; the authors found no difference between types
in regard to stent patency or patient survival. Both CSEMS and USEMS had a nearidentical stent failure rate (24% versus 23%) and no statistical difference between
the time it took for 25% of the stents to occlude (145 days for CSEMs, versus
199days for the USEMS). Furthermore, median survival time of the patients was
similar (116 versus 174days), but stent migration was more common in the patients
with CSEMS (3% versus 0%) [15]. While a more recent meta-analysis in 2011 of
ve multicenter randomized trials comparing CSEMS and USEMS suggested a
modest benet to CSEMS over USEMS in regard to stent patency the increased risk
of stent migration likely outweighs this marginal trend towards increased
patency [16].
It has been suggested that patients with intact gallbladders should receive uncovered SEMS, with the intent of reducing the risk of cystic duct obstruction and resultant cholecystitis, although no strong data exists to support this. This may be of
more concern when contrast is seen in the gallbladder during ERCP.There is a risk
of acute cholecystitis due to cystic duct outow obstruction. Surgery is typically not
490
I. Elkhatib and M. Mesleh
a rst resort and may not be an option at all. A common option is placement of a
cholecystostomy tube with interventional radiology. This drain will likely never
come out and a newer option is EUS-guided cholecystostomy using an axios stent
to decompress the gallbladder into the duodenum. This therefore is not an option if
the duodenum is also obstructed.
Biliary stenting in the setting of malignant obstruction can be challenging due to
tumor involvement of the duodenal wall or duodenal obstruction that prevents
access to the ampulla. In these cases, interventional radiology with percutaneous
biliary access has traditionally been used. However, recently a variety of EUSguided techniques have been used to access the biliary system and place stents
[17–19]. The endosonographic approach can be either a transgastric or transduodenal puncture of the biliary tree to pass a guide wire antegrade though the papilla for
stent placement or creation of a choledocho-duodenostomy or hepatico- gastrostomy.
Of note, the current complication rate of these approaches is about 20% and needs
to be performed in a tertiary care center with extensive interventional endoscopic
experience. Immediate interventional radiology and surgical back up should be
available [20].
Stent Obstruction
As pancreatic cancer patients with biliary stents live longer due to improved oncologic treatment options, the concern for developing cholangitis or biliary obstruction has increased. This is due to either accumulation of biolm and sludge or
related to food impaction. Recent studies suggest that the chance of stent occlusion
and cholangitis at 1year is as high as 46% [21, 22]. If patients are actively receiving
treatment with chemotherapy, the immunosuppression can increase the severity of
their illness. Patients should be instructed that any shaking chills (rigors) or fevers
likely represent biliary obstruction. Sometimes this is transient with relatively normal liver tests, and sometimes will be associated with jaundice and elevated liver
tests. Patients with severe symptoms need to go to the emergency room for evaluation and probable hospitalization, while those with mild symptoms can sometimes
be managed with outpatient oral antibiotics. Patients with suspected stent occlusion
should be considered for repeat ERCP in order to sweep out any debris/food from
the stent and/or place a new stent. Occasionally for long-term management or
repeatedly occluding metal stents, the patient will be placed on oral ursodeoxycholic acid (to increase biliary secretion and ow) and/or prophylactic ERCP biliary
stent cleaning with balloon sweep.
Future directions in palliative biliary stenting include potential endoscopic placement of drug-eluting stents to increase stent patency and deliver local therapy as
well as radio frequency ablation of the tumor in-growth within the stents. Newer
stents and instruments may allow quick and effective endoscopic choledochoduodenostomy or hepatico-gastrostomy with expanding opportunity of endoscopic
therapy for proximal biliary blockage from metastatic disease.
29 Palliation ofPancreatic Cancer
491
Surgical Options
Surgical options for biliary decompression include hepaticojejunostomy, choledochojejunostomy and cholecystojejunostomy. The choice of which type of surgical
procedure to perform depends on the common bile duct diameter and surgeon’s
preference. The efcacy of surgical bypass in successfully decreasing hyperbilirubinemia has been estimated at up to 90% [23]. Even with this very effective technique, as the tumor progresses, the new anastomosis can become occluded as the
malignancy progresses. For tumors in the head of the pancreas, a hepaticojejunostomy may be preferred because it will be anatomically more distant from the tumor.
Traditionally, a hepaticojejunostomy is created in an end-to-side or side-to-side
anastomosis between the bile duct and Roux-en-Y loop of jejunum. An end-to-side
anastomosis is easy to visualize and ensures a widely patent anastomosis but
requires circumferential dissection around the bile duct. If this circumferential dissection is difcult due to tumor progression or lymphadenopathy, then a side-to-side
anastomosis may be favorable. Knowledge of the vasculature to the bile duct is
important during dissection to decrease ischemia, which may lead to leak or stenosis.
The Roux limb may be brought up to the hepatic hilum in an ante-colic or retrocolic fashion. Ideally, the roux limb should be distanced as much as possible from
the primary tumor to decrease the future risk of roux limb occlusion if the tumor
progresses. The anastomosis should be constructed with an absorbable suture to
decrease the risk of stricture and stone formation. The choice of running vs interrupted suture will depend on the duct size and surgeon preference.
While this surgical bypass has been historically done in an open fashion, the
increasing usage of minimally invasive surgery may decrease length of stay, wound
infection rate and postoperative pain. The biliary anastomosis can be performed
laparoscopic or robotically in high-volume centers with appropriate experience.
The risks of surgery include bleeding, biliary leak, and anastomotic stricture. In
addition, the risks of general anesthesia are pertinent in patients who may have a
poor performance status due to their advanced malignancy. These risks are critical
for consideration when discussing options with the patient and treatment team.
Endoscopic Versus Surgical Intervention
Endoscopy is the more effective initial approach. Compared to surgical bypass,
endoscopic biliary drainage has been shown to have a decreased length of stay,
lower morbidity, lower mortality, and improved quality of life [24]. This can help
initiate chemotherapy sooner since recovery from a major operation is not needed.
There are multiple factors which need to be considered when deciding on an
optimal approach. The most obvious decision may be based on the technical feasibility of the technique. If there is a large bulky pancreatic malignancy that is extending into the hepatic hilum, a surgical bypass may not be technically possible due to