Pancreatic lesions will cause a degree of surrounding inflammation causing pancreatitis. There is a tendency to overestimate the lesion. Moreover, it is almost impossible to differentiate malignant from benign tissue on CT or ultrasound.. To determine whether the pancreatic lesion is operable or not the surgeon need to know the interface with the portal vein. Unfortunately, current imaging techniques are not reliable to provide this information. Biopsy of the pancreas is a risky procedure. Complications include pancreatitis and fistula development.

The criteria for surgical exploration are as follows:

1. Reasonable suspicion of malignancy in the head of pancreas.

2. Patient fit enough to tolerate major surgery

3. No evidence of disease progression--distant or local-regional spread.

Generally in most centres about 30% undergo exploratory surgery. About 15% are resectable. However, the outlook for patients undergoing successful surgery are also disappointing. As such, palliative care services are often requested very early in the management. The predominant symptoms requiring palliation include jaundice, pain and duodenal obstruction.

Jaundice may be managed surgically and endoscopically. The risk associated with endoscopic stenting include failure to place the stent, stent blockage by debris and tumour overgrowth of the stent. Surgical bypass usually involve an anastomosis between the proximal biliary tree and the jejunum such as choledochojejunostomy or hepaticojejunostomy whcih provide durable relief of jaundice.

As stent technology continue to advance, the advantages of endoscopic stenting will surpass the surgical method. However, the current position is that surgical bypass is indicated in exploratory surgery if found inoperable.

As for duodenal obstruction, there is controversy as to whether prophylactic bypass should be performed. Advocates claim that nausea and vomiting while uncommon is usually so severe that routine bypass is justified.

Pain is usually very severe in pancreatic cancer. There has been some suggestion that the injection of 50% alcohol into the region of the coeliac axis at the time of exploratory surgery will facilitate subsequent pain management.