胰腺癌:腹腔镜切除术

Objective： To assess current role of laparoscopic resection for pancreatic cancer, so as to improve the surgical management of pancreatic cancer. Methods： A comprehensive review of articles from PubMed was carried out. Results： Currently, the advantages of a complete laparoscopic pancreatoduodenectomy （LPD） are still outweighed by the morbidity associated with the procedure. However, laparoscopic distal pancreatectomy （LDP） offers patients benefits in terms of postoperative recovery and the length of hospital stay with similar morbidity and mortality to open surgery. Hand-assisted laparoscopic surgery can help to overcome the limitation of a complete laparoscopic surgery while maintaining a minimally invasive approach. Conclusion： Current literature suggests that laparoscopic resection of pancreatic cancer is feasible and safe in experienced hands. The hand-assisted laparoscopic surgery shows a promising future in pancreatic cancer surgery.     

A nomogram to preoperatively predict 1-year disease-specific survival in resected pancreatic cancer following neoadjuvant chemoradiation therapy

Objective: This study aimed to develop a nomogram to predict the 1-year survival of patients with pancreatic cancer who underwent pancreatectomy following neoadjuvant treatment with preoperatively detectable clinical parameters. Extended pancreatectomy is necessary to achieve complete tumor removal in borderline resectable and locally advanced pancreatic cancer. However, it increases postoperative morbidity and mortality rates, and should be balanced with potential benefit of long-term survival....     

Long-term outcomes after laparoscopic colectomy

AIM:To evaluate long-term outcomes in a large series of patients who randomly received laparoscopic or open colorectal resection.METHODS:From February 2000 to December 2004,six hundred sixty-two patients with colorectal disease were randomly assigned to laparoscopic(LPS,n = 330) or open(n = 332) colorectal resection.All patients were analyzed on an intention-to-treat basis.Long-term follow-up was carried out every 6 mo by office visits.In 526 cancer patients five-year overall and disease-free survival were evaluated.Median oncologic follow-up was 96 mo.RESULTS:Eight(4.2%) LPS group patients needed conversion to open surgery.Overall long-term morbidity rate was 7.6%(25/330) in the LPS vs 11.1%(37/332) in the open group(P = 0.17).In cancer patients,fiveyear overall survival was 68.6% in the LPS group and 64.0% in the Open group(P = 0.27).Excluding stage Ⅳ patients,five-year local and distant recurrence rates were 32.5% in the LPS group and 36.8% in the Open group(P = 0.36).Further,no difference in recurrence rate was found when patients were stratified according to cancer stage.CONCLUSION:LPS colorectal resection was associated with a slightly lower incidence of long-term complications than open surgery.No difference between groups was found in overall and disease-free survival rates.     

Current status and challenges in sentinel node navigation surgery for early gastric cancer

Although a number of feasibility studies for sentinel node (SN) concepts in gastric cancer have been conducted since 2000,there remains a debate regarding detailed detection techniques and oncological safety.Two important multicenter phase Ⅱ clinical trials were performed in Japan that used different methods and reached different conclusions;one confirmed acceptable results with a false-negative rate of 7％,and the other showed an unacceptably high false-negative rate of 46.4％.The Sentinel Node Oriented Tailored Approach (SENORITA) trial is a multicenter randomized controlled phase Ⅲ trial being performed in Korea.Patient enrollment is now complete and the long-term results are currently awaited.Recently,an image-guided SN mapping technique using infrared ray/fluorescence was introduced.This method might be a promising technology because it allows the clear visualization of SNs.With regard to the primary tumor,the non-exposed endoscopic wall-inversion surgery technique and non-exposure endolaparoscopic full-thickness resection with simple suturing technique have been reported.These methods prevent abdominal infection and tumor seeding and can be good alternatives to conventional laparoscopic gastric wedge resection.For indications,SN navigation surgery can be extended to patients who underwent non-curative endoscopic resection.Although a few studies have been performed on these patients,sentinel concepts may be beneficial to patients as they omit the need for additional gastrectomy.SN navigation surgery can lead to actual organ-preserving surgery and plays a key role in improving the quality of life of patients with early gastric cancer in the future.     

