People may need treatment for their symptoms even before a diagnosis is made. Symptoms can include pain, weight loss, and itching due to jaundice (see ‘Signs and symptoms of pancreatic cancer’). Doctors may prescribe strong analgesics, such as morphine, for the pain, and medicine to control the itching. They may also ask a dietitian to advise the patient to try to prevent further weight loss.
The jaundice is due to a blocked bile duct. To relieve it the doctor may decide to insert a stent to open the bile duct. The stent is a thin plastic or metal tube that is used to support a narrowed part of the bile duct and to prevent it from narrowing again. The decision to insert a stent can be difficult to make.
Mr Ross Carter is a consultant surgeon in upper gastrointestinal (GI) and pancreatico-biliary surgery at Glasgow Royal Infirmary.
Treating the symptoms of pancreatic cancer depends largely on how it presents, and at what stage of disease it presents. When a patient develops jaundice, for instance, one of the areas where we have been trying to improve the patient pathway is to avoid the early introduction of stents before the patient has been properly assessed. In that there is some evidence that putting in stents before doing operations may actually have an adverse effect on the outcome. So what we try and do is to assess the patient relatively rapidly, when they present with jaundice, and make a decision whether surgery may be appropriate, or whether the patient would be better having a stent inserted first. Now, a stent is simply, either a plastic or a metal tube, which is used to hold the sides of the bile duct open, so that the bile from the liver can pass through the narrowed area of the pancreas and out into the intestine. And in allowing the liver to drain then, it allows the jaundice to resolve. The stents can be put in either by endoscopic routes, that’s with a telescope through the stomach and finding the lower end of the bile duct in the duodenum at the ampulla vater and inserting the tube from the bottom up, or alternatively, it can be done from the top down by, under local anaesthetic, putting a needle through the skin on the right hand side, through the liver and then down through the narrowed area into the intestine from the top down.
The doctor may use endoscopic retrograde cholangio pancreatography (ERCP) to place the stent (see ‘Endoscopies and biopsies’). If this is not possible the doctor can use another procedure called percutaneous transhepatic cholangiography (PTC), which involves inserting the stent through the skin of the abdomen in the x-ray department.
Most people we interviewed who had had a stent inserted had had it done during ERCP. Some people found the procedure frightening, uncomfortable or even painful, but others remembered little about it. Some people (or their relative) had had more than one stent inserted. Theadora’s mother, for example, had had five stents inserted during the course of her illness. John’s wife had had a plastic stent replaced by a metal one, with good results.
Steve is an office worker (retired due to ill health). He is married. Nationality/ethnic background' White British.
And they confirmed that yes the bile duct was blocked and it was explained that the, the usual treatment for this is something called a stent. And a stent is in my layman’s language is a an expanding tube which can be fed into the bile duct and when it’s in the right place it pops open, and it immediately forces the bile duct back open and allows all that nasty stuff which is supposed to be digesting your food, out of your pancreas, out of your bile duct and back where it’s supposed to be inside your body.
This is done by inserting a tube down your throat. The, the procedure is called an ERCP, I can never remember what that stands for. It’s a very long complicated name but it’s a tube that they feed down your throat, and they can actually steer it all the way into the bile duct, and a surgeon does this for you. It’s not a comfortable procedure, you lie on your side, and she sprays something on the back of your throat to numb the back of your throat to stop you gagging and trying, trying to resist this tube. And you have a general anaesthetic so you drift off to sleep. When you come round you, your throat feels quite sore because it’s had this tube down it and you feel groggy from the effects of the anaesthesia.
So you had an anaesthetic, rather than a sedative?
It was a sedative, but in effect I fell asleep and I was out for, for a good while, yes, heavily sedated I suppose you would call it. When I woke up I didn’t feel very well, I was in considerable pain from…, I had a bad back, or what felt like a bad back. And this is because the pancreas is inflamed and other organs around that area are quite sore, and there’s some discomfort from a sore throat as well. So I was actually given a painkiller to deal with that. That took a while to arrive which was unfortunate. They have to get permission to give you the painkiller. It was actually given to me intravenously which I didn’t react well to, and it made me feel immediately nauseous, which was a very uncomfortable feeling, but that, that did pass quite quickly.
Did they do a biopsy at the same time?
Yes they did, they take, a biopsy is a little scraping, they take a little bit of the tumour, remember it’s just a, they call it a tumour at this stage, and that goes off for testing. So at this stage I’m still not, I haven’t had a confirmed diagnosis of cancer as such, they are still dealing with a tumour.
So within a very short time this stent, it’s marvellous because the jaundice starts to disappear and your yellowness starts to fade, your eyes become white instead of yellow, the rash stops forming and you no longer feel very itchy. So great relief after probably, yes, over a week of being very uncomfortable with the jaundice, it starts to fade over the course of maybe 48 hours. And rather than being quite unwell within probably 48 hours, I was able to be up and about and doing, and I actually was able to leave the hospital for a couple of hours, go out and have a meal out and get a break from the hospital and feeling unwell, and hospitalised in a hospital is not a very nice place to be at the best of times. So yes I would say a stent, a stent is a, is a marvellous thing.
Age at interview:
Age at diagnosis:
Helen is married and has 2 children. She is a clerical officer. Ethnic background/Nationality' White British.
Because of, I had a blockage, apparently, in my bile duct and they couldn’t see, it was all very clouded, so they couldn’t tell me for certain whether something was there. They did a test, not a test, a procedure called ERCP, where they put a tube down, and they can see everything, they can explore it to see what’s there. Because of the blockage they couldn’t get all the way. But they did put a little stent in to help clear the [bile duct], so that there was a clear path for the bile to go through, which cleared my jaundice then, which was a difficult, I found it a difficult procedure, because you, although they sedate you while you’re, while you’re having it done, you are aware of it, especially towards the end of what they’re doing. And it was quite painful afterwards. So I was in pain for quite a while after the procedure. But the jaundice did clear thankfully, because they’d got the stent in place.
So you had this procedure. You were still in hospital.
I had that procedure. And unfortunately after the procedure I got pancreatitis, which was very bad, and I was very, very poorly. They were giving me antibiotics intravenously. I think they stopped me, I couldn’t, I wasn’t allowed to drink or eat, and they also catheterised me at one point, because they needed to monitor my input and output, which was very important. They were constantly doing observations, temperature, pulse, blood pressure etc. Things were quite tricky. And it wasn’t till I was really on the mend that the surgeon actually said to me, came to see me, my consultant, and he said, “We were very, very worried about you.” And he said, “Do you know what I mean?”
Did you get an infection in the pancreas as a result of the procedure?
I did. Yes, it was, it was very nasty. It took quite a while to get rid of it. But once that was on the mend, I was fine and I was back up on my feet and, and I could go home then. But it was a case of waiting then to see a specialist in the field of pancreatic cancer.
Did they do a biopsy at the same time they put the stent in?
They did, yes. But it was inconclusive again. They couldn’t really get to it properly to, to get a good biopsy. So that was, it was all very, although I was told, on more than one occasion in hospital, that they suspected it was going to be a tumour, they couldn’t, they couldn’t say, “Yes, it was definitely.” They could only say, “It’s more than likely going to be.”
Sometimes the doctors try to insert a stent during an endoscopy, but do not succeed, so they insert the stent through the skin of the abdominal wall. A local anaesthetic is used to numb the area around the puncture site. Then a special dye is injected through the skin, and through the liver, into the bile duct, to show up the blockage, then x-rays are taken (percutaneous transhepatic cholangiography). A hollow needle is inserted into the bile duct, and a thin guide wire inserted into it. The wire is guided to the area of obstruction. The X-ray helps the doctor to see where to put the wire. Once the wire is in place, the doctor feeds the stent, which looks like a tube, along the wire until it is in place inside the bile duct. Then the doctor can pull out the wire.
Less invasive means of imaging the bile ducts include transabdominal ultrasound. Richard (Interview 22) thought that his doctor had used ultrasound to help him insert a stent in the right place.
Richard is single. He is a teacher (now retired). Ethnic background/Nationality' White British.
So how long were you in hospital to have this stent?
Oh, well, in the end a long time, for something like, something over a week I suppose. I missed the whole of Easter 2007 I remember. Because I had this problem over the INR [a blood clotting test] and the jaundice and we had to wait for that to clear up. Then, the idea was to put the stent in, down through, down through my mouth, and there was a valve in the end of the pancreatic duct, as I understand it, and they were going to force the stent in against the valve, the opposite way to the, to which the valve is meant to operate. And the valve was too strong. They couldn’t do it. So, so that operation had to be aborted. And then, so they then tried again by coming into my abdomen through the side here and putting the stent in. And that was successful. So it took…, and, and then I had to wait then for the liver function to, to regain its normal state.
Age at interview:
Age at diagnosis:
Richard was a finance director for a multi-national company. He is now retired. He is divorced and has three children. Nationality/ethnic background' White British.
Can you say a little bit more about the procedure they had to do to put the stent in, in the end through your stomach?
Was that under anaesthetic for example?
That was again under local anaesthetic. It was, what happened was I was kept in over night, in the hospital after my failed endoscopy. And they said, “We, we are going to try and get someone to do it tomorrow morning.” And sure enough I went down and I was given a similar form of sedation, where I, it wasn’t a general anaesthetic, but it was somehow a little bit more powerful than a local anaesthetic. I lay on my side, there was an insertion made in my side, guided in by an ultrasound camera, and the whole process took about ten minutes.
And again was painless. And I was then taken back to the ward. I slept for an hour or so, and two hours later I was right as rain, and very, very hungry.
So that’s good to know. So not a painful procedure?
No. And then a couple of weeks later I had a similar procedure done to take a biopsy which was again an insertion in my side, guided by ultrasound, and a sample was taken which enabled them to finally confirm the diagnosis that it was cancer.
Where possible, major surgery is performed to remove the cancer (see‘Potentially Curative Surgery’). If during the operation the surgeon finds that the cancer has spread too far and cannot be removed they may do a smaller operation to bypass the bile duct or duodenum to relieve symptoms caused by jaundice or a blockage of the duodenum.
When one man came round from the anaesthetic he was very disappointed to learn that the surgeon had only been able to bypass his bile duct instead of removing the tumour. Another man awoke to discover he had had a bypass operation to relieve a block in the small intestine.
He is a retired rigger; he is married with three children.
It was cancer round the pancreas and the tubes were, when my food goes through that way, I’ve not got a very clear, I asked for a technical definition I did get one, verbally but I didn’t get it in writing so I can’t explain exactly what it is but, I was getting chronic indigestion and turned yellow, jaundice and went to the hospital and I was two weeks in there and I had several different scans, they couldn’t make up their minds even then what it was. I don’t know really why so I came home for Christmas from the hospital, went back in two week’s time and they opened me up then to have a look and you know found that it was too far gone to do any, to undergo surgery and so they made up two tubes from bits and pieces of my intestine some where, that part of my flesh. They made two by-pass tubes round the bit that was being strangled so that I could still eat and drink and it was a bit of a relearning process because I’ve lost all of my refinements, all of the digestive refinements you know you don’t realise what a wonderful mechanism you’ve, it’s, got in there until you lose a bit of it, [laugh].
Ben started to vomit due to a bowel blockage some time after a failed operation to remove his tumour, so was opened up a second time for a gastrojejunostomy.
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