Update on management of pancreatic cancer: a literature review.

BACKGROUND AND OBJECTIVE: Pancreatic cancer is an aggressive malignancy with high mortality. At the time of diagnosis, majority of patients (80-90%) present with either locally advanced unresectable disease or metastatic disease. Even after curative resection, the recurrence rate remains quite high. This article aimed at reviewing the updated management of pancreatic cancer. METHODS: We identified literature by searching Medline and PubMed from January 2010 to June 2023 using the keywords. KEY CONTENT AND FINDINGS: A multidisciplinary approach is essential to optimize the outcomes for both curable and advanced diseases. Management of pancreatic cancer divided into resectable, borderline resectable, locally advanced, and metastatic diseases. Surgery and adjuvant chemotherapy is a standard treatment approach for resectable pancreatic cancer. The recommended adjuvant chemotherapy regimen for patients with good functional status is modified FOLFIRINOX (5-fluorouracil, folinic acid, irinotecan, and oxaliplatin). The recommended adjuvant chemotherapy regimen for patients with suboptimal functional status is gemcitabine plus capecitabine or monotherapy gemcitabine. The optimal treatment strategy for borderline resectable pancreatic cancer is still uncertain. Traditionally, upfront surgery is the choice of treatment. There is increasing evidence showing benefits of neoadjuvant therapy in borderline resectable pancreatic cancer. However, the optimal neoadjuvant treatment regimen was not certain yet. Advancement of chemotherapy has a positive impact for the survival of advanced disease. For patients with good functional status, the recommended first-line systemic chemotherapy for unresectable locally advanced disease or metastatic disease is combination chemotherapy regimens such as FOLFIRINOX, gemcitabine plus nab-paclitaxel. For patients with suboptimal functional status, the recommended first-line systemic chemotherapy for unresectable locally advanced disease or metastatic disease is gemcitabine plus capecitabine or monotherapy gemcitabine. Recently, more researches showed promising results in the use of nanoliposomal irinotecan, targeted agents such as a poly [adenosine diphosphate (ADB)-ribose] polymerase inhibitor, tyrosine receptor kinase (TRK) inhibitors, and immune checkpoint-inhibitors. CONCLUSIONS: Pancreatic cancer is a challenging disease for management. Radical surgery itself is not enough for prolong survival. The improvement of chemotherapy, target agents and immunotherapy with multidisciplinary approach will be the only solution for improvement of survival outcome and quality of life for patients with pancreatic cancer.

Concomitant Bouveret's syndrome and biliary obstruction: A tailored treatment approach for an elderly patient.

INTRODUCTION AND IMPORTANCE: Bouveret's syndrome is a very rare form of gallstone ileus, that occurs when a sizable gallstone enters the gastrointestinal tract via a bilioenteric fistula and is impacted in the pylorus or proximal duodenum, causing gastric outlet obstruction. It usually occurs in a geriatric population with multiple comorbidities, and causes significant morbidities and mortalities. CASE PRESENTATION: An 88-year-old patient with concomitant Bouveret's syndrome and biliary obstruction was presented. The duodenal obstructed stone and biliary stone were successfully removed by endoscopic approach. The patient resumed diet on day-1 and recovered smoothly. CLINICAL DISCUSSION: Due to the rarity of Bouveret's syndrome, there are no standardized recommendations for the management of these patients, including open, laparoscopic surgical approach or endoscopic approach. Minimally invasive treatment was tailored to the condition of the patient and clinical findings. CONCLUSION: The best approach is the one tailored to each patient, with the consideration of the patient's medical condition, age, comorbidities, life expectancy, and available expertise. This article highlights the key features of the disease, and the precautions during endoscopic treatment.