PATIENTS with painful chronic pancreatitis and a dilated pancreatic duct benefit more from early surgery than an endoscopy-first approach, according to findings from the ESCAPE randomised clinical trial.
Conducted across 30 Dutch hospitals between 2011–2018, the study followed 88 patients to compare the long-term effectiveness of early surgery or and endoscopy-first approach after a median follow-up of 98 months.
Patients in the early surgery group reported a markedly lower average Izbicki pain score than those who underwent an endoscopy-first approach (33 versus 51). Pain relief was also more common among the early surgery patients: 45% (14 of 31 patients) reported complete pain relief, compared to just 20% (6 of 30 patients) in the endoscopy-first group.
Reintervention rates reinforced the benefits of early surgery. Only 26% (11 of 43 patients) in the early surgery group required additional procedures after the initial 18-month follow-up, compared to 44% (19 of 43 patients) in the endoscopy-first group. Moreover, patient satisfaction was higher among those receiving early surgery, with 71% (22 of 31 patients) describing themselves as “very satisfied,” compared to 33% (10 of 30 patients) in the endoscopy-first cohort.
Patients who initially underwent endoscopy but later required surgery experienced worse outcomes than those who had surgery upfront. This subgroup, representing 51% of the endoscopy-first group (22 of 43 patients), had a higher mean Izbicki pain score of 52 and significantly lower rates of complete pain relief (12%) compared to early surgery recipients (55%). Additionally, achieving endoscopic ductal clearance did not improve pain outcomes, as those with clearance had pain scores comparable to patients without it.
The findings highlight early surgery as the more effective strategy for managing chronic pancreatitis with a dilated main pancreatic duct. Delaying surgery in favour of an endoscopy-first approach often results in poorer pain management and lower patient satisfaction, with outcomes unlikely to improve even if endoscopic ductal clearance is achieved.
Ada Enesco, EMJ
Reference
van Veldhuisen CL et al. Long-term outcomes of early surgery vs endoscopy first in chronic pancreatitis: follow-up analysis of the ESCAPE randomized clinical trial. JAMA Surg. 2024; DOI:10.1001/jamasurg.2024.5182.
