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HOME > Clin Endosc > Volume 59(4); 2026 > Article
Review Latest advancements in endoscopic palliative care for patients with pancreatic cancer
Raquel Gonçalves1,2,3orcid, Joel Silva1,2,3orcid, Eduardo Rodrigues-Pinto1,2,3orcid
Clinical Endoscopy 2026;59(4):497-509.
DOI: https://doi.org/10.5946/ce.2025.227
Published online: April 28, 2026

1Gastroenterology Department, Local Health Unit of São João Hospital, Porto, Portugal

2World Gastroenterology Organization Training Center, Porto; 3Faculty of Medicine, University of Porto, Porto, Portugal

3Faculty of Medicine, University of Porto, Porto, Portugal

Correspondence: Eduardo Rodrigues-Pinto Gastroenterology Department, São João University Hospital Center, Porto. Al. Prof. Hernâni Monteiro, 4200–319 Porto, Portugal E-mail: edu.gil.pinto@gmail.com
• Received: July 10, 2025   • Revised: August 25, 2025   • Accepted: August 26, 2025

© 2026 Korean Society of Gastrointestinal Endoscopy

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Pancreatic cancer is a major cause of cancer-related mortality and is frequently diagnosed at advanced stages when surgery is no longer an option. Most patients require palliative care to manage symptoms, such as jaundice, pain, and gastric outlet obstruction (GOO). Therapeutic endoscopic options, including endoscopic ultrasound (EUS)-guided techniques, have become essential for improving quality of life. We conducted a literature review focusing on the current palliative endoscopic therapy options for advanced pancreatic cancer. Malignant biliary obstruction is primarily treated using endoscopic retrograde cholangiopancreatography. However, when this method is complex or unsuccessful, EUS-guided biliary drainage is considered a reliable and safe alternative. Irradiating stents may increase stent patency times and patient survival. EUS-guided gastroenterostomy, if technical expertise is available, is becoming the first option for GOO in patients with longer survival, with enteral stenting being preferred for patients with limited life expectancies or when the EUS option is not available. Although EUS-guided celiac plexus neurolysis and pancreatic duct drainage play a role in pain management, EUS-guided radiofrequency ablation remains under investigation. In conclusion, endoscopic and EUS-guided interventions provide safe, minimally invasive, and highly effective approaches for the palliative care of pancreatic cancer, enhancing patients’ quality of life and minimizing the need for more invasive surgical procedures.
  • Keywords: Biliary obstruction; Endoscopy, digestive system; Palliative care; Pancreatic neoplasms
Pancreatic cancer (PC) is the 7th leading cause of cancer-related deaths worldwide, with a predicted tendency to increase in prevalence in the coming years.1 In the United States, the average annual incidence of PC between 2015 and 2019 was approximately 13.2 cases per 100,000 individuals. Projections for 2025 estimate 67,440 new cases and 51,980 deaths related to PC.2
While surgery remains the only potential curative option for PC, most patients are diagnosed at advanced stages, often with locally advanced tumors or distant metastases, owing to the lack of early symptoms,2,3 precluding curative surgery at the time of diagnosis. The five-year overall survival rate at diagnosis is approximately 10%.2 For patients with unresectable PC, the median survival time after chemoradiotherapy ranges from 11 to 15 months.2-4
Patients with unresectable PC frequently experience pain, early fullness, nausea, gastric outlet obstruction (GOO), and obstructive jaundice due to local progression, which leads to a significant decline in their quality of life,5 as shown in Figure 1. Therapeutic endoscopy provides several treatment options for palliative PC. It provides multiple options, assisting patients throughout their oncologic treatments while aiming to enhance their quality of life. Consequently, both endoscopic and endoscopic ultrasound (EUS)-guided procedures are commonly used in this context.
In this paper, we discuss endoscopic intervention options for palliative care of PC-related complications, including biliary obstruction, GOO, and cancer-related pain.
Most patients with PC (80%) report abdominal pain, which is one of the most debilitating symptoms that significantly reduces their quality of life and performance status.6 Investigations revealed that pain is adversely associated with reduced survival rates. Severe abdominal pain requiring multiple analgesics, including opioids, is experienced by 40% of patients with PC.7
Abdominal pain is often of multifactorial etiology, resulting from two principal mechanisms: ductal hypertension secondary to obstruction of pancreatic drainage, which may result in pain that worsens after meals, or neuropathic pain due to infiltration of nerve plexuses, which results in constant pain.7
