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I. Elkhatib and M. Mesleh
the inability to safely access uninvolved hepatic ducts. Alternatively, if the patient
has had previous gastric surgery, such as a Roux-en-Y gastric bypass, the ampulla
and biliary system may not be approachable via traditional endoscopic approach. In
this case, a surgical bypass may be the preferred approach.
Another technical consideration involves the extent of disease. In the setting of
stage IV pancreatic adenocarcinoma with carcinomatosis and malignant ascites, a
surgical approach to biliary bypass would be contraindicated due to the signicant
abdominal burden of disease.
Based on the invasive nature of surgery, this approach is associated with increased
morbidity and mortality. However, compared to stenting, surgical bypass tends to
last longer after the rst intervention. As patients continue to live longer due to
improved chemotherapy regimens, surgical bypass has the theoretical advantage of
not requiring multiple re-interventions due to stent occlusion. But this has not been
proven yet in randomized control trials.
Historically, patients who were brought to surgery for an oncologic resection but
were found to be locally unresectable or with metastatic disease may have received
a palliative biliary bypass. But this situation is becoming less frequent due to the
increasing use of neoadjuvant chemotherapy, and often already having an endoscopically placed biliary stent already in place at the time of any surgery. When a
patient already has an endoscopic drain in place, the benets of performing a surgical bypass are unclear.
Duodenal Obstruction
The head, neck, and uncinate process of the pancreas are directly adjacent to all
segments of the duodenum. For this reason, duodenal obstruction from either tumor
invasion or extrinsic compression is common inlocally advanced pancreatic cancer,
leading to gastric outlet obstruction and symptoms of nausea, vomiting, dehydration, esophagitis, and oral intake intolerance. Despite not commonly being present
on diagnosis, up to 20–40% of patients with pancreatic cancer will develop this
cancer-related complication during their course [23].
Initial symptoms could be as mild as nausea, but progress to daily large volume
vomiting. Imaging (plain lms or CT) reveals a massively distended, uid-lled
stomach. Endoscopy plays an important role in management of this complication by
helping establish diagnosis by visualization of retained food in the stomach and
often the inability to pass the endoscope beyond the stomach or duodenum. It also
offers different therapeutic options like placing enteric stents and/or a venting gastrostomy tube.
As was the case with biliary obstruction, medical management for advanced duodenal obstruction is ineffective, and complete NPO status may be mandatory for
symptomatic control in this setting. However, gastric and salivary secretions continue, and even when patients have no oral intake, symptoms of obstruction will
persist. Thus, concomitant upper intestinal decompression is often required, using a
29 Palliation ofPancreatic Cancer
493
nasogastric tube to gravity or pump suction, or a venting (decompressive) gastrostomy tube (PEG).
In addition to being uncomfortable to the patient, a major disadvantage of nasogastric tube decompression is the unstable nature of the tube, which often is dislodged. For this reason, nasogastric tube gastric decompression is only used as a
temporary solution or in patients in whom death is imminent.
Duodenal Stents
Over the past decade, duodenal stenting has evolved to become the most favored
and most natural option for the management of duodenal obstruction in patients
with unresectable pancreatic cancer. There have been many studies published evaluating the efcacy, feasibility, and safety of endoscopically deployed duodenal stents,
all of which have shown a signicant palliative benet, a relatively low morbidity
prole, decreased length of hospitalization, and signicant overall cost reduction,
especially when compared to surgical gastrojejunostomy [25–28]. In one study, the
median survival time for patients with pancreatic cancer who underwent duodenal
stent placement compared with those who underwent surgical gastrojejunostomy
was 94 and 92days, charges were $9921 and $28,173, and duration of hospitalization was 4 and 14days, respectively (p value <0.005) [25]. The majority of the
published experience with enteric stenting is derived from mostly small comparative studies and case series. A systematic review of 44 studies that looked at enteric
stenting (1046 patients) versus gastrojejunostomy (297 patients) noted there were
no signicant differences between stent placement and gastrojejunostomy in regard
to technical success (96% versus 100%, respectively), early complications (7% versus 6%) or late complications (18% versus 17%). Initial clinical success (i.e., symptomatic control) was higher after stent placement (89% versus 72%) although
recurrent obstructive symptoms were more common after stent placement (18%
versus 1%) [29].
