Concomitant laparoscopic gastric and biliary bypass and bilateral thoracoscopic splanchnotomy: the full package of minimally invasive palliation for pancreatic cancer

Introduction: Pancreatic cancer is unresectable in 80% or more of patients. Biliary and duodenal obstruction and intractable abdominal and back pain are the most common complications of the disease. These complications may be palliated effectively using minimally invasive techniques. Their combined application in a single setting is presented and discussed in this article. Case report: A 59-year-old man with a locally advanced carcinoma of the head of the pancreas presented with obstructive Jaundice and intractable pain requiring opiate analgesia. An attempt at endoscopic biliary stenting was unsuccessful, and a percutaneous biopsy was deemed unsafe. Preoperative magnetic resonance cholangiography showed cystic duct insertion abutting the upper limit of the biliary stricture. A laparoscopic Roux-en-Y hepaticojejunostomy, prophylactic loop gastroenterostomy, and tumor biopsy were combined with a bilateral thoracoscopic splanchnotomy. Result: Surgery and subsequent recovery were uneventful, and the patient was discharged from hospital on the fourth postoperative day off opiates. He remained free of jaundice and severe pain, until 6 months later, when he represented with Jaundice, cachexia, and proximal small bowel obstruction secondary to multiple liver and penitoneal metastases. He underwent further palliative laparoscopic enteric bypass with resolution of the intestinal obstruction, but died of the disease 10 days later. Conclusion: Laparoscopic gastric and biliary bypass and bilateral thoracoscopic splanchnotomy may be safely combined to provide an effective comprehensive minimally invasive palliation of incurable pancreatic cancer.