Pain management in PC typically starts by adjusting the analgesic doses, usually from nonsteroidal anti-inflammatory drugs to opioids. However, despite following the World Health Organization (WHO) analgesic steps, these treatments often fail to provide complete pain relief. Pancreatic duct drainage and EUS-guided interventions to treat pain associated with PC, such as celiac plexus neurolysis (CPN), celiac ganglia neurolysis (CGN), and radiofrequency ablation (RFA) of the celiac ganglia, have been explored over the years and may play a role in the management of this multifactorial complication of PC.
Pain due to pancreatic duct obstruction, analogous to that in chronic pancreatitis, results from tumor-related ductal compression, impaired enzyme outflow, and subsequent intraductal hypertension. Cross-sectional imaging frequently reveals ductal dilatation. In this setting, pancreatic duct stenting may effectively decompress the duct and relieve symptoms in selected patients.8
Over the past 15 years, observational studies with limited sample sizes have corroborated the therapeutic value of pancreatic duct stenting in the management of obstructive pain, with reported postoperative pain relief rates ranging from 61% to 100%.8-11 Gao et al.8 demonstrated that in selected patients with obstructive-type PC pain, particularly those with radiologically confirmed pancreatic duct dilation, endoscopic pancreatic duct drainage via endoscopic retrograde cholangiopancreatography (ERCP) resulted in significant short-term pain relief and improvement in quality of life, with notably higher pain remission rates at 1 and 3 months compared to patients without duct dilation.
In 2025, Sun et al.9 showed that at two months post-ERCP, the proportion of patients reporting no pain or only mild pain was 95.0% in the double-stent group (patients with fully covered self-expandable metal biliary stents and pancreatic duct stents) and 68.4% in the single-stent group (patients with only fully covered self-expandable metal biliary stents). At three months, these rates were 95.0% and 47.4%, respectively, and at six months, they were 77.5% and 15.8%, respectively, with all differences reaching statistical significance. Analysis of postoperative analgesic use, classified according to the WHO three-step analgesic ladder, showed that the double-stent group required significantly fewer moderate and strong opioids than the single-stent group at 1, 3, and 6 months. A systematic review and meta-analysis supported this approach as an effective and relatively safe palliative option, showing low rates of stent migration (3.6%) and occlusion (3.0%) with minimal serious adverse events (AEs).12
More recently, EUS-guided pancreatic duct drainage has emerged as a promising alternative in cases in which ERCP fails, offering high clinical success and acceptable safety in a broad cohort of patients, including those with unresectable PC. Overall, endoscopic drainage should be considered as a multimodal palliative strategy, with selection based on ductal anatomy, local expertise, and procedural feasibility.13
The celiac plexus is located in the retroperitoneum over the celiac trunk and the superior mesenteric artery.7,14 PC commonly invades the retroperitoneal nerve plexus.6,7,14
In EUS-guided CPN (EUS-CPN), EUS is used to deliver a neurolytic substance, such as alcohol, directly into the celiac plexus. The goal is to reduce or eliminate pain, improve the patient's quality of life, and potentially reduce the need for systemic opioid use.14 Pure ethanol is commonly administered after bupivacaine injections during CPN. In a study involving 20 patients, Leblanc et al.15 demonstrated the safety of injecting 20 mL of 0.75% bupivacaine followed by either 10 mL or 20 mL of alcohol for EUS-CPN.
Overall, EUS-CPN is a valuable and safe tool in palliative care for patients with PC, offering pain relief, reducing opioid use, and improving quality of life with minor adverse effects, such as diarrhea (38%), transient postural hypotension (1%–3%), and, in rare cases, paraplegia.14,15
A meta-analysis reported that EUS-CPN results in a significant reduction of pain among patients with PC, with a risk ratio (RR) of 0.83 (95% confidence interval [CI], 0.83–0.83), and achieves complete pain relief in some cases, reflected by an RR of 0.09 (95% CI, 0.09–0.09).14 The duration of effective pain control generally ranges from 3 to 6 months.16
Recently, Koulouris et al.17 reported that among 727 patients with PC treated with EUS-CPN, 53% to 80% experienced pain relief, regardless of the technique used (central, bilateral, or CGN injection). These studies also showed that EUS-CGN had higher response rates, with 76% (95% CI, 71%–82%; I2, 0.01%; p=0.38) at week 2 and 58% (95% CI, 48%–69%; I2, 64.9%) at week 4.
Wyse et al.18 reported that early EUS intervention helped reduce pain and possibly decreased morphine usage in patients with pain and unresectable PC, particularly 3 months after treatment. While increasing the number of procedures may not enhance pain relief, CGN has proven to be more effective than standard CPN.
Kamata et al.19 conducted a multicenter investigation to assess the effectiveness of combining EUS-CPN and EUS-CGN in 51 patients with PC. They found that 82.4% of patients experienced a decrease of 3 or more points on the pain scale (numerical rating scale, NRS) 1 week after the procedure. Nevertheless, only 27.4% of the patients attained complete pain relief, defined as an NRS score of 0, 1 week after treatment. The combination of EUS-CPN and EUS-CGN demonstrated superior efficacy and a higher rate of complete pain relief than EUS-CPN alone.
