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Endoscopic vs. Surgical Drainage for Chronic Pancreatitis

At 2 years, surgery patients had lower pain scores and better physical-health scores than did endoscopy patients.

Pancreatic-duct (PD) obstruction is an important etiologic factor for pain in chronic pancreatitis (CP) patients; thus, PD decompression is an appropriate treatment for symptomatic patients with markedly dilated PDs. To compare outcomes of endoscopic and surgical drainage, researchers from Amsterdam enrolled 39 patients with CP, obstruction of the PD (due to strictures, stones, or both), dilation of the PD (5 mm proximal to stenosis), and severe recurrent pancreatic pain (not relieved by non-narcotic analgesics). Patients were randomized to endoscopic therapy, consisting of sphincterotomy, pancreatic stone removal (extracorporeal shockwave lithotripsy for stones >7 mm), stricture dilation, and stenting, or to surgical treatment with longitudinal pancreaticojejunostomy.

The primary outcome was pain during the 2-year follow-up, expressed as the average of Izbicki pain scores (a validated scale for CP) obtained at 6 weeks and at 3, 6, 12, 18, and 24 months after decompression procedures. Secondary outcomes were pain relief at 2 years, physical and mental health (assessed using the SF-36 questionnaire), morbidity, mortality, length of hospital stay, number of procedures, and changes in endocrine and exocrine functions. The groups were similar in demographics and clinical characteristics, except for more ongoing alcohol abuse in the surgery group (P=0.05). Because a safety review showed a significant difference in the primary outcome favoring surgery (P<0.001), the study was terminated early.

Endoscopic therapy resolved obstructions in 53% of cases. Pancreaticojejunostomies were 100% successful at resolving obstructions, and patency was maintained in all PDs during follow-up. At 2 years, surgery patients had lower pain scores (P<0.001) and better physical-health summary scores (P=0.003); more surgery patients than endoscopy patients had complete or partial pain relief (75% vs. 32%; P=0.007). The groups did not differ significantly in length of hospital stay, complications, or changes in pancreatic function. Endoscopy patients underwent significantly more procedures than surgery patients (median, 8 vs. 3; P<0.001).

Comment: Of the many causes of pain in chronic pancreatitis, pancreatic-duct hypertension is one of the most common. These results showed that, at 2 years, surgical drainage was more effective than endoscopic treatment of PD obstruction. This benefit could be related to reduction in pancreatic interstitial pressure that is seen with surgery (from opening the pancreatic capsule). Whereas pancreaticojejunostomy offers drainage along the entire length of the PD, endoscopic stenting can obstruct side branches and cause new strictures and doesn’t prevent new strictures or prevent new stone impaction after stent removal. This study didn’t include a cost analysis, and longer follow-up is needed, as surgical studies have shown that the efficacy of longitudinal pancreaticojejunostomy dissipates with time. An editorialist theorizes about why pain relief in the endoscopy group was so low, and she suggests that endoscopic decompression is still a reasonable treatment option, depending on patient preferences.

— Stuart Sherman, MD

Published in Journal Watch Gastroenterology February 14, 2007

Citation(s):

Cahen DL et al. Endoscopic versus surgical drainage of the pancreatic duct in chronic pancreatitis. N Engl J Med 2007 Feb 15; 356:676-84.

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Elta GH. Is there a role for the endoscopic treatment of pain from chronic pancreatitis? N Engl J Med 2007 Feb 15; 356:727-9.

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• Medline abstract (Free)