After stent placement, the vast majority of patients will be able to tolerate soft
solids or a full diet [30]. Despite initial rapid clinical success, anywhere from 15%
to 40% of patients who receive enteric stenting for malignant obstruction will
require re-intervention for recurrent symptoms of obstruction. In the only multicenter randomized controlled trial comparing enteral stenting to surgical gastrojejunostomy, the median duration of relief was 50days for the stent group compared to
72days for the surgical group [25]. The reasons for symptom recurrence included
tumor in-growth into stent, stent migration, multifocal obstructions distal to duodenum, diffuse peritoneal carcinomatosis with bowel encasement, and functional gastroparesis due to tumor effect on regional neural networks (celiac axis). Thus, the
endoscopic placement of self-expanding enteric stents for the palliation of gastric
outlet obstruction in patients with unresectable pancreatic cancer is an effective
intervention, with decreased length of hospitalization and overall costs as compared
to surgery, although with a moderate re-intervention rate after 2months. In-stent
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I. Elkhatib and M. Mesleh
tumor growth can usually be managed by placement of additional stents through the
original stent, and stent migration is a rare occurrence.
There are several FDA-approved dedicated duodenal stents commercially available in the United States, all of which are uncovered self-expandable metal stents
(Figs.29.3 and 29.4). The available diameters range from 20 to 22mm, with length
options including 6, 9, and 12cm. The stents can be deployed through the accessory
channel of a therapeutic endoscope or colonoscope and are deployed via a 10 Fr
160cm or 225cm long delivery system. Length of procedure varies highly, depending on the amount of difculty the endoscopist encounters in trying to traverse the
stricture, aspirate gastric contents, but an average of 1 h of endoscopy time should
be allotted. Procedures should be done in rooms equipped with uoroscopy and in
the presence of skilled nurses trained in ERCP and advanced procedure skills. Stents
can be deployed through the scope under direct visualization or via uoroscopic
guidance of catheter deployment over a guide wire.
In settings in which both biliary and enteric stenting is anticipated, biliary stent
placement should be performed prior to enteral stenting, when possible, in order to
increase the odds of technical success in biliary cannulation. Occasionally, duodenal stents may be placed prior to ERCP to facilitate passage of ERCP scope and biliary stent placement. In such a situation, biliary cannulation may be facilitated by
EUS-guided antegrade passage of guide wire for cannulation.
Risks of enteral stenting for malignancy-induced gastroduodenal obstructions
include bleeding, perforation, and distal stent migration, in addition to stent obstruction, which is mainly due to tumor inltration. A systematic review of 606 patients
in whom an enteral stent was placed revealed severe complications (bleeding and
perforation) in 1.2% of cases and stent migration in 5%. Stent obstruction occurred
Fig. 29.3 Endoscopic
view of a fully deployed
fully uncovered metal
duodenal stent
29 Palliation ofPancreatic Cancer
Fig. 29.4 Fluoroscopic
image of a metal duodenal
stent with central wasting
in region of tumor
495
in 18% of cases. There was 0% case-related mortality. Mean survival period was
12.1weeks [31]. With improved devices and equipment, these complications are
likely to be even fewer in number.
A newer option has emerged with endoscopic ultrasonography-guided gastroenterostomy. Not all centers have the equipment or expertise, but this endoscopic gastrojejunostomy is gaining traction. An international multicenter randomized
controlled trial (NCT03823690) from 2023 showed in patients with malignant gastric outlet obstruction, endoscopic ultrasonography-guided gastroenterostomy can
reduce the frequency of re-intervention, improve stent patency, and result in better
patient-reported eating habits compared with duodenal stenting, and the procedure
should be used preferentially over duodenal stenting when expertise and required
devices are available [32].
Venting Percutaneous Gastrostomy Tubes (PEG)
Decompressive PEG tubes can be placed endoscopically, percutaneously via uoroscopy or surgically, and allow for a more stable access route to the stomach [33].
The access port can then be used for intermittent decompression throughout the day,
usually to gravity, and can remain clamped when asymptomatic. Decompressive
PEG tubes have been used with good efcacy and relatively low complication rate
for malignant gastric outlet obstructions although the majority of the published
studies are from gynecologic malignancies [34]. One study that did look at the
effect of venting PEG tubes for decompression of outlet obstruction from gastrointestinal malignancies, including pancreatic cancer, showed a technical and clinical
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I. Elkhatib and M. Mesleh
success rate of 89% (41 of 46 patients) and tube utilization duration on average of
60 ± 91days. In addition, 88% of patients were able to remain on a liquid and soft
food diet [35]. The authors use a special fenestrated 24 Fr tube to maximize drainage, which is not currently commercially available.