Some studies have identified factors associated with poor response to EUS-CPN. Notably, direct tumor invasion of the celiac plexus and ethanol injection, predominantly on the left side, were both significantly associated with negative outcomes.20 Han et al.21 conducted a retrospective analysis of 58 patients with PC who underwent EUS-CPN and observed that 74.1% of the patients experienced adequate pain control after the first week, with 67.2% maintaining this response at 4 weeks. Moreover, their findings indicated that invasion of the celiac plexus was a key factor associated with the reduced effectiveness of pain relief following EUS-CPN. The presence of distant metastases and invisible ganglia was an additional negative predictor.
Several studies have shown that EUS-CPN provides more consistent and effective pain relief than the percutaneous approach, with reported success rates ranging from 70% to 90%.22 The direct visualization provided by EUS allows for highly accurate needle placement and targeted delivery of neurolytic agents, which is particularly important in patients with distorted anatomy due to tumor growth or previous surgery. In terms of safety, EUS-CPN has fewer AEs.23 The ability to visualize and avoid major vessels during injection significantly reduces the risk of vascular injury, retroperitoneal bleeding, and inadvertent puncture of adjacent organs.20
More recently, the potential clinical outcomes of EUS-guided RFA have been explored. RFA has the potential to impair tumor growth, enhance perfusion within the remaining tumor tissue, and stimulate a systemic antitumor immune response. The reported techniques include targeting the celiac plexus/visualized ganglia or pancreatic lesions. In the former, a 1Fr monopolar probe is advanced through a 19-gauge needle to target either the celiac plexus or the identified ganglia. According to Bang et al.,24 pain management and quality of life outcomes improved relative to traditional EUS-CPN. When performing RFA on pancreatic lesions, the procedure can be carried out either sequentially from the distal to the proximal end or focused centrally within the lesion, leveraging the “thermal diffusivity effect.” Small studies in patients with locally advanced or metastatic PC have suggested the potential benefits of pain relief and quality of life, and in some cases, survival.24-29
Finally, in a clinical trial evaluating EUS-guided celiac ganglion irradiation using iodine-125 seeds, patients experienced significantly reduced pain scores at 4 weeks compared with those undergoing conventional EUS-CPN.23
Current evidence remains limited by small sample sizes, methodological heterogeneity, and short follow-up periods, and definitive conclusions regarding the effectiveness of EUS-guided RFA or celiac ganglion irradiation in unresectable PC cannot yet be drawn. Larger, well-designed comparative trials are warranted.
Malignant biliary obstruction (MBO) requires careful assessment and individualized treatment. ERCP continues to be the primary procedure for biliary drainage because of its high success rates. However, EUS-guided biliary drainage (EUS-BD) is gaining recognition as a reliable option with promising outcomes. Endoscopic options for MBO are summarized in Figure 2. MBO is classified as either proximal (hilar) or distal, a distinction that significantly influences treatment strategies and outcomes. The following sections outline the best approach for managing malignant distal biliary obstruction (MDBO), as up to 70% of patients with PC present with MDBO.4
The key efficacy outcomes of randomized trials and meta-analyses comparing ERCP with EUS-BD for MDBO are summarized in Table 1.30-32
Using the “Surveillance, Epidemiology, and End Results (SEER)-Medicare” program, Tavakkoli et al.33 demonstrated in a 2020 retrospective study involving 14,807 patients with unresectable PC that biliary drainage (versus no drainage) was associated with improved patient survival. When compared to percutaneous transhepatic biliary drainage (PTBD), ERCP-guided drainage was linked to reduced mortality (hazard ratio, 0.67), shorter hospital stays (7±5.7 vs. 9.6±6.6 days, p<0.001), and lower healthcare costs, with no differences in hospitalizations or readmissions at 30 days. Stent selection for ERCP depends on factors such as stricture location, prognosis, and device availability. In a 2021 meta-analysis with 1,005 patients, Scatimburgo et al.34 reported no significant difference between self-expandable metal stents (SEMSs) and plastic stents regarding clinical success (risk difference [RD], −0.03; 95% CI, −0.01 to 0.07; I2=0%), AEs (RD, −0.03; 95% CI, −0.10 to 0.03; I2=57%), or mean survival (mean difference [MD], −0.63 days; 95% CI, −18.07 to 19.33; I2=54%). However SEMSs were associated with fewer reinterventions (RD, −0.34; 95% CI, −0.46 to −0.22; I2=57%) and significantly longer stent patency (MD, 125.77 days; 95% CI, 77.5–174.01). SEMSs are usually preferred even in patients with a life expectancy shorter than 4 months.35
