Early pain relief surgery improves long-term chronic pancreatitis outcomes

Surgery for pain relief in chronic pancreatitis should be considered at an earlier stage than current practice, suggest the results of a Dutch study.

Researchers in this large cohort study (n=266) found that duration of pain of less than 3 years (OR=1.81), no prior use of opioids (OR=2.14), and five or fewer endoscopic procedures before surgery (OR=2.46) were all independently and significantly associated with greater postoperative pain relief.

The patients were followed up for a median time of 62 months after undergoing pancreatic resection and drainage. They had a median pain duration of 36 months, and 58% of patients achieved pain relief.

A short duration of pain before surgery was also significantly associated with less endocrine pancreatic insufficiency.

"All these findings favor a treatment strategy that allows for surgery at an earlier stage in chronic pancreatitis over the current practice of delayed surgery," say the authors.

It is thought to be the first study to directly address the timing of surgery in chronic pancreatitis and could therefore contribute to clarifying the currently variable guidelines.

In the study, published in the Archives of Surgery, the authors present a nomogram that could help predict the likelihood of postoperative pain relief on an individual basis and therefore help aid decision-making. It shows that patients with all three risk factors had a 23% chance of postoperative pain relief whereas the probability increased to 75% in those with no risk factors.

The authors highlight the current difficulty for guidelines in balancing the relative pros and cons of surgery, compared with opioids and endoscopy.

Opioids are associated with risks including dependency, sensitization, and an eventual need for surgery in 75% of patients. Meanwhile, it has already been noted that the cumulative morbidity risk from repeated endoscopic interventions could be substantial; the results from this study now show that repeated interventions lead to a less favorable outcome when surgery is eventually performed.

The results of this study support the hypothesis of the randomized controlled trial, Early Surgery versus Optimal Current Step-Up