If the degree of outlet obstruction permits, a gastrojejunal tube (GJ tube or PEG-J
tube) can be placed via the PEG site, in which there is jejunal access for feeding,
and a separate intragastric portion which can be used for decompression.
Thus, a combination of medical management with anti-nausea and anti-secretory
therapies combined with a decompressive PEG tube is a management option for
patients needing palliation for pancreatic cancer-related gastric outlet obstruction,
despite a lack of published literature on the matter. This approach results in an externally positioned tube over the patient’s abdomen, and severely limits the patient’s
ability to tolerate a normal diet. There are also risks involved in PEG placement
such as bleeding, infection, perforation, and is not always technically possible. In
patients with carcinomatosis with malignant ascites, this is a relative contraindication to PEG placement.
Surgical Gastrojejunostomy (Duodenal Bypass)
Patients may have symptomatic duodenal obstruction at presentation or may develop
an obstruction while on treatment due to tumor progression from an advanced pancreatic malignancy. For these patients, surgical bypass with a gastrojejunostomy
should be considered. Most experts advocate for a loop side-to-side gastrojejunostomy. The anastomosis can be done either hand-sewn or stapled anastomosis, with
neither showing any clear superiority. Care must be taken to not cause angulation of
the outow limb of the jejunum or narrowing the anastomosis during the
construction.
Even after surgical bypass, there can be signicant delayed gastric emptying.
Therefore, we recommend an isoperistaltic, retro-colic, and retrogastric anastomosis to decrease this risk [36]. Typically, a loop of jejunum approximately 30–40cm
distal to the ligament of Treitz is brought up through a defect in the transverse mesocolon. The posterior wall of the stomach is exposed, and an anastomosis is created
to the posterior wall, near the greater curve. This can be done in an open, laparoscopic or robotic fashion (Fig.29.5). The benets of minimally invasive surgery
include decreased length of stay and postoperative pain.
In patients who do not have a symptomatic duodenal obstruction, there is controversy around prophylactic surgical bypass. Prophylactic gastrojejunostomy is
sometimes done during an attempted oncologic surgery if the patient is found to
have unresectable disease, in order to prevent impending (or treat) duodenal obstruction [23]. A meta-analysis of several prospective studies evaluated the benet of
prophylactic surgical gastrojejunostomy plus biliodigestive anastomosis versus no
bypass or biliary anastomosis alone. In the prophylactic gastrojejunostomy group,
the risk of developing gastric outlet obstruction during follow-up was signicantly
29 Palliation ofPancreatic Cancer
Fig. 29.5 Laparoscopic
gastrojejunostomy.
Retro-colic and retrogastric
anastomosis
497
lower than the group without surgical bypass (odds ratio [OR] 0.06, 95% condence
interval 0.02–0.21; p<0.001) and mortality rates were similar for both groups [37].
For this reason, many surgeons advocate prophylactic gastrojejunostomy for prevention of gastric outlet obstruction in patients in whom exploratory laparotomy
reveals unresectable disease.
There are critics to this approach, who question the true benet of prophylactic
surgery in these patients, citing the high rate of delayed gastric emptying postoperatively (up to 50% of patients in one study) [38], the increased length of hospitalization [31], as well as the fact that a large portion of patients with pancreatic cancer
will not develop outlet obstruction until the terminal weeks of their disease [39]. A
single-center study examined a group of 155 consecutive patients who underwent
laparoscopic staging for pancreatic adenocarcinoma, and the presence of subsequent surgical bypass was documented after a mean follow-up length of 5.9months.
During this follow-up period, 81% of patients died from their disease (125 patients).
Only three patients (2%) required a subsequent gastrojejunostomy for outlet
obstruction [40]. The authors of that study advocated against the use of prophylactic
gastrojejunostomy as a routine practice, but rather, to be used in the setting of documented obstruction.