While fully covered SEMSs (FC-SEMSs) seem to be associated with lower tumor ingrowth, they are also associated with higher migration, higher tumor overgrowth, and sludge formation.4 Meta-analyses of multiple randomized controlled trials found no significant differences in patency, clinical outcomes, or AEs, such as cholecystitis or pancreatitis, between the two stent types.36-38 In patients with PC, anti-migration FC-SEMSs may have a longer time to recurrent biliary obstruction,4,39 a benefit not seen with standard FC-SEMSs, with no major differences in procedure-related AEs between the groups. Although it is still unclear which type of stent is best for unresectable MDBO in PC, FC-SEMSs with anti-migration features may be more effective. Japanese guidelines currently recommend the use of FC-SEMSs in these patients.4 Maintaining stent patency in the long term can be challenging, as occlusion occurs in up to half of the cases within the initial 6 to 8 months. To address this issue, drug-eluting and drug-irradiating stents have been developed. While there is no scientific evidence demonstrating the benefit of the use of drug-eluting stents, irradiating stents may be associated with increased patency time (212 vs. 104 days), lower stent re-stenosis, and increased survival (202 vs. 140 days, p=0.020), with no differences in technical success or AEs.40
ERCP-guided endobiliary RFA’s impact on long-term stent patency has also been studied in the past decade.41,42 Endoscopic RFA may reduce tumor burden through localized damage and influence tumor immunity, offering survival benefits for patients not eligible for curative surgery.41,42 However, based on the analysis of available evidence, this topical treatment does not appear to provide significant advantages over conventional SEMSs in terms of stent patency or patient survival for non-primary bile duct malignancies, including liver, gallbladder, and PCs.41,42 This is reflected in recent consensus statements on endoscopic RFA for malignant biliary strictures.43
EUS-BD may serve as an effective alternative in cases of unsuccessful ERCP, challenging biliary cannulation, or altered postsurgical anatomy. In such situations, EUS-BD is a less invasive approach, associated with fewer procedure-related AEs (8.80% vs. 31.22%, p=0.022) and reduced rates of reintervention (0.34 vs 0.93, p=0.02) when compared to PTBD.44
The first multicenter retrospective study that compared ERCP and EUS-BD found similar technical success rates (94.23% for ERCP vs. 93.26% for EUS-BD; p=1.00) and identical AE rates (8.65%). However, ERCP was associated with a 4.8% incidence of postprocedural pancreatitis.45 A supporting meta-analysis showed both techniques demonstrated similar effectiveness in biliary drainage (ERCP, 94.73%; EUS, 93.67%; odds ratio [OR], 1.20; 95% CI, 0.44–3.24), with no significant difference in overall AEs (ERCP, 22.3%; EUS, 15.2%; OR, 1.59; 95% CI, 0.89–2.84). Importantly, post-procedure pancreatitis was more frequently observed after ERCP than after EUS (9.5% vs. 0%; RD, 8%; 95% CI, 1%–14%).30
In patients with a gastroduodenal stent or double obstruction, EUS-BD demonstrated superior technical and clinical outcomes compared with ERCP.46,47 A separate systematic review and meta-analysis further confirmed comparable success rates between the techniques, with fewer reinterventions needed following EUS-BD.48
Wang et al.49 showed in a systematic review of 1,192 patients undergoing EUS-BD after ERCP failure that the technical and clinical success rates were 94.7% and 91.6%, respectively. The AEs rate was 23% and included bile leak (4%), bleeding (4%), pneumoperitoneum (3%), stent migration (3%), cholangitis (2%), abdominal pain (2%), and peritonitis (1%).
EUS-BD can be divided according to the anatomic location and puncture site used to access the biliary tract: choledochoduodenostomy (CDS), hepaticogastrostomy (HGS), and gallbladder drainage (GBD). In patients without GOO, EUS-CDS is typically the first-line approach if the distal common bile duct (CBD) is accessible and dilated, owing to its lower complexity when compared with HGS,50 despite similar technical and clinical success rates (94.1% vs. 93.7%, and 88.5% vs. 84.5%, respectively). Regarding stent options for EUS-CDS, both SEMSs and more recent lumen-apposing metal stents (LAMSs) are viable alternatives in the setting of MDBO,51,52 with current evidence showing no significant differences in terms of technical success, clinical outcomes, or postprocedural AEs.53 However, experts generally prefer LAMSs to FC tubular SEMSs. This is due to the lower complexity involved in the procedure, especially if the freehand method is used, with fewer steps and device exchanges and no risk of wire dislodgement.53,54 A systematic review and meta-analysis that included seven studies with 284 patients who underwent EUS-BD using LAMSs after failed ERCP reported high rates of both technical and clinical success (95.7% and 95.9%, respectively).51 The combined rate of AEs following the procedure was 5.2%, and the recurrence rate was 8.7%. These findings were later supported by a recent large multicenter study.52
