Endoscopic or surgical intervention for painful obstructive chronic pancreatitis
Endoscopy and surgery are the treatments of choice in patients with chronic pancreatitis and a dilated pancreatic duct. In this review we compared these two intervention modalities. We found that surgery achieved pain relief in a higher proportion of patients than with endoscopy. Surgery also had other advantages like improved quality of life and reduced risk of developing exocrine pancreatic insufficiency. The studies seemingly showed no difference in complications after intervention between endoscopy and surgery, but lacked the power to establish this with sufficient reliability. We also compared surgery to conservative treatment. Results of one trial suggested that surgery early in the disease achieved better pain relief and preservation of pancreatic function. The trial, however, was small, which precluded drawing reliable conclusions.
Available from: PubMed Central
- "Resection is considered in patients who have failed other forms of therapy or those who are not candidates for a drainage procedure (usually patients with predominantly small duct disease). This may result in exocrine and endocrine dysfunction, as these patients may not have enough remaining functioning pancreatic reserve considering their history of chronic pancreatitis.6,7,31,32 Denervation can be achieved using an open surgical approach or using thoracoscopic surgery/bilateral thoracoscopic splanchnicectomy.33,34 "
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ABSTRACT: Abdominal pain is a principal and in many cases, the only observable symptom of chronic pancreatitis. Like all chronic pain conditions, managing abdominal pain in chronic pancreatitis remains an onerous task for health care providers. Different mechanisms have been postulated in trying to better understand the pathogenesis of pain in chronic pancreatitis. This review seeks to take a broad look at the various options that are available to providers in trying to achieve pain relief and a better quality of life for chronic pancreatitis patients.
Available from: Dirk J Gouma
- "No exact levels of Izbicki scores are known for this research arm. The one small RCT by Nealon et al. that has studied the topic of early surgery in chronic pancreatitis only presented pain as proportion of patients with pain relief (94% for the early surgical group versus 13% for the non-surgical group) [13,15]. We choose not to use these values for our sample size calculations for several reasons: "
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In current practice, patients with chronic pancreatitis undergo surgical intervention in a late stage of the disease, when conservative treatment and endoscopic interventions have failed. Recent evidence suggests that surgical intervention early on in the disease benefits patients in terms of better pain control and preservation of pancreatic function. Therefore, we designed a randomized controlled trial to evaluate the benefits, risks and costs of early surgical intervention compared to the current stepwise practice for chronic pancreatitis.
The ESCAPE trial is a randomized controlled, parallel, superiority multicenter trial. Patients with chronic pancreatitis, a dilated pancreatic duct (≥ 5 mm) and moderate pain and/or frequent flare-ups will be registered and followed monthly as potential candidates for the trial. When a registered patient meets the randomization criteria (i.e. need for opioid analgesics) the patient will be randomized to either early surgical intervention (group A) or optimal current step-up practice (group B). An expert panel of chronic pancreatitis specialists will oversee the assessment of eligibility and ensure that allocation to either treatment arm is possible. Patients in group A will undergo pancreaticojejunostomy or a Frey-procedure in case of an enlarged pancreatic head (≥ 4 cm). Patients in group B will undergo a step-up practice of optimal medical treatment, if needed followed by endoscopic interventions, and if needed followed by surgery, according to predefined criteria. Primary outcome is pain assessed with the Izbicki pain score during a follow-up of 18 months. Secondary outcomes include complications, mortality, total direct and indirect costs, quality of life, pancreatic insufficiency, alternative pain scales, length of hospital admission, number of interventions and pancreatitis flare-ups. For the sample size calculation we defined a minimal clinically relevant difference in the primary endpoint as a difference of at least 15 points on the Izbicki pain score during follow-up. To detect this difference a total of 88 patients will be randomized (alpha 0.05, power 90%, drop-out 10%).
The ESCAPE trial will investigate whether early surgery in chronic pancreatitis is beneficial in terms of pain relief, pancreatic function and quality of life, compared with current step-up practice.
Available from: Femke Anne Mauritz
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ABSTRACT: OBJECTIVE To evaluate the effect of timing of surgery on the long-term clinical outcome of surgery in chronic pancreatitis (CP). DESIGN Cohort study with long-term follow-up. SETTING Five specialized academic centers. PATIENTS Patients with CP treated surgically for pain. INTERVENTIONS Pancreatic resection and drainage procedures for pain relief. MAIN OUTCOME MEASURES Pain relief (pain visual analogue score ≤4), pancreatic function, and quality of life. RESULTS We included 266 patients with median follow-up of 62 months (interquartile range, 31-112). Results were presented as odds ratios (ORs)with 95% confidence intervals after correction for bias using bootstrap-corrected analysis. Pain relief was achieved in 149 patients (58%). Surgery within 3 years of symptoms was independently associated with more pain relief (OR, 1.8; 95% CI, 1.0-3.4; P = .03) and less endocrine pancreatic insufficiency (OR, 0.57; 95% CI, 0.33-0.96; P = .04). More pain relief was also observed in patients not taking opioids preoperatively (OR, 2.1; 95% CI, 1.2-4.0; P = .006) and who had 5 or fewer endoscopic treatments prior to surgery (OR, 2.5; 95% CI, 1.1-6.3; P = .04). The probability of achieving pain relief varied between 23% and 75%, depending on these risk factors. CONCLUSIONS The timing of surgery is an important risk factor for clinical outcome in CP. Surgery may need to be considered at an earlier phase than it is now, preferably within 3 years of symptomatic CP. Likelihood of postoperative pain relief can be calculated on an individual basis using the presented nomogram.
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