Pancreatic cancer–Neoadjuvant therapy

In spite of the high mortality in pancreatic cancer, significant progress is being made. This review discusses multimodality therapy for patients with pancreatic cancer. Surgical therapy currently offers the only potential monomodal cure for pancreatic adenocarcinoma. However only 10%–20% of patients present with tumors that are amenable to resection, and even after resection of localized cancers, long term survival is rare. The addition of chemoradiation therapy significantly increases median survival. To achieve long-term success in treating this disease it is therefore increasingly important to identify effective neoadjuvant/adjuvant multimodality therapies. Preoperative chemoradiation for potentially resectable pancreatic cancer has the following advantages: (1) neoadjuvant treatment would eliminate the delay of adjuvant treatment due to postoperative complications; (2) neoadjuvant treatment could avoid unnecessary surgery for patients with metastatic disease evident on restaging after neoadjuvant therapy; (3) downstaging after neoadjuvant therapy may increase the likelihood for negative surgical margins; and (4) neoadjuvant treatment could prevent peritoneal tumor cell implantation and dissemination caused during surgery. This review systematically summarizes the current status, controversies, and prospects of neoadjuvant treatment of pancreatic cancer.     

Laparoscopic liver resection: Current role and limitations

Laparoscopic liver resection (LLR) for the treatment of benign and malignant liver lesions is often performed at specialized centers. Technological advances, such as laparoscopic ultrasonography and electrosurgical tools, have afforded surgeons simultaneous improvements in surgical technique. The utilization of minimally invasive techniques for liver resection has been reported to reduce operative time, decrease blood loss, and shorten length of hospital stay with equivalent postoperative mortality and morbidity rates compared to open liver resection (OLR). Non-anatomic liver resection and left lateral sectionectomy are now routinely performed laparoscopically at many institutions. Furthermore, major hepatic resections are performed by pure laparoscopy, hand-assisted technique, and the hybrid method. In addition, robotic surgery and single port surgery are revealing early promising results. The consensus recommendation for the treatment of benign liver disease and malignant lesions remains unchanged when considering a laparoscopic approach, except when comorbidities and anatomic limitations of the liver lesion preclude this technique. Disease free and survival rates after LLR for hepatocellular carcinoma and metastatic colon cancer correspond to OLR. Patient selection is a significant factor for these favorable outcomes. The limitations include LLR of superior and posterior liver lesions; however, adjustments in technique may now consider a laparoscopic approach as a viable option. As growing data continue to reveal the feasibility and efficacy of laparoscopic liver surgery, this skill is increasingly being adopted by hepatobiliary surgeons. Although the full scope of laparoscopic liver surgery remains infrequently used by many general surgeons, this technique will become a standard in the treatment of liver diseases as studies continue to show favorable outcomes.     

胰腺癌:治疗性切除术

Resecting pancreatic cancer is the only chance for cure for this devastating disease . It increases survival significantly and may also contribute to a better quality of life . While median survival for patients with unresectable pancreatic cancer is only about 4-8 months, resective surgery improves prognosis to a median survival of 14-20 months and 5-year survival rates of up to 25% . A few studies compared curative resection versus incomplete （R1 and R2） resections whereas only one randomized trial was conducted comparing surgery versus chemoradiation . All these studies confirmed the survival benefit seen in the retrospective data analyses：     

术前支气管动脉灌注化疗在肺癌手术中的临床研究

Objective： How to improve the postoperative 5-year survival rate for lung cancer and to give more patients a chance of surgery have become research hotspots. The aim of this research is to evaluate the clinical and pathohistological responses and effects of preoperative bronchial artery infusion （BAI） chemotherapy in patients with locally advanced （stage Ⅲ） non-small cell lung cancer （NSCLC）. Methods： A total of 92 patients with locally advanced NSCLC were randomly divided into two groups. BAI group received BAI chemotherapy for 2 cycles before surgical resection. Surgery group received operation only. The complete resection rate and clinical response were compared between the two groups. Results： In the BAI group, the clinical response rate and the pathohistological response rate were 68.3% and 51.3%, respectively. The complete resection rate in the BAI group was 89.7%, which was significantly higher than that in the surgery group （72.5%） （P 〈 0.05）. The 1- and 2-year survival rate was 100.0% and 80.6% in the BAI group, and 94.1% and 60.0% in the surgery group. Conclusion： BAI neoadjuvant chemotherapy is safe and effective, which has a good clinical and pathohistological response. It might increase the complete resection rate of the tumor and improve the long term survival rate of stage Ⅲ NSCLC patients.     