Endoscopic Versus Surgical Intervention
The decision regarding ideal intervention for patients with advanced malignancy
causing duodenal obstruction must be personalized for each patient. A multidisciplinary discussion, including the patient’s wishes, is critical. Some patients may
want to avoid surgery and associated morbidity at all costs.
There may be technical aspects that are contraindications for surgery. For example, signicant carcinomatosis or malignant ascites increase the morbidity of surgical bypass. Specically, there is an increased risk of anastomotic failure leading to
life-threatening gastric leak. Additionally, the anastomosis may not be technically
possible because of tumor involvement on the surface of the stomach or bowel.
498
Conversely, because of the higher long-term patency rates, for patients in whom
survival is expected to extend beyond 6–9months, surgical bypass may be a more
appropriate consideration. This would prevent repeat endoscopic interventions
associated with duodenal stenting.
I. Elkhatib and M. Mesleh
Abdominal Pain
Abdominal pain can be a signicant feature of patients with unresectable locally
advanced pancreatic cancer and a major contributor to decreased quality of life in
these patients. The celiac plexus is located below and anterior to the diaphragm and
surrounds the origin of the celiac trunk and is responsible for transmitting the sensation of pain for the pancreas. Pain in pancreatic cancer comes from nociceptive
stimulation of the nerves that supply the pancreas, which in turn transmit this pain
signal to the celiac plexus and from there travel to the thalamus and cortex of the
brain, ending in the perception of pain [41].
Management of malignancy-related pain in pancreatic cancer can be achieved
via tumor therapy with chemotherapy and radiation therapy, with medical therapy
(narcotic pain medications), or with nerve blocks (i.e., celiac plexus neurolysis
(CPN), celiac ganglia blocks). CPN may be achieved via percutaneous, surgical, or
endoscopic means [42]. It is important to note that medical management of pancreatic cancer-induced pain using narcotics is highly effective. Non-opioid analgesics,
on the other hand, are rarely capable of controlling patients’ symptoms [43]. The
use of narcotics is sometimes associated with several side-effects, such as constipation and nausea, which in turn require symptomatic control with additional medications. Co-management of terminal pancreatic cancer patients with a Pain
Management specialist or Palliative Service specialist, where opioid analgesics are
given in an effective and satisfactory manner and potential side-effects are managed
appropriately. This approach tends to increase the yield of noninvasive management
of cancer-related pain even further.
Celiac Plexus Neurolysis
CPN involves the direct injection of ethanol into the area of the celiac plexus and
can be done via Endoscopic Ultrasound (EUS) or via percutaneous injection, often
with image guidance, such as Computer Tomography (CT). EUS has the theoretical
advantage of augmenting needle localization and spread of the ethanol injectate.
There have been no large trials that have directly compared EUS-guided CPN to
percutaneous CPN in order to reliably compare differences in efcacy and safety
prole. However, in the setting of palliation of pancreatic cancer pain, it does appear
that EUS-guided CPN is a safe and effective option, although infrequently needed
with current oncologic management.
29 Palliation ofPancreatic Cancer
499
There have been multiple small trials evaluating the efcacy of EUS-guided
CPN in patients with pancreatic cancer. Two meta-analyses noted the percentage of
patients with pain relief between 73% and 80% [44, 45]. There were no randomized
placebo-controlled trials among the studies evaluated, and pain relief was often
objectively quantied using visual pain analogs and amount of narcotic use. One
study looked at patients’ pain scores at 2, 4, 8, and 12weeks after EUS CPN compared to baseline, and noted that at each follow-up time point, 82–91% of patients
required the same or less pain medication and 79–88% of patients had persistent
improvement in their pain score [46]. Another prospective study followed patients
for up to 6months after EUS CPN and noted a sustained effect of decreased pain
scores for up to a median of 24weeks [47]. In all studies, no patients reported complete resolution of pain, and no patients were able to completely discontinue systemic narcotics.
Early use of CPN has been associated with an improved response rate, with the
theory that as cancer progresses, the etiology of the pain becomes more multifactorial and less responsive to loco-regional therapies, such as CPN [48]. In a randomized double-blind controlled trial comparing early EUS-guided CPN (done at the
time of staging EUS) to standard narcotic therapy in 96 patients (48 per study arm),
pain relief scores were greater at 3months in the CPN arm, whereas Quality of Life,
survival, and morphine consumption were not statistical signicant between the two
groups. Other factors that may predict a poor response to EUS-guided CPN include
direct invasion of cancer into the celiac plexus and unilateral injection of ethanol [49].