EUS-HGS is generally reserved for patients with dilation of the left intrahepatic ducts and an inaccessible CBD or GOO, as it allows for the creation of a fistulous tract between the stomach and the left intrahepatic bile duct, bypassing the CBD.55 Despite being a more complex procedure with a higher rate of AEs, EUS-HGS shows clinical and technical success similar to that of EUS-CDS.26
EUS-guided GBD has emerged as a viable rescue option after unsuccessful ERCP and EUS-CDS or HGS, offering a safe and effective solution for patients with MDBO in whom the cystic duct remains unobstructed. A recent multicenter study including 48 patients achieved a technical success rate of 100% and a clinical success rate of 81.3%, with AEs occurring in 10.4% of the cases.
Ultimately, the decision between drainage approaches depends on several factors, including the endoscopist’s experience, potential risks, and specific anatomical considerations, such as the presence of a dilated bile duct or intrahepatic ducts, duodenal obstruction, or surgically altered anatomy.31,56,57
Considering the promising observation that EUS-BD requires fewer reinterventions with a reduced risk of post-procedure pancreatitis than ERCP, EUS-BD is now being explored as a potential primary therapy instead of ERCP for patients with MDBO.32 However, while ERCP remains effective for biliary decompression irrespective of bile duct dilation, EUS-guided interventions typically require a bile duct diameter >12 mm to ensure procedural feasibility. In a recent retrospective study of 439 patients, Bang et al.58 found that over a 3-year period, 44.9% of patients who underwent ERCPs had an insufficiently dilated bile duct, which was not suitable for EUS-guided intervention. Therefore, although essential as a rescue procedure, EUS-BD should not be considered, at least not yet, as a universal primary approach in this setting.
Figure 3 shows the endoscopic approach to distal biliary strictures in patients with PC.
PC is one of the most frequent causes of GOO in Western countries, affecting 15% to 25% of these patients. It occurs when a mechanical obstruction is caused by pyloric or duodenal stenosis.59,60 GOO-related symptoms include abdominal pain, nausea, vomiting, early satiety, anorexia, bloating, and weight loss, which often progress to cachexia. Associated malnutrition can contribute to dystrophy, fatigue, dehydration, and electrolyte imbalances.61 Thus, malignant GOO significantly affects patient fitness (limiting treatment options), quality of life, and ultimately, patient survival.
Due to the lack of minimally invasive options, surgical gastrojejunostomy (SGJ) has long been the standard treatment for malignant GOO, providing durable symptom relief in up to 72% of patients by restoring food passage. However, SGJ carries significant risks, including high postoperative morbidity, prolonged hospital stays, and delays in initiating chemotherapy. These concerns are especially relevant in older and medically complex GOO populations. Despite advancements in surgical techniques, morbidity rates continue to range from 13% to 55%, with mortality rates ranging from 2% to 36%.
To address this, less invasive treatments have been developed, improving outcomes such as time to re-feeding, hospital stays, and costs of enteral stent (ES) placement and, recently, EUS-guided gastro-entero-anastomosis (EUS-GEA). The choice between EUS-GEA and enteral stenting depends on several factors, with the former usually reserved for patients with a higher expected survival. Several clinical findings (ascites, carcinomatosis, poor nutritional status, and jaundice) or prognostic scores62 may help in selecting the best therapeutic option.
Current evidence shows a favorable safety profile and shorter hospitalization with endoscopic therapeutic options compared to SGJ for the treatment of malignant GOO, with similar clinical success rates.
A systematic review of 19 studies with 1,281 patients showed pooled technical and clinical success rates of 97.3% and 85.7%, respectively.60,63 A 2018 systematic review found that ES allowed a quicker return to oral intake and a shorter hospital stay than SGJ but was nonetheless associated with higher symptom recurrence and reintervention rates.60,64
In a 2023 propensity score-matched study by Tamura et al.,65 short-term outcomes were better in patients who underwent ES placement than in those who underwent SGJ, with a mean follow-up of 129.2 days. However, long-term AEs occurred in 25.5% of patients in the ES group, and survival analysis showed a significantly longer overall survival in the SGJ group. While ES offers quicker symptom relief, its main limitation is the high rate of stent-related issues, often requiring repeated interventions, particularly in patients expected to live longer than 6 months. Recent evidence points to a lower likelihood of oral intake after 1 month with ES placement than with SGJ and EUS-GEA.66
Regarding stent coverage, a systematic review of five trials involving 443 patients with malignant GOO compared FC and uncovered SEMSs (U-SEMSs). The FC-SEMS group had fewer stent occlusions (necessary to treat, 5) but showed a higher risk of migration (RD, 0.09; 95% CI, 0.04–0.14; I2=9%; necessary to harm, 11).67