A gist of gastrointestinal stromal tumors: A review

Gastrointestinal stromal tumors (GISTs) have been recognized as a biologically distinctive tumor type, different from smooth muscle and neural tumors of the gastrointestinal tract (GIT). They constitute the majority of gastrointestinal mesenchymal tumors of the GIT and are known to be refractory to conventional chemotherapy or radiation. They are defined and diagnosed by the expression of a proto-oncogene protein detected by immunohistochemistry which serves as a crucial diagnostic and therapeutic target. The identification of these mutations has resulted in a better understanding of their oncogenic mechanisms. The remarkable antitumor effects of the molecular inhibitor imatinib have necessitated accurate diagnosis of GIST and their distinction from other gastrointestinal mes-enchymal tumors. Both traditional and minimally invasive surgery are used to remove these tumors with minimal morbidity and excellent perioperative outcomes. The revolutionary use of specific, molecularlytargeted therapies, such as imatinib mesylate, reduces the frequency of disease recurrence when used as an adjuvant following complete resection. Neoadjuvant treatment with these agents appears to stabilize disease in the majority of patients and may reduce the extent of surgical resection required for subsequent complete tumor removal. The important interplay between the molecular genetics of GIST and responses to targeted therapeutics serves as a model for the study of targeted therapies in other solid tumors. This review summarizes our current knowledge and recent advances regarding the histogenesis, pathology, molecular biology, the basis for the novel targeted cancer therapy and current evidence based management of these unique tumors.     

胰腺癌:新辅助治疗

In spite of the high mortality in pancreatic cancer, significant progress is being made. This review discusses multimodality therapy for patients with pancreatic cancer. Surgical therapy currently offers the only potential monomodal cure for pancreatic adenocarcinoma. However only 10%-20% of patients present with tumors that are amenable to resection, and even after resection of localized cancers, long term survival is rare. The addition of chemoradiation therapy significantly increases median survival. To achieve long-term success in treating this disease it is therefore increasingly important to identify effective neoadjuvant/adjuvant multimodality therapies. Preoperative chemoradiation for potentially resectable pancreatic cancer has the following advantages： （1） neoadjuvant treatment would eliminate the delay of adjuvant treatment due to postoperative complications; （2） neoadjuvant treatment could avoid unnecessary surgery for patients with metastatic disease evident on restaging after neoadjuvant therapy; （3） downstaging after neoadjuvant therapy may increase the likelihood for negative surgical margins; and （4） neoadjuvant treatment could prevent peritoneal tumor cell implantation and dissemination caused during surgery. This review systematically summarizes the current status, controversies, and prospects of neoadjuvant treatment of pancreatic cancer.     

A Serum Biomarker Model to Diagnose Pancreatic Cancer Using Proteomic Fingerprint Technology

OBJECTIVE To establish a serum protein pattern model for screening pancreatic cancer. METHODS Twenty-nine serum samples from patients with pancreatic cancer were collected before surgery,and an additional 57 serum samples from age and sex-matched individuals without cancer were used as controls.WCX magnetic beans and a PBS Ⅱ-C protein chip reader (Ciphergen Biosystems Inc) were employed to detect the protein fingerprint expression of all serum samples. The resulting profiles comparing serum from cancer and normal patients were analyzed with the Biomarker Wizard system,to establish a model using the Biomarker Pattern system software. A double-blind test was used to determine the sensitivity and specificity of the model. RESULTS A group of 4 biomarkers(relative molecular weights were 5,705 Da,4,935 Da,5,318 Da,3,243 Da) were selected to set up a decision tree to produce the classification model to effectively screen pancreatic cancer patients.The results yielded a sensitivity of 100%(20/20),specificity of 97.4% (37/38).The ROC curve was 99.7%.A double-blind test used to challenge the model resulted in a sensitivity of 88.9% and a specificity of 89.5%. CONCLUSION New serum biomarkers of pancreatic cancer have been identified.The pa ern of combined markers provides a powerful and reliable diagnostic method for pancreatic cancer with high sensitivity and specificity.     

Surgery of extra-axial tumors of the cerebral base

Because of the complex structure of the cranial base and its close proximity to cranial nerves and vessels, surgery in this area is associated with considerable risk of morbidity and mortality. Multiple approaches to each part of the cranial base have been developed over the past few decades, ranging from small modifications of more traditional approacbes to complex and sophisticated new techniques. However, experience has shown that optimal outcome is achieved if the selected approach is not associated with significant approach-related morbidity. Furthermore, not all cranial base tumors can be cured by surgery. The selection of operative approach and the goal of surgery should be part of the whole treatment strategy. The attempt to achieve complete resection can, therefore, be justified only if the associated long-term morbidity is minimal.     

