The majority of patients with pancreatic carcinoma (hepaticojejunostomy) unfortunately will have palliative treatment and palliation of symptoms is important to improve Quality of Life. The most common symptoms that require palliation are jaundice, gastric outlet obstruction and pain. Obstructive jaundice should be treated with a biliary bypass, the optimal palliation in relatively fit patients and endoscopic stenting is preferred in patients with short survival (3-6 months). To prevent gastric outlet obstruction a prophylactic gastroenterostomy should be performed routinely during bypass surgery. Symptomatic patients after earlier stenting of the bile duct can be treated nowadays by duodenal stenting. Pain management is according to the progressive analgesic ladder but a (percutaneous) neurolytic celiac plexus block may be indicated. Currently a R1 (palliative) resection is acceptable in high volume centres but so far there is a very limited role for planned R2 palliative resections.