Takashi et al.,68 in a meta-analysis of six randomized controlled trials and 12 observational studies (2,431 patients), found no significant difference in stent dysfunction rates between uncovered-SEMSs (U-SEMSs) and FC-SEMSs. However, heterogeneity was observed, mainly owing to variations in the types of tumors (intrinsic vs extrinsic) that caused GOO. In the intrinsic tumor group, there was no difference in the dysfunction rates, whereas in the extrinsic tumor group, U-SEMSs had a lower rate of dysfunction compared to FC-SEMSs.
AEs from duodenal stenting ranged from 0% to 30%, depending on the study definitions. Minor events included mild pain, nausea, and vomiting, whereas major complications included bleeding, perforation, and stent migration. SEMS placement can increase the risk of biliary dysfunction in patients with secondary malignant GOO or simultaneous biliary obstruction. In a study by Hamada et al.,69 33 of 410 patients with MDBO received a duodenal SEMS, and 17 (52%) developed biliary dysfunction, averaging 64 days post-placement.70 A recent 20-year study by Tamura et al.65,68 reported that duodenal stent placement for palliating malignant GOO symptoms led to recurrent obstruction in 59% of patients, typically within a median of 28 days.
In 2018, a multicenter retrospective study evaluated the feasibility and safety of performing ERCPs through previously placed ESs in 71 patients with combined malignant GOO and biliary obstruction. The procedure demonstrated a high overall technical success rate of 85%, with varying success rates depending on the obstruction type: highest in types I (87%) and III (100%), and lower in type II (76%). Clinical success generally mirrors the technical success. AEs were rare, occurring in only three patients (4.2%), and the average post-procedure survival was 4.6 months. These findings suggest that ERCP may be performed through ESs, particularly when EUS-guided therapeutic options are not available.71
A comparative summary of the SEMS types for malignant GOO, including technical/clinical success, migration, ingrowth/occlusion, and reintervention, is provided in Table 2.
EUS-GEA is a new, minimally invasive alternative to surgery and ES for the treatment of malignant GOO and was first reported by Khashab et al. in 2015.72,73 Growing evidence supports the benefits of EUS-GEA. In cases of concurrent biliary and duodenal obstructions, the EUS-guided approach may be preferred, depending on the obstruction's location.60
EUS-GEA is conceptually similar to SGJ, with the aim of establishing a connection between the stomach and a segment of the jejunum. The procedure involves identifying a suitable jejunal loop and creating a gastrojejunostomy or jejunojejunostomy under endoscopic and ultrasound guidance. Bi-flanged LAMSs, especially those with electrocautery-enhanced delivery systems, are the preferred devices for creating anastomoses, significantly improving the technical success of the procedure. Despite no differences in technical and clinical success between LAMS with 15 mm or 20 mm diameters, a significantly higher proportion of patients in the 20 mm group tolerated a soft solid/complete diet at the end of follow-up, and the time to oral diet was significantly shorter in the 20 mm group. EUS-GE remains a technically demanding intervention, primarily due to the challenge of accurately identifying and keeping the target jejunal loop closely aligned with the stomach.74 There are several deployment techniques, ranging from direct to device-assisted (EUS-guided double-balloon-occluded gastrojejunostomy bypass or through-the-scope dual-balloon exchangeable enteroclysis cateter). Despite being comparable in terms of success and AE rates, the direct technique seems to be associated with shorter procedure times, while device-assisted methods may be a safer option for beginners, as they provide a more stable and distended jejunum for puncture.74 Regarding technical expertise, previously experienced operators required 25 and 40 procedures to achieve proficiency and mastery, respectively.74,75
Recent meta-analyses have shown that EUS-GEA has achieved more than 90% technical success and up to 90% clinical effectiveness. A multicenter study published this year found that EUS-GEA had a long-term clinical success rate of 91.1% and a technical success rate of 87.5%.76,77 similar to those seen with SGJ for treating GOO.78 Martinet et al.78 reported a relatively low overall AE rate of 10.5% and a symptom recurrence rate of 5.9% within a follow-up period of up to 5 months. A matched study comparing EUS-GEA with ES demonstrated that EUS-GEA had a higher clinical success rate (100% vs. 75%, p=0.006) and a lower recurrence rate (3.7% vs. 33.3%, p=0.02) and showed a tendency for a shorter interval before initiating chemotherapy. EUS-GEA is usually a safe technique, with a 12.9% AE rate in a study of 104 patients, which is consistent with the 13.1% pooled rate from meta-analyses. This rate was significantly lower than the AE rate for SGJ (13.4% vs. 33.3%, p<0.001).79-81
These results suggest that EUS-GEA may be considered among the preferred modalities for treating malignant GOO in centers with appropriate expertise and resources, whereas ES remains an effective and widely available alternative, particularly when EUS-GEA is not feasible or available.