Laparoscopic approach for hepatocellular carcinoma： where is the limit？

Hepatocellular cancer （HCC） is the sixth most common malignant tumor worldwide and the most common primary liver cancer （1）. Liver resection or liver transplantation is the therapeutic gold standards in patient with HCC. Due to advanced disease, extrahepatic metastases, or inadequate liver reserve, only 15% to 30% of patients with HCC can undergo to surgery （2）. Five-year risk of recurrence of HCC after resection is as high as 70% because the underlying chronic liver disease continues to put the patient at risk for the development of new cancer nodules （3）. Starting from the assumption that recurrence may be newly treated with surgery, laparoscopic approach is recommended,     

Is there a role for surgery in stage Ⅲ A-N2 non-small cell lung cancer?

The role of surgery in stage ⅢA-N2 non-small cell lung cancer(NSCLC) remains controversial.Most important prognostic factors are mediastinal downstaging and complete surgical resection.Different restaging techniques exist to evaluate response after induction therapy and these are subdivided into non-invasive,invasive and alternative or minimally invasive techniques.In contrast to imaging or functional studies,remediastinoscopy provides pathological evidence of response after induction therapy.Although technically more challenging than a first procedure,remediastinoscopy can select patients for subsequent thoracotomy and provides prognostic information.An alternative approach consists of the use of minimally invasive staging procedures as endobronchial or endoscopic esophageal ultrasound to obtain an initial proof of mediastinal nodal involvement.Mediastinoscopy is subsequently performed after induction therapy to evaluate response.In this way,a technically more difficult remediastinoscopy can be avoided.Stage ⅢA-N2 NSCLC represents a heterogenous spectrum of locally advanced disease and different subsets exist.When N2 disease is discovered during thoracotomy after negative,careful preoperative staging a resection should be performed if this can be complete.Postoperative radiotherapy will decrease local recurrence rate but not overall survival.Adjuvant chemotherapy increases survival and is presently recommended in these cases.Most patients with pathologically proven N2 disease detected during preoperative work-up will be treated by induction therapy followed by surgery or radiotherapy.In two large,recently completed,phase Ⅲ trials there was no difference in overall survival between the surgical and radiotherapy arm,but in one trial there was a difference in progression-free survival in favor of the surgical arm.In the surgery arm the rate of local recurrences was also lower in both trials.Surgical resection may be recommended in those patients with proven mediastinal downstaging after induction therapy who can preferentially be treated by lobectomy.Pneumonectomy has a significantly higher mortality and morbidity rate,especially after induction chemoradiotherapy.Patients with bulky N2 disease are mostly treated with combined chemoradiotherapy although the precise treatment scheme has not been determined yet.     

Gastric cancer: Where is the place for the surgeon,the oncologist and the endoscopist today?

Gastric cancer remains a major health issue and a leading cause of death worldwide.While the incidence is decreasing in western countries,there has been a shift to more proximal cancers of the diffuse type,which are usually more aggressive and associated with a worse prognosis.Radical surgery still offers the only chance of long term survival,but surgery has reached a plateau of effectiveness and more aggressive approaches like"ultraradical" lymphadenectomy have not improved prognosis.There are three options to improve the situation:Earlier detection,neoadjuvant chemotherapy and adjuvant therapy.Whilst systematic gastroscopic screening makes sense in countries with a high incidence of gastric cancer,in other regions targeted investigation of risk groups including first-degree relatives of cancer patients,patients with a chronic corpusdominant gastritis or with defined genetic abnormalities may help to detect cancer at an earlier stage.Neoadjuvant chemotherapy has meanwhile proved to significantly improve the prognosis not only in patients with a locally advanced cancer who cannot be resected for cure but but also in those who are potentially amenable to curative resection.In the largest randomised study so far reported,perioperative chemotherapy raised overall survival after 5 years from 23%to 36%.The role of adjuvant chemotherapy has been discussed for over 30 years.Meta-analyses demonstrate a small but significant effect which,however,seems to be restricted to Asian patients.In a large USstudy,adjuvant radiochemotherapy appeared to significantly improve outcomes.However,less than 50%of the study patients underwent a systematic lymphadenectomy and so the results of the therapy group were not better to those of"only resected"patients in two large European studies.Thus,the indication of adjuvant(radio-)chemotherapy in gastric cancer currently remains uncertain.Endoscopists have found a therapeutic role through endoscopic resection of early cancers,introduced mainly by Japanese authors.With the development of high resolution endoscopy,endosonography and adequate equipment,the endoscopic curative resection of T1a-tumors(restricted to the mucosal layer) has been established.     

