Early surgery ‘should be preferred approach’ over endoscopy-first in chronic pancreatitis
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Key takeaways:
- Patients who underwent early surgery vs. endoscopy-first approach reported a lower Izbicki pain score.
- Pain was “significantly worse” among those who underwent endoscopy but progressed to surgery.
Among patients with chronic pancreatitis and a dilated pancreatic duct, early surgery significantly improved patient-reported outcomes vs. an endoscopy-first approach, with researchers recommending it “should be the preferred approach.”
“The initial report of the ESCAPE multicenter, randomized clinical trial at 18 months follow-up found early surgery superior to an endoscopy-first approach in patients with painful chronic pancreatitis in terms of pain scores,” Charlotte L. van Veldhuisen, MD, of the department of surgery at Amsterdam University Medical Center, and colleagues wrote in JAMA Surgery. “However, it has been questioned whether the favorable outcomes of early surgery are sustainable in the long term.”
They continued, “In addition, many centers still start with an endoscopy-first approach, as this is considered less invasive than abdominal surgery, and because subgroup analysis of the initial ESCAPE trial showed no benefit of surgery when endoscopic complete ductal clearance was achieved. ... However, it is also unknown how this approach influences patient outcomes in the long term.”
In the ESCAPE trial, hospitals involved in the Dutch Pancreatitis Study Group enrolled 88 patients (mean age, 61 years; 24% women) with symptomatic chronic pancreatitis and dilated pancreatic ducts between April 2011 and September 2018. Patients were randomly assigned 1:1 to early surgery or an endoscopy-first approach, which included lifestyle modifications and medical treatment followed by surgery.
The primary outcome was pain evaluated by the Izbicki pain score and secondary outcomes included VAS score, complete pain relief, disease progression and pancreatic insufficiency.
Researchers investigated long-term outcomes by extending follow-up after the initial 18 months, with a mean follow-up of 98 months.
According to results, patients in the early surgery group had a more favorable mean Izbicki pain score vs. those in the endoscopy-first group (33 vs. 51; P = .03) and more patients who underwent early surgery reported complete pain relief (45% vs. 20%). In addition, in a questionnaire completed by 61 patients (early surgery = 31 vs. endoscopy first = 30), more patients in the early-surgery group reported being “very satisfied” with treatment (71% vs. 33%; P = .003).
Results from post-hoc analyses showed pain via the mean Izbicki score was “significantly worse” among patients who progressed to surgery following endoscopy vs. those who underwent early surgery (52 vs. 33) and fewer patients reported complete pain relief (12% vs. 55%).
Researchers noted 24 patients in the endoscopy-first group achieved complete ductal clearance; however, there was no significant difference in pain based on the Izbicki score between those with complete ductal clearance vs. without (49 vs. 53).
In addition, improved outcomes were observed in the early surgery group vs. patients who achieved ductal clearance in the endoscopy-first group; however, statistical significance was only achieved for VAS score (29 vs. 48; P = .047).
“In patients with symptomatic chronic pancreatitis and a dilated main pancreatic duct, early surgery was superior to an endoscopy-first approach in terms of Izbicki pain scores, number of reinterventions, VAS scores and patient satisfaction,” van Veldhuisen and colleagues wrote. “Notably, endoscopic complete ductal clearance did not improve patient outcomes. Also, outcomes were worse if patients underwent surgery after failed endoscopy compared to up-front early surgery.”
They continued, “The present findings clearly strengthen the recommendation that early surgery should be the preferred approach for these patients and leave little room for an endoscopy-first approach.”
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