Up to 10% of patients with advanced PC develop combined malignant GOO and MDBO, and the latter usually occurs first.82,83 As previously stated, ERCP with SEMS placement is the standard method of biliary drainage. However, patients with duodenal invasion (DI), which affects up to one-third of patients with PC-SEMSs placed via ERCP, are more prone to early blockage of sludge and food due to increased duodenobiliary reflux. In such cases, EUS-BD may be a suitable alternative.82,83
Previous studies have shown that EUS-BD provides longer stent patency than ERCP-BD in patients with duodenal stents. Additionally, recent evidence suggests that EUS-HGS may result in longer stent function and fewer complications than EUS-CDS in these cases.82,84 Takahara et al.82 showed that EUS-HGS is associated with a lower risk of early stent blockage than ERCP in patients with PC with asymptomatic DI, although it was not associated with improved overall stent patency.
PC presents a formidable clinical challenge, characterized by debilitating symptoms such as abdominal pain, MDBO, and GOO, all of which severely impact patients’ quality of life and overall prognosis. Effective palliation of these complications remains paramount for improving patient outcomes. Figure 4 outlines the therapeutic approaches for complications associated with advanced PC.
Abdominal pain, which affects up to 80% of patients with PC, is often multifactorial in origin and is notoriously difficult to manage with conventional analgesic regimens alone. Pancreatic duct decompression and CPN have emerged as minimally invasive and efficacious techniques, offering substantial pain relief, reducing opioid consumption, and improving quality of life with a favorable safety profile. Recent evidence suggests that EUS-guided interventions targeting the celiac ganglia may provide superior and more durable pain control than traditional methods. Therefore, more data are required regarding the role of EUS-RFA in pain control.
ERCP continues to be the standard of care for biliary drainage, demonstrating high technical success and cost-effectiveness. However, EUS-BD has proven to be a valuable alternative in cases of failed ERCP or complex anatomical variations, providing comparable efficacy with lower AE rates, particularly for postprocedural pancreatitis. While the use of SEMSs is preferred for palliative drainage, ongoing innovations such as irradiating stents may increase stent patency and potentially extend survival.
GOO, another frequent and debilitating complication of PC, has historically necessitated SGJ, which is associated with significant morbidity. Advances in endoscopic techniques, particularly ES placement and EUS-GEA, have introduced highly effective and minimally invasive alternatives.
In conclusion, the integration of advanced endoscopic interventions into the palliative management of PC has significantly transformed the therapeutic landscape. Continued research and refinement of these techniques are essential to further optimize outcomes, reduce complications, and individualize treatment strategies based on patient clinical profiles and preferences. The integration of early palliative care into the treatment plan at the time of diagnosis is increasingly being recognized as essential for improving quality of life. This approach includes not only pain management but also nutritional support, psychological counseling, and coordination of care among multidisciplinary teams. The combination of these interventions, when implemented early, can significantly reduce hospitalizations and AEs, allowing for a better overall patient experience.
Fig. 1.
Clinical manifestations and complications associated with advanced pancreatic cancer.
ce-2025-227f1.jpg
Fig. 2.
Endoscopic treatment of malignant distal biliary obstruction. (A) Endoscopic retrograde cholangiopancreatography biliary drainage using a biliary self-expandable metal stent. (B) Endoscopic ultrasound-guided biliary drainage. Red arrow, choledochoduodenostomy; black arrow, hepaticogastrostomy.
ce-2025-227f2.jpg
Fig. 3.
Sites of progression of advanced pancreatic cancer evolving in major clinical manifestations. Red: Celiac plexus as the target of endoscopic ultrasound-guided neurolysis. Green, distal biliary obstruction; blue, gastric/duodenal outlet obstruction.
ce-2025-227f3.jpg
Fig. 4.
Algorithm for the management of clinical manifestations of advanced pancreatic tumors. ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasound; SEMS, self-expandable metal stent. a)Hydrocodone, codeine, tramadol. b)Morphine, methadone, fentanyl, oxycodone, buprenorphine, tapentadol, hydromorphone, oxymorphone.
ce-2025-227f4.jpg
Table 1.
ERCP vs. EUS-BD for malignant distal biliary obstruction: key effectiveness outcomes
Outcome ERCP EUS-BD Evidence
Technical success Similar Similar ELEMENT RCT; pooled RCT meta-analysis31,32
Clinical/drainage success ≈95% ≈94% Kakked 2020 meta-analysis30
Reinterventions Higher Lower Pooled RCTs/meta-analyses32
Post-ERCP pancreatitis Higher (≈9.5%) Lower (≈0%) Meta-analysis; RCTs align30,32
Overall adverse events Similar Similar No significant difference in pooled analyses30,32
Length of stay Longer Shorter Meta-analyses of RCTs32

