Surgical Drainage Outdoes Endoscopic Treatment for Pancreatic Duct

AMSTERDAM, The Netherlands, Feb. 14 -- For patients with chronic pancreatitis, surgical drainage of the pancreatic duct was more effective than endoscopic drainage, and offered superior pain relief, according to randomized trial.

Surgery provided more rapid, effective, and sustained pain relief, better overall physical health, and required fewer repeat procedures, Djuna Cahen, M.D., of the Academic Medical Center here, and colleagues. reported in the Feb. 15 issue of the New England Journal of Medicine.

In a randomized trial to compare endoscopic and surgical drainage of the pancreatic duct, during 24 months of follow-up, pain scores were twice as high for the endoscopy patients compared with the surgical group, they said.

The clinical relevance of diminished pain is substantial, Dr. Cahen said. "It reflects the difference between having no pain and having pain daily, or between taking no sick leave for pain and being permanently unable to work."

In the trial, 39 symptomatic patients with chronic pancreatitis and a distal obstruction of the pancreatic duct but without an inflammatory mass were recruited from a specialized outpatient clinic of the Academic Medical Center here. Patients were recruited from January 2000 to October 2004.

Nineteen patients were randomized to endoscopic transampullary drainage of the pancreatic duct, while 20 were assigned to operative pancreaticojejunostomy.

During 24 months of follow-up, the surgical patients compared with those treated endoscopically had lower Izbicki pain scores (25 versus 51, P

The observed outcome, the researchers said, implies that surgical drainage leads to more effective decompression. It is possible, they said, that during endoscopic treatment, outflow from secondary side branches might be compromised by the presence of a stent. In addition, after endoscopic treatment, recurrence of strictures and formation of new intraductal stones are common. Endoscopic stenting might even facilitate these conditions, they suggested.

An advantage of surgery, they suggested, might be that the longitudinal anastomosis ensures drainage over the full length of the pancreas. Also, opening the capsule during surgical drainage might alleviate interstitial pressure.

Among the special features of this study, the researchers noted, is that the validated pain scoring system was specifically designed for chronic pancreatitis, and patients completed pain assessment in private.

Also, they said, the patients were treated in centers with experts in the endoscopic treatment of pancreatitis and shockwave therapy, and the results might be worse in less experienced hands. On the other hand, they said, the surgical procedure is considered relatively easy to perform.

The results of this study cannot be extrapolated to all patients with ductal obstruction due to chronic pancreatitis, the researchers advised. Patients with an inflammatory mass were excluded, because treatment is more complicated for these patients. Furthermore, the cohort had complex pathologic features with a combination of strictures and stones in most patients.

Summing up, Dr. Cahen said, "On the basis of the outcome of the study, we regard surgical drainage as the preferred treatment in such patients. In cases of less extensive disease, endoscopic treatment may still be a valuable alternative, and future studies should be aimed at answering this question."