**6. Conclusions**

470 New Advances in the Basic and Clinical Gastroenterology

Fig. 5. A case of duodenal obstruction caused by locally advanced pancreatic cancer (A) and was successfully treated with a SEM duodenal stent (B).This patient also had a SEM biliary

Approximately 70% of patients with unresectable pancreato-biliary cancer develop clinically important pain, which can significantly reduce the quality and quantity of life of these patients (Andren-Sandberg et al., 1999). Good pain relief is, therefore, an essential part of effective palliative care. Although opioid analgesics are most commonly used as the first line pain relieved medication, one third of patients experience inadequate control of pain with significant side effects such as constipation and drowsiness (Andren-Sandberg et al., 1999). In these patients, neurolytic celiac plexus block under radiological or surgical guidance with absolute alcohol can be performed with up to 90% success rate (Mercadante et al., 2003; Wong et al., 2004; Noble and Gress, 2006). Recent studies have shown that EUS-guided neurolysis is equally effective but has significantly fewer serious complications associated with surgical or percutaneous approaches (O'Toole and Schmulewitz, 2009; Puli et al., 2009)

Fig. 6. Celiac ganglia can be visualized clearly on EUS imaging (panel A). Examples of EUS

guided celiac ganglion blockage with alcohol injection (panel B).

stent inserted for biliary drainage prior to the duodenal stent placement (C).

**5.3 Alleviation of pain** 

Despite the recent advances in diagnostic modalities, chemo-radiotherapy, surgical and post-operative care, the overall prognosis of pancreato-biliary malignancies has barely changed over the last few decades. The management of these patients is often complex and requires expertise in many fields. Thus, multidisciplinary teams are necessary to optimize the overall care. As the majority of these patients are diagnosed in advanced stages, good palliative care measures are essential to the management. Fortunately, a number of advances in endoscopic techniques have been made to improve the quality of life of these patients and avoid unnecessary surgery.
