This article is the summary/review of the following article:
Ahmed Ali, U., Pahlplatz, J. M., Nealon, W. H., van Goor, H., Gooszen, H. G., & Boermeester, M. A. (2015). Endoscopic or surgical intervention for painful obstructive chronic pancreatitis. The Cochrane Database of Systematic Reviews, 3, CD007884. doi:10.1002/14651858.CD007884.pub3
Background
Chronic pancreatitis (CP) is a progressive inflammatory condition of the pancreas. Many different factors, including genetic links, auto-immunity, metabolic abnormalities, and anatomical malformations, are thought to cause CP; however, alcohol is the leading cause of CP in the Western world. Ongoing inflammation can eventually lead to fibrosis and loss of pancreatic function, which is often associated with the development of diabetes, malabsorption, weight loss, and general deterioration in the individual's health.
Severe, constant, and disabling abdominal pain is the most common presenting symptom, which can have a major impact on the affected individual's quality of life with consequent repeated hospitalizations and absence from work. Although the pathogenesis of the pain is not completely understood, it is thought that ductal and parenchymal hypertension, caused by an elevated pressure in the main pancreatic duct due to the presence of strictures, calculi, or both, plays an important role. CP cannot be cured; therefore, the primary goals of treatment are to achieve long-term pain relief, manage complications, and improve quality of life.
Currently, management of obstructive CP consists of a stepwise approach, commencing with conservative management of symptoms, followed by endoscopic and surgical interventions to relieve the pressure in the pancreatic duct and establish adequate drainage of pancreatic excretions. To date, evidence-based treatment recommendations are lacking, perhaps due to the absence of clear agreement around the best choice between endoscopic and surgical interventions for patients with painful obstructive CP.
Objectives
To assess and compare the effects and complications of surgical and endoscopic interventions in the management of pain for obstructive CP.
Interventions/Methods
This review included randomized control trials that investigated endoscopic or surgical interventions for the treatment of obstructive CP (with a dilated pancreatic duct). Participants were required to have a confirmed diagnosis of CP, with dilation of the pancreatic duct, and pain needed to be the primary indication for the intervention. Included studies needed to make comparisons between endoscopic intervention and surgical intervention, endoscopic intervention and conservative treatment, or surgical intervention and conservative management. Each intervention was defined as follows:
* Endoscopic intervention: An endoscopic retrograde cholangiopancreatography performed with therapeutic intent and in which papillotomy, dilation of the pancreatic duct, or placement of a pancreatic ductal stent was performed.
* Surgical intervention: Any surgical procedure used for the treatment of obstructive CP, including pancreaticojejunostomy, resection-drainage procedures (e.g., Frey, Beger), or a (pylorus-preserving) pancreaticoduodenectomy.
* Conservative treatment: Noninvasive therapy, mainly medical treatment of pain and nutritional supportive treatment.
The primary outcomes measured were pain relief, that is, the proportion of participants achieving pain relief compared with the situation prior to the intervention; presence of major postinterventional complications, including intra-abdominal abscess, ileus-necessitating surgery, pancreatitis flare-up, bleeding, anastomotic leakage, sepsis, abdominal fascial dehiscence (Platzbauch), and myocardial infarction; and mortality.
Results
A total of 29 potentially relevant publications were selected for full-text reviewing after screening of titles and abstracts, of which only three were eligible for inclusion in the review. No trials were identified that compared endoscopic intervention with conservative treatment. Two of the trials, based in the Czech Republic and the Netherlands, compared endoscopic interventions with surgical interventions, involving a total of 111 participants (55 in endoscopic group, 56 in surgical group). The pooled data demonstrated that there was a higher proportion of patients with pain relief (partial or complete) in the surgical group when compared with the endoscopic group, both at middle/long-term follow-up (2-5 years: risk ratio [RR] = 1.62; 95% confidence interval [CI] [1.22, 2.15]) and long-term follow-up (>=5 years: RR = 1.56; 95% CI [1.18, 2.05]).
The remaining trial, based in the United States, compared surgical intervention with conservative treatment, involving 32 participants (17 in the surgical group, 15 in the conservative group) and demonstrated that surgical intervention resulted in a higher percentage of participants with pain relief (16 of 17 [94%] participants in the surgical group; two of 15 [13%] in the conservative group). No differences were found in terms of major postinterventional complications or mortality, although the number of participants did not allow for this to be reliably evaluated.
Conclusions
The authors conclude that surgery is more effective than endoscopic treatment for the relief of pain associated with severe CP that involves dilation of the pancreatic duct. Surgical intervention also appears to be a promising approach to the relief of pain and maintenance of pancreatic function in the early stages of CP. There did not appear to be any difference between surgery and endoscopic treatment in terms of morbidity and mortality, which was difficult to detect due to the size of the reviewed trials. The authors therefore caution that as well as the need for further trials, any decisions for either intervention should be made after informing patients about the risks associated with both treatments and openly discussing the gaps in current knowledge.
Implications for Practice
Pain control is an important factor in the treatment of CP; however, the current conservative stepwise approach to management can often lead to patients experiencing severe uncontrolled pain before surgical intervention is considered. The evidence from this review demonstrates that surgical intervention can achieve good long-term pain control in patients with obstructive CP. However, there is a need for further rigorous-quality research that examines the effectiveness of surgical intervention in larger cohorts of patients to be able to apply the findings more generally.