In the future, as more advances are made in the understanding of pain pathophysiology and newer management tools (narcotics, spinal stimulators), endoscopy
might not play a signicant role.
Serious complications with EUS-guided CPN are rare and include asymptomatic
hypotension, severe self-limited post-procedural pain, and retroperitoneal abscess.
The incidence of these complications is low, with one series of 230 EUS-guided
CPN or CPB showing an overall complication rate of 1.8% (1 patient developed
retroperitoneal abscess, 1 patient developed hypotension, and 2 patients developed
pain) [50].
Transient diarrhea, lasting usually up to 7days, is common after EUS CPN,
occurring in up to 44% of patients, and reects the sympathetic blockade that can
occur after injection [50]. This same sympathetic blockade is responsible for the
transient orthostatic hypotension that can occur. There does not seem to be any
reports of cardiac arrhythmias after CPN.
Surgical Celiac Plexus Block
In patients who are already in the operating room for surgical palliation of biliary or
duodenal obstruction, the option of a surgical celiac plexus block is also available.
The technique can be performed in a minimally invasive or open surgery. In
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laparoscopic or robotic surgery, the use of an ultrasound probe can assist in nding
the origin of the celiac axis along the aorta. Then using this imaging guidance, the
celiac plexus can be injected with 50% ethanol. Typically, bilateral injections along
the aorta, near the celiac origin are needed. Access to this area can be achieved by
opening the gastrohepatic ligament and following the left gastric artery down to the
celiac axis.
In open surgery, palpation of the aorta and celiac origin are useful to guide the
injection. The surgeon uses their non-dominant hand to palpate the aorta and holds
it stable while injecting. Typically, neurolysis is similarly performed with injection
of 50% ethanol. This can be injected into the retroperitoneum to the right and left
sides of the aorta. While the risks are low, they do include bleeding, paraplegia, and
anterior spinal syndrome [51].
With the increasing expertise of interventional gastroenterology, EUS-guided
celiac neurolysis has replaced surgical block in most institutions.
Summary
As patients with pancreatic cancer live longer with improved oncologic therapy,
there are increasing numbers of patients with unresectable disease who develop
complications of biliary obstruction, duodenal obstruction and pain. Palliative procedures for pancreatic cancer are continuing to develop and the options for endoscopic and surgical palliation are improving. There are several safe, effective, and
benecial options for patients. A multidisciplinary discussion with surgeons, interventional gastroenterology, interventional radiology, medical oncology, radiation
oncology, and the patient are critical to deciding which intervention will provide the
best palliation for these patients.
References
1. Howlader N, Noone A, Krapcho M, Neyman N, Aminou R, Waldron W, etal. SEER cancer
statistics review, 1975–2008. Bethesda, MD: National Cancer Institute; 2010.
2. Schmidt CM, Powell ES, Yiannoutsos CT, Howard TJ, Wiebke EA, Wiesenauer CA,
et al. Pancreaticoduodenectomy: a 20-year experience in 516 patients. Arch Surg.
2004;139(7):718–25; discussion 725–7.
3. Sarr MG, Cameron JL.Surgical palliation of unresectable carcinoma of the pancreas. World J
Surg. 1984;8(6):906–18.
4. Bergasa NV. Medical palliation of the jaundiced patient with pruritus. Gastroenterol Clin N
Am. 2006;35(1):113–23.
5. Speer AG, Cotton PB, Russell RC, Mason RR, Hateld AR, Leung JW, etal. Randomised trial
of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice. Lancet.
1987;2(8550):57–62.
29 Palliation ofPancreatic Cancer
6. Saluja SS, Gulati M, Garg PK, Pal H, Pal S, Sahni P, etal. Endoscopic or percutaneous biliary drainage for gallbladder cancer: a randomized trial and quality of life assessment. Clin
Gastroenterol Hepatol. 2008;6(8):944–950.e3.
7. Pinol V, Castells A, Bordas JM, Real MI, Llach J, Montana X, et al. Percutaneous selfexpanding metal stents versus endoscopic polyethylene endoprostheses for treating malignant
biliary obstruction: randomized clinical trial. Radiology. 2002;225(1):27–34.
