Surgery, Endocopy, or Medicine for Chronic Pancreatitis?
Endoscopic therapy can be the best initial approach for patients with chronic pancreatitis, according to the July issue of Clinical Gastroenterology and Hepatology.
Chronic pancreatitis is a progressive inflammatory disease characterized by abdominal pain and damage to endocrine and exocrine pancreatic tissue. Much of the pain results from intraductal hypertension, caused by pancreatic duct obstruction by stones or strictures. Other factors that contribute to pain include ongoing inflammation, peripheral or central neuropathic processes, and pancreatic or peri-pancreatic complications (such as pseudocysts, biliary strictures, and compression of surrounding structures).
Endoscopy and surgery are frequently used to treat patients with painful pancreatitis with ductal obstruction, to alleviate the pressure in the pancreatic duct and ensure adequate drainage of pancreatic secretions. Medical management is preferred for patients with small duct disease. However, there have been no large studies to compare efficacy of these approaches.
Bridger Clarke et al. performed a retrospective analysis of the use, effectiveness, and long-term outcomes of 71 patients with chronic pancreatitis who received endoscopic treatment, 44 that received surgery, and 48 that received medical treatment.The medical treatments included non-narcotic or narcotic analgesics, supplementation of pancreatic enzymes, counseling for abstinence from alcohol and tobacco, and dietary changes.
Clarke et al. found that endoscopic therapy was safe and reduced symptoms in 50% of patients. Among patients for whom it was not successful, 50% had successful outcomes after subsequent surgery (Whipple, Frey, Puestow, Beger, or Duval procedures; total pancreatectomy with auto-islet cell transplant; distal pancreatectomy; or another approach). Symptoms resolved in 31% of symptomatic patients who received only medical therapy.
A unique aspect of the study was that it evaluated surgical outcomes of patients that did not respond to endoscopic therapy. This ‘negative selection’ of patients could explain their lower surgical success rate, compared with previous studies. The approach, however, is consistent with the current guidelines—using endoscopy as an initial approach, reserving surgery for cases of failure or recurrence of symptoms. The overall clinical success rate of endoscopy plus surgery was 66%.
Clarke et al. associated a shorter duration of disease with a higher clinical success rate, indicating that pancreatitis becomes or irreversible as it progresses, and should be treated early in the disease course.
The authors propose a stepwise approach for managing chronic pancreatitis, starting with medical management. However, patients with symptoms and certain morphologic features should be considered for endoscopic therapy early in the disease course. A subset of patients will require surgical intervention, with or without endoscopic therapy as a bridge to surgery, based on an individualized assessment of risk and benefit.
In an editorial that accompanies the article, D. Nageshwar Reddy et al. say that although previous studies reported that more patients had pain relief from surgery, endoscopy might still be preferred, because of its lower degree of invasiveness. Surgery could then be reserved for patients in whom endoscopy is ineffective. Unlike surgery, endoscopy can be performed repeatedly for pain recurrences.
More Information on Chronic Pancreatitis:
- The National Library of Medicine Website on Chronic Pancreatitis
- The Mayo Clinic Website on Chronic Pancreatitis
Read the article online. This article has accompanying CME activities and a video abstract.
Clarke B, Slivka A, Tomizawa Y, et al. Endoscopic therapy is effective for patients with chronic pancreatitis. Clin Gastroenterol Hepatol 2012;10:795–802.
Read the accompanying editorial.
Reddy DN, Ramchandani MJ and Talukdar R. Individualizing therapy for chronic pancreatitis. Clin Gastroenterol Hepatol 2012;10:803–804.