**5. Palliative care for pancreatic cancer patients**

Pancreatic cancer is the twelfth most common cancer in the world and the seventh leading cause of cancer death. It has a poor survival rate, it mortality rate about 4.0% of all cancer deaths [78–80]. Now a day surgical resection is the only choice for treatment, however, only 20% of pancreatic cancer is surgically removable at the time of diagnosis [81–83]. The maximum survival rates are 22–26 months in patients who are undergoing surgical resection and taking adjuvant therapy resect able to improve survival [84–87] latest studies evaluating the effect of neoadjuvant therapy on highly picked patients with resect able disease have led to median survival life about 44 months in patients with R0 resection, node-negative disease [88–90].

#### **5.1 Planned operative and endoscopic palliation**

Choledochojejunostomy or Roux-en-Y hepatico was surgical palliation that was most commonly done. But its performance fell out of favor as a result of a high probability of cystic duct, gastric outlet, or duodenal obstruction by the tumor over time, as well as the likelihood of bile reflux into the stomach. The placing of endoscopic biliary stents throughout endoscopic retrograde cholangiopancreatography (ERCP) is the favorite method for palliation of obstructive jaundice in patients with metastatic or unresectable pancreatic cancer. Development in endoscopic technology results in successful stent placement in more than 90% of patients during ERCP with the same efficacy, but less mortality and morbidity in comparison with surgical palliation with biliary-enteric bypass. After all, studies still present the majority of patients who are stented have an enhancement in quality of life, even with higher rates of recurrence [91–93]. Prophylactic gastrojejunostomy was associated with a diminished incidence of late GOO (gastric outlet obstruction). It was also indicated in patients with unresectable periampullary cancer that undergo exploratory laparotomy [94–96].

#### **5.2 Endoscopic palliation**

Treatment of gastric outlet obstruction can be done endoscopically, with placing of large self-expanding stents which are successful in 92–100% of cases permitting patients to take back oral intake in 24 hours in 73–93% of patients. Even though patients can control their own drink liquids and salivary secretions, stent obstruction usually occurs with solid food [91, 93].

#### **5.3 Thromboembolic disease**

Pancreatic cancer patients have one of the highest frequencies of pulmonary embolism (PE) or deep venous thrombosis (DVT) with incidence rates between 17 and 57%. Anticoagulation drugs with low-molecular-weight heparin or a direct oral anticoagulant are useful in patients who develop a VTE. Many studies estimate this risk, showing a 10–25% risk of VTE, with minimization to 5–10% with thromboprophylaxis but no effect on survival. Treatment includes treatment with low weight molecular heparin (LWMH), unfractionated heparin, or oral anticoagulation [97].
