Endoscopic Versus Surgical Treatment of Chronic Pancreatitis
Endoscopic Versus Surgical Treatment of Chronic Pancreatitis
Chronic pancreatitis is a progressive inflammatory disease of the pancreas characterized by
 destruction of pancreatic parenchyma and subsequent fibrosis. Patients with chronic
 pancreatitis can be treated with medical management, endoscopic therapy and surgical
 treatment. Among the various theories of causation of pain in chronic pancreatitis, there is
 theory of ductal hypertension. In this the pancreatic duct obstruction resulting in ductal
 dilatation, ductal hypertension and parenchymal hypertension is thought to be the cause of
 pain. For patients with dilated ducts, ductal decompression is advocated. Ductal
 decompression can be achieved by endoscopy and by surgery. Surgery comprises of lateral
 pancreaticojejunostomy with or without headcoring. Endoscopic treatment includes
 sphincterotomy, dilatation of strictures, removal of stones with or without extracorporeal
 shock wave lithotripsy (ESWL) and stenting. The pros and cons of endoscopic versus surgical
 therapy are debated. Lateral pancreaticojejunostomy relieves chronic abdominal pain in
 65%-93% of patients. Morbidity and mortality rates are generally low, averaging 20% and 2%,
 respectively. Long-term follow-up of patients after lateral pancreaticojejunostomy reveals
 that up to 50% of patients develop recurrent symptoms and 10%-35% fail to obtain pain relief.
 Studies indicate that more than 60% of patients undergoing pancreatic endotherapy are pain
 free 1 year after the procedure. There are only two randomized controlled trials comparing
 endoscopic treatment with the surgical therapy. In this study the investigators will be
 conducting a randomized trial, to compare endoscopic and surgical treatment of chronic
 pancreatitis. Outcome variables measured in the study will include pain relief, quality of
 life, morbidity, mortality, length of hospital stay and changes in pancreatic function.
Chronic pancreatitis is a progressive inflammatory disease of the pancreas characterized by
 destruction of pancreatic parenchyma and subsequent fibrosis. The prevalence of chronic
 pancreatitis has been found to be very high in southern India (114-200/100 000 population).
 Alcohol is the most common etiology worldwide, while idiopathic pancreatitis is the most
 common type in India and China, accounting for approximately 70% of all cases of chronic
 pancreatitis. It is a cause of considerable morbidity in the form of pain, steatorrhea and
 diabetes mellitus. Natural history of chronic pancreatitis is characterized by variable
 course stretching over decades with recurrent acute pancreatitis in the early stage and
 steatorrhea, diabetes and pancreatic calcification in the later stages. Pain is a prominent
 clinical feature of chronic pancreatitis and the most troublesome symptom for which medical
 attention is often sought. Unfortunately, despite much work, the pathophysiology of pain in
 CP remains poorly understood. Multiple factors have been suspected, which include
 inflammation, encasement of sensory nerves by the fibrotic process and neuropathy, and duct
 obstruction, which can lead to high back pressure and parenchymal ischemia. Increased
 pressure in the main pancreatic duct is likely to be an important cause of pain, particularly
 in patients with duct dilatation. This explanation forms the conceptual basis for both
 endoscopic and surgical drainage procedures. Approximately one half of patients with pain
 owing to chronic pancreatitis come to an intervention aimed principally at pain relief, along
 with relief of bile duct, duodenal, and major venous obstruction. Patients with chronic
 pancreatitis can be treated with medical management, endoscopic therapy and surgical
 treatment. For patients with dilated ducts, ductal decompression is advocated. The pros and
 cons of endoscopic versus surgical therapy are debated.

 The modified Puestow or lateral pancreaticojejunostomy is the most commonly employed surgical
 procedure. Lateral pancreaticojejunostomy relieves chronic abdominal pain in 65%-93% of
 patients. Morbidity and mortality rates are generally low, averaging 20% and 2%,
 respectively. Long-term follow-up of patients after lateral pancreaticojejunostomy reveals
 that up to 50% of patients develop recurrent symptoms and 10%-35% fail to obtain pain relief.

 Overall more than 60% of patients undergoing pancreatic endotherapy are pain free 1 year
 after the procedure. There are only two randomized controlled trials comparing endoscopic
 treatment with the surgical therapy.

 Dite et al. reported the first trial. Surgery consisted of resection (80 %) and drainage (20
 %) procedures, while endotherapy included sphincterotomy and stenting (52 %) and/or stone
 removal (23 %). In the entire group, the initial success rates were similar for both groups,
 but at the 5-year follow-up, complete absence of pain was more frequent after surgery (37 %
 vs. 14 %), with the rate of partial relief being similar (49 % vs. 51 %). In the randomized
 subgroup, results were similar (pain absence 34 % after surgery vs. 15 % after endotherapy,
 relief 52 % after surgery vs. 46 % after endotherapy). The increase in body weight was also
 greater by 20 - 25 % in the surgical group, while new-onset diabetes developed with similar
 frequency in both groups (34 - 43 %), again with no differences between the results for the
 whole group and the randomized subgroup. The authors concluded that surgery is superior to
 endotherapy for long-term pain reduction in patients with painful obstructive chronic
 pancreatitis.

 Cahen et al. reported the second trial. All symptomatic patients with chronic pancreatitis
 and a distal obstruction of the pancreatic duct but without an inflammatory mass were
 eligible for the study. Thirty-nine patients underwent randomization: 19 to endoscopic
 treatment (16 of whom underwent lithotripsy) and 20 to operative pancreaticojejunostomy.
 During the 24 months of follow-up, patients who underwent surgery, as compared with those who
 were treated endoscopically, had lower Izbicki pain scores (25 vs. 51, P<0.001) and better
 physical health summary scores on the Medical Outcomes Study 36-Item Short-Form General
 Health Survey questionnaire (P=0.003). At the end of follow-up, complete or partial pain
 relief was achieved in 32% of patients assigned to endoscopic drainage as compared with 75%
 of patients assigned to surgical drainage (P=0.007). Rates of complications, length of
 hospital stay, and changes in pancreatic function were similar in the two treatment groups,
 but patients receiving endoscopic treatment required more procedures than did patients in the
 surgery group (a median of eight vs. three, P<0.001). Authors concluded that surgical
 drainage of the pancreatic duct was more effective than endoscopic treatment in patients with
 obstruction of the pancreatic duct due to chronic pancreatitis.

 Both these trials had a small sample size. The population studied was also different. ESWL
 was not included in protocol in one of the trials. In one of the trials only pancreatic duct
 drainage was chosen as the surgical therapy. The proposed study will compare surgery with
 endoscopic therapy in Indian population with chronic pancreatitis. The outcomes compared
 would include pain relief, quality of life, morbidity, mortality, length of hospital stay and
 changes in pancreatic endocrine and exocrine function.
Inclusion Criteria:

 -  Diagnosis of chronic pancreatitis

 -  Failed medical treatment

 -  Dilated pancreatic duct ( > 5mm)

 Exclusion Criteria:

 -  Age under 12 or more than 70 years

 -  Pregnancy

 -  Multiple (> 3) large stone (> 1.5 cm) in head of pancreas or stones present throughout
 head, body and tail

 -  Contraindications to surgery

 -  American Society of Anesthesiologists class IV

 -  Portal hypertension

 -  Contraindications to endoscopic treatment

 -  Gastrectomy with Billroth II reconstruction

 -  Other pancreatitis-related complications requiring surgery

 -  Previous interventional therapy for chronic pancreatitis

 -  Pancreatic endotherapy

 -  Previous surgery

 -  Suspected pancreatic cancer

 -  Refusal to participate