Clinical importance and surgical decision-making regarding proximal resection margin for gastric cancer

Because of the intramural spread of gastric cancer,a sufficient length of a resection margin has to be attained to ensure complete excision of the tumor.There has been debate on an adequate length of proximal resection margin(PRM) and its related issues.Thus,the objective of this article is to review several studies on PRM and to summarize the current evidence on the subject.Although there is some discrepancy in the recommended values for PRM between authors,a PRM of more than 2-3 cm for early gastric cancer and 5-6 cm for advanced gastric cancer is thought to be acceptable.Once the margin is confirmed to be clear,however,the length of PRM measured in postoperative pathologic examination does not affect the patient’s survival,even when it is shorter than the recommended values.Hence,the recommendations for PRM length should be applied only to intraoperative decision-making to prevent positive margins on the final pathology.Given that a negative resection margin is the ultimate goal of determining an adequate PRM,development and improvement of reliable methods to confirm a negative resection margin intraoperatively would minimize the extent of surgery and offer a better quality of life to more patients.In the same context,special attention has to be paid to patients who have advanced stage or diffuse-type gastric cancer,because they are more likely to have a positive margin.Therefore,a wider excision with intraoperative frozen section(IFS) examination of the resection margin is necessary.Despite all the attempts to avoid positive margins,there is still a certain rate of positive-margin cases.Since the negative impact of a positive margin on prognosis is mostly obvious in low N stage patients,aggressive further management,such as extensive re-operation,is required for these patients.In conclusion,every possible preoperative and intraoperative evaluation should be thoroughly carried out to identify in advance the patients with a high risk of having positive margins;these patients need careful management with a wider excision or an IFS examination to confirm a negative margin during surgery.     

Extent of lymphadenectomy has no impact on postoperative complications after gastric cancer surgery in Sweden

Objective:Curative gastric cancer surgery entails removal of the primary tumor with adequate margins including regional lymph nodes.European randomized controlled trials with recruitment in the 1990's reported increased morbidity and mortality for D2 compared to D 1.Here,we examined the extent of lymphadenectomy during gastric cancer surgery and the associated risk for postoperative complications and mortality using the strengths of a population-based study.Methods:A prospective nationwide study conducted within the National Register of Esophageal and Gastric Cancer.All patients in Sweden from 2006 to 2013 who underwent gastric cancer resections with curative intent were included.Patients were categorized into D0,D 1,or D 1 +/D2,and analyzed regarding postoperative morbidity and mortality using multivariable logistic regression.Results:In total,349 (31.7％) patients had a D0,494 (44.9％) D1,and 258 (23.4％) D1+/D2 lymphadenectomy.The 30-d postoperative complication rates were 25.5％,25.1％ and 32.2％ (D0,D1 and D1+/D2,respectively),and 90-d mortality rates were 8.3％,4.3％ and 5.8％.After adjustment for confounders,in multivariable analysis,there were no significant differences in risk for postoperative complications between the lymphadenectomy groups.For 90-d mortality,there was a lower risk for D1 vs.D0.Conclusions:The majority of gastric cancer resections in Sweden have included only a limited lymphadenectomy (D0 and D1).More extensive lymphadenectomy (D1+/D2) seemed to have no impact on postoperative morbidity or mortality.     

Prospective,single-center cohort study analyzing the efcacy of complete laparoscopic resection on recurrent hepatocellular carcinoma

