For all patients the aim is to relieve jaundice, duodenal obstruction, weight loss, and pain. The majority of patients will present with advanced disease, and a third present with disease so advanced only pain relief and symptomatic palliative care is possible.
Oral pancreatic enzyme supplements may be required for pancreatic exocrine insufficiency. Non-surgical relief of jaundice is indicated for patients with unresectable disease and those unfit for resection of localized disease. Prior to any procedure attention is required to ensure adequate urine output and correction of coagulopathy, anaemia, and hypoproteinaemia. Antibiotic prophylaxis is mandatory.
Endoscopic stents have relative low morbidity rates and metallic stents are preferred for patients with expected longer survival. Percutaneous transhepatic stenting has a higher complication rate. Surgical biliary bypass is indicated for younger patients with a low tumour burden; 10-15% of these will develop duodenal obstruction, so prophylactic duodenal bypass may be indicated.
Following these palliative manoeuvres the median survival rate is dismal—between 3 and 6 months; the overall five-year survival rate is 0.5%.
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