8. Levy MJ, Baron TH, Gostout CJ, Petersen BT, Farnell MB. Palliation of malignant extrahepatic biliary obstruction with plastic versus expandable metal stents: an evidence-based
approach. Clin Gastroenterol Hepatol. 2004;2(4):273–85.
9. Kadakia SC, Starnes E.Comparison of 10 French gauge stent with 11.5 French gauge stent in
patients with biliary tract diseases. Gastrointest Endosc. 1992;38(4):454–9.
10. Moss AC, Morris E, Leyden J, MacMathuna P.Malignant distal biliary obstruction: a systematic review and meta-analysis of endoscopic and surgical bypass results. Cancer Treat Rev.
2007;33(2):213–21.
11. Chen VK, Arguedas MR, Baron TH.Expandable metal biliary stents before pancreaticoduodenectomy for pancreatic cancer: a Monte-Carlo decision analysis. Clin Gastroenterol Hepatol.
2005;3(12):1229–37.
12. Yoon WJ, Lee JK, Lee KH, Lee WJ, Ryu JK, Kim YT, etal. A comparison of covered and
uncovered Wallstents for the management of distal malignant biliary obstruction. Gastrointest
Endosc. 2006;63(7):996–1000.
13. do Park H, Kim MH, Choi JS, Lee SS, Seo DW, Kim JH, et al. Covered versus uncovered
wallstent for malignant extrahepatic biliary obstruction: a cohort comparative analysis. Clin
Gastroenterol Hepatol. 2006;4(6):790–6.
14. Telford JJ, Carr-Locke DL, Baron TH, Poneros JM, Bounds BC, Kelsey PB, etal. A randomized trial comparing uncovered and partially covered self-expandable metal stents in the palliation of distal malignant biliary obstruction. Gastrointest Endosc. 2010;72(5):907–14.
15. Kullman E, Frozanpor F, Soderlund C, Linder S, Sandstrom P, Lindhoff-Larsson A, etal.
Covered versus uncovered self-expandable nitinol stents in the palliative treatment of malignant distal biliary obstruction: results from a randomized, multicenter study. Gastrointest
Endosc. 2010;72(5):915–23.
16. Saleem A, Leggett CL, Murad MH, Baron TH.Meta-analysis of randomized trials comparing the patency of covered and uncovered self-expandable metal stents for palliation of distal
malignant bile duct obstruction. Gastrointest Endosc. 2011;74(2):321–327.e1–3.
17. Shami VM, Kahaleh M.Endoscopic ultrasound-guided cholangiopancreatography and rendezvous techniques. Dig Liver Dis. 2010;42(6):419–24.
18. Maranki J, Hernandez AJ, Arslan B, Jaffan AA, Angle JF, Shami VM, etal. Interventional
endoscopic ultrasound-guided cholangiography: long-term experience of an emerging alternative to percutaneous transhepatic cholangiography. Endoscopy. 2009;41(6):532–8.
19. Shah JN, Marson F, Weilert F, Bhat YM, Nguyen-Tang T, Shaw RE, et al. Single-operator,
single-session EUS-guided anterograde cholangiopancreatography in failed ERCP or inaccessible papilla. Gastrointest Endosc. 2012;75(1):56–64.
20. Gupta K, Mallery S, Hunter D, Freeman ML.Endoscopic ultrasound and percutaneous access
for endoscopic biliary and pancreatic drainage after initially failed ERCP.Rev Gastroenterol
Disord. 2007;7(1):22–37.
21. Buxbaum JL, Biggins SW, Bagatelos KC, Inadomi JM, Ostroff JW. Inoperable pancreatic cancer patients who have prolonged survival exhibit an increased risk of cholangitis.
JOP. 2011;12(4):377–83.
22. Pola S, Muralimohan R, Cohen B, Fehmi S, Savides T.Cholangitis is common in cancer survivors with metal biliary stents. Gastrointest Endosc. 2011;73(4 Suppl):AB360.
23. Singh SM, Longmire WP Jr, Reber HA.Surgical palliation for pancreatic cancer. The UCLA
experience. Ann Surg. 1990;212(2):132–9.
24. Smith AC, Dowsett JP, Rusell RC, etal. Randomized trial of endoscopic stenting versus surgical bypass in malignant low bile duct obstruction. Lancet. 1994;344:1655–60.
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