ERCP, endoscopic retrograde cholangiopancreatography; EUS-BD, endoscopic ultrasound-guided biliary drainage; RCT, randomized controlled trial.

Table 2.
Duodenal SEMS for mGOO: covered vs. uncovered: effectiveness comparison
Outcome Covered SEMS Uncovered SEMS Comment
Technical success Similar Similar No significant difference
Clinical success Similar Similar No significant difference
Migration Higher Lower Migration increased with covered stents
Tumor ingrowth Lower Higher Covered stents reduce ingrowth/occlusion
Stent dysfunction Similar Similar or lower in extrinsic tumors Subgroup (extrinsic tumor) may favor uncovered SEMS for lower dysfunction
Reintervention No consistent difference No consistent difference
Adverse events Similar Similar Includes bleeding, perforation, etc.

SEMS, self-expandable metal stent; mGOO, malignant gastric outlet obstruction.

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        Latest advancements in endoscopic palliative care for patients with pancreatic cancer
        Clin Endosc. 2026;59(4):497-509.   Published online April 28, 2026
        DOI: https://doi.org/10.5946/ce.2025.227
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      Latest advancements in endoscopic palliative care for patients with pancreatic cancer
      Image Image Image Image
      Fig. 1. Clinical manifestations and complications associated with advanced pancreatic cancer.
      Fig. 2. Endoscopic treatment of malignant distal biliary obstruction. (A) Endoscopic retrograde cholangiopancreatography biliary drainage using a biliary self-expandable metal stent. (B) Endoscopic ultrasound-guided biliary drainage. Red arrow, choledochoduodenostomy; black arrow, hepaticogastrostomy.
      Fig. 3. Sites of progression of advanced pancreatic cancer evolving in major clinical manifestations. Red: Celiac plexus as the target of endoscopic ultrasound-guided neurolysis. Green, distal biliary obstruction; blue, gastric/duodenal outlet obstruction.
      Fig. 4. Algorithm for the management of clinical manifestations of advanced pancreatic tumors. ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasound; SEMS, self-expandable metal stent. a)Hydrocodone, codeine, tramadol. b)Morphine, methadone, fentanyl, oxycodone, buprenorphine, tapentadol, hydromorphone, oxymorphone.

      Fig. 1.

      Fig. 2.

      Fig. 3.

      Fig. 4.

      Latest advancements in endoscopic palliative care for patients with pancreatic cancer
      Outcome ERCP EUS-BD Evidence
      Technical success Similar Similar ELEMENT RCT; pooled RCT meta-analysis31,32
      Clinical/drainage success ≈95% ≈94% Kakked 2020 meta-analysis30
      Reinterventions Higher Lower Pooled RCTs/meta-analyses32
      Post-ERCP pancreatitis Higher (≈9.5%) Lower (≈0%) Meta-analysis; RCTs align30,32
      Overall adverse events Similar Similar No significant difference in pooled analyses30,32
      Length of stay Longer Shorter Meta-analyses of RCTs32
      Outcome Covered SEMS Uncovered SEMS Comment
      Technical success Similar Similar No significant difference
      Clinical success Similar Similar No significant difference
      Migration Higher Lower Migration increased with covered stents
      Tumor ingrowth Lower Higher Covered stents reduce ingrowth/occlusion
      Stent dysfunction Similar Similar or lower in extrinsic tumors Subgroup (extrinsic tumor) may favor uncovered SEMS for lower dysfunction
      Reintervention No consistent difference No consistent difference
      Adverse events Similar Similar Includes bleeding, perforation, etc.
      Table 1. ERCP vs. EUS-BD for malignant distal biliary obstruction: key effectiveness outcomes

      ERCP, endoscopic retrograde cholangiopancreatography; EUS-BD, endoscopic ultrasound-guided biliary drainage; RCT, randomized controlled trial.

      Table 2. Duodenal SEMS for mGOO: covered vs. uncovered: effectiveness comparison

      SEMS, self-expandable metal stent; mGOO, malignant gastric outlet obstruction.

      Table 1.

      Table 2.

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