Background: Laparoscopic hepatectomy is increasingly being used to treat hepatocellular carcinoma (HCC). How?ever, few studies have examined the treatment of recurrent HCC in patients who received a prior hepatectomy. The present prospective study compared the clinical efcacy of laparoscopic surgery with conventional open surgery in HCC patients with postoperative tumor recurrence. Methods: We conducted a prospective study of 64 patients, all of whom had undergone open surgery once before, who were diagnosed with recurrent HCC between June 2014 and November 2014. The laparoscopic group (n = 31)underwent laparoscopic hepatectomy, and the control group (n tion time, intraoperative blood loss, surgical margins, postoperative pain scores, postoperative time until the patient= 33) underwent conventional open surgery. Opera?could walk, anal exsufation time, length of hospital stay, and inpatient costs were compared between the two groups. The patients were followed up for 1 year after surgery, and relapse?free survival was compared between the two groups. Results: All surgeries were successfully completed. No conversion to open surgery occurred in the laparoscopic group, and no serious postoperative complications occurred in either group. No significant difference in inpatient costs was found between the laparoscopic group and the control group (P = 0.079), but significant differencesbetween the two groups were observed for operation time (116.7 ± 37.5 vs. 148.2 ± 46.7 min, P = 0.031), intraopera?tive blood loss (117.5 ± 35.5 vs. 265.9 ± 70.3 mL, P = 0.012), postoperative time until the patient could walk (1.6 ± 0.6vs. 2.2 ± 0.8 days, P < 0.05), anal exsufation time (2.1 ± 0.3 vs. 2.8 ± 0.7 days, P = 0.041), visual analogue scale pain score (P < 0.05), postoperative hepatic function (P < 0.05), and length of hospital stay (4.5 ± 1.3 vs. 6.0 ± 1.2 days,P= 0.014). During the 1?year postoperative follow?up period, 6 patients in each group had recurrent HCC on the side of the initial operation, but no significant difference between groups was observed in the recurrence rate or relapse?free survival. In the laparoscopic group, operation time, postoperative time until the patient could walk, anal exsufation time, and inpatient costs were not different (P > 0.05) between the patients with contralateral HCC recur?rence (n = 18) and those with ipsilateral HCC recurrence (n = 13). However, intraoperative blood loss was signifi?cantly less (97.7 ± 14.0 vs. 186.3 ± 125.6 mL, P = 0.012) and the hospital stay was significantly shorter (4.2 ± 0.7 vs. 6.1 ± 1.7 days, P = 0.021) for the patients with contralateral recurrence than for those with ipsilateral recurrence. Conclusions: For the patients who previously underwent conventional open surgical resection of HCC, complete laparoscopic resection was safe and effective for recurrent HCC and resulted in a shorter operation time, less intraop?erative blood loss, and a faster postoperative recovery than conventional open surgery. Laparoscopic resection was especially advantageous for the patients with contralateral HCC recurrence.     

Current status of robot-assisted gastric surgery

In an effort to minimize the limitations of laparoscopy,a robotic surgery system was introduced,but its role for gastric cancer is still unclear.The objective of this article is to assess the current status of robotic surgery for gastric cancer and to predict future prospects.Although the current study was limited by its small number of patients and retrospective nature,robot-assisted gastrectomy with lymphadenectomy for the treatment of gastric cancer is a feasible and safe procedure for experienced laparoscopic surgeons.Most studies have reported satisfactory results for postoperative short-term coutcomes,such as:postoperative oral feeding,gas out,hospital stay and complications,compared with laparoscopic surgery;the difference is a longer operation time.However,robotic surgery showed a shallow learning curve compared with the familarity of conventional open surgery;after the accumulation of several cases,robotic surgery could be expected to result in a similar operation time.Robotic-assisted gastrectomy can expand the indications of minimally invasive surgery to include advanced gastric cancer by improving the ability to perform lymphadenectomy.Moreover," total" robotic gastrectomy can be facilitated using a robotsewing technique and gastric submucosal tumors near the gastroesophageal junction or pylorus can be resected safely by this novel technique.In conclusion,robotassisted gastrectomy may offer a good alternative to conventional open or laparoscopic surgery for gastric cancer,provided that long-term oncologic outcomes can be confirmed.     

Pancreatic cancer–Palliative therapy: stenting

Pancreatic cancer remains a common and very lethal malignancy with a median survival of approximately 6 months. Surgical resection offers the only potentially curative approach but many patients (80% or more) are ineligible for this kind of therapy, because of age, comorbidities, or locally advanced or metastatic disease that does not benefit from resection. Thus, for many patients with pancreatic cancer treatment remains palliative and endoscopic therapy to relieve bile duct or gastric outlet obstruction becomes of special importance. Although both surgical and non surgical palliative procedures can relieve biliary and duodenal obstruction particularly endoscopic treatment with plastic prostheses or self expanding metal stents was shown to be not only highly effective but also to be burdened with only few complications. The present article summarizes the palliative endoscopic treatment in patients with non resectable pancreatic cancer.