Here we talk about people's experiences of having their pancreatic symptoms treated with stents and bypass surgery.
People may need treatment to manage the
symptoms of pancreatic cancer before the cancer itself is treated. Symptoms can include pain, itching (from jaundice), sickness or weight loss. Your doctor might give you painkillers for the pain and medicine to control the itching. They may also ask a dietitian to give advice to prevent weight loss.
Sometimes pancreatic cancer can block your bile duct and cause jaundice. It can also cause a blockage in your intestine causing sickness and weight-loss. These blockages can be treated by stents and bypass surgery.
Stents
A stent is a thin plastic or metal tube. Doctors use a stent to support part of the bile duct and help keep it open. Stents can also be used to treat a blockage in the small intestine (duodenum).
A consultant explains why it is important to assess the situation carefully before inserting a stent and describes how it is done.
A consultant explains why it is important to assess the situation carefully before inserting a stent and describes how it is done.
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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.
Putting in a stent with ERCP
ERCP was used in the case of most of the people we spoke to. Some people found it scary, uncomfortable or even painful. Others rdidn't remember much about it. Some people had more than one stent out in. Theadora’s mother had five stents during the course of her illness. John’s wife had a plastic stent replaced by a metal one, with good results.
Steve had a stent inserted to relieve his jaundice. He felt much better after the procedure. The surgeon did a biopsy at the same time.
Steve had a stent inserted to relieve his jaundice. He felt much better after the procedure. The surgeon did a biopsy at the same time.
Age at interview: 47
Sex: Male
Age at diagnosis: 47
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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.
Helen had a stent inserted to relieve jaundice and had a biopsy at the same time. Afterwards she developed pancreatitis and was very ill.
Helen had a stent inserted to relieve jaundice and had a biopsy at the same time. Afterwards she developed pancreatitis and was very ill.
Age at interview: 49
Sex: Female
Age at diagnosis: 47
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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.”
Putting in a stent with PTC
If this is not possible to use ERCP the doctor can go in through the wall of your tummy. This procedure is called percutaneous transhepatic cholangiography (PTC). Dye is injected through the skin, and liver, into the bile duct, to show up the blockage, then x-rays are taken (percutaneous transhepatic cholangiography) to help the doctor to see where to put the stent.
Another way doctors use to see inside the bile ducts is transabdominal ultrasound. Richard (Interview 22) thought that his doctor had used ultrasound to help him insert a stent in the right place.
When Richard needed a stent the surgeon tried to insert one using an endoscopy but was unsuccessful. The surgeon managed to insert it through the skin.
When Richard needed a stent the surgeon tried to insert one using an endoscopy but was unsuccessful. The surgeon managed to insert it through the skin.
Age at interview: 63
Sex: Male
Age at diagnosis: 60
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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.
Richard's surgeon failed to insert a stent using ERCP. The surgeon used ultrasound to help him insert a stent through Richard's abdominal wall.
Richard's surgeon failed to insert a stent using ERCP. The surgeon used ultrasound to help him insert a stent through Richard's abdominal wall.
Age at interview: 59
Sex: Male
Age at diagnosis: 58
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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?
Yes.
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.
Bypass surgery
Where possible, doctors can do surgery to remove the cancer. In some cases the surgeon might find that the cancer has spread too far and can't be removed. If this happens, they may do a smaller operation to bypass the bile duct or duodenum (the first part of the small intestine). This can help stop the symptoms of jaundice or unblock the duodenum.
One man had surgery but the surgeon was unable to to remove his tumour (cancer). Instead the surgeon had only been able to bypass the bile duct. The man was very disappointed when he woke up from the surgery. Another man awoke to discover he had had a bypass operation to relieve a block in his small intestine.
Surgeons performed a gastrojejunostomy to overcome the obstruction caused by the tumour and to relieve his symptoms.
Surgeons performed a gastrojejunostomy to overcome the obstruction caused by the tumour and to relieve his symptoms.
Age at interview: 72
Sex: Male
Age at diagnosis: 70
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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's surgeon wasn't able to remove his tumour. Some time later his bowel became blocked and he started being sick. He then had another operation to bypass the blockage.
Last reviewed November 2020.
Last updated November 2020.
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