Gohil Vishal B, Klapman Jason B
Gastrointestinal Tumor Program, Section of Endoscopic Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL, 33612, USA.
Curr Treat Options Gastroenterol. 2017 Sep;15(3):333-348. doi: 10.1007/s11938-017-0145-z.
Pancreas cancer is a fourth-leading cause of cancer death in the USA and its incidence is rising as the population is aging. The majority of patients present at an advanced stage due to the silent nature of the disease and treatment have focused more on palliation than curative intent. Gastroenterologists have become integral in the multidisciplinary care of these patients with a focus on providing endoscopic palliation of pancreas cancer. The three most common areas that gastroenterologists palliate endoscopically are biliary obstruction, cancer-related pain, and gastric outlet obstruction. To palliate biliary obstruction, the procedure of choice is to perform endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement. We tend to place covered self-expandable metal stents (SEMS) due to their longer patency and removability unless the patient has resectable disease. Pancreas cancer pain is a result of tumor infiltration of the celiac plexus and can be severe and poorly responsive to narcotics. To improve pain control, neurolysis of the celiac plexus has been performed for decades. Since 1996, neurolysis of the celiac area has been performed endoscopically by Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis. This has proven to be as safe and effective as traditional non-endoscopic methods and has allowed the patients to decrease their narcotic use and improve their pain control. This should be done early on in the course of the disease to have maximal effect. Gastric outlet obstruction (GOO) occurs in approximately 15-20% of patients with pancreas cancer. Endoscopic palliation of GOO can be performed by placing uncovered metal enteral stents across the obstruction. This procedure has proven to be very effective in patients who have a short life expectancy (less than two to 6 months) while surgical bypass should be considered for patients with longer life expectancies because it offers better long-term symptom relief. This chapter will review the current literature, latest advancements, and optimal techniques for endoscopic palliation of pancreatic cancer.
胰腺癌是美国癌症死亡的第四大主要原因，且随着人口老龄化，其发病率正在上升。由于该疾病症状隐匿，大多数患者就诊时已处于晚期，治疗更多地侧重于缓解症状而非治愈。胃肠病学家在这些患者的多学科护理中发挥着不可或缺的作用，重点是为胰腺癌患者提供内镜下缓解治疗。胃肠病学家进行内镜下缓解治疗的三个最常见部位是胆道梗阻、癌性疼痛和胃出口梗阻。为缓解胆道梗阻，首选的方法是进行内镜逆行胰胆管造影（ERCP）并放置胆道支架。除非患者患有可切除的疾病，否则我们倾向于放置覆膜自膨式金属支架（SEMS），因为它们的通畅时间更长且可移除。胰腺癌疼痛是由于肿瘤浸润腹腔神经丛所致，可能非常严重且对麻醉药物反应不佳。为了更好地控制疼痛，腹腔神经丛松解术已经实施了数十年。自1996年以来，通过内镜超声引导下腹腔神经丛松解术在内镜下进行腹腔区域的神经松解。事实证明，这与传统的非内镜方法一样安全有效，并且使患者能够减少麻醉药物的使用并改善疼痛控制。这应该在疾病过程的早期进行，以获得最大效果。胃出口梗阻（GOO）发生在约15%至20%的胰腺癌患者中。内镜下缓解GOO可通过在梗阻部位放置无覆膜金属肠内支架来进行。对于预期寿命较短（少于2至6个月）的患者，该手术已被证明非常有效，而对于预期寿命较长的患者应考虑手术旁路，因为它能提供更好的长期症状缓解。本章将回顾胰腺癌内镜下缓解治疗的当前文献、最新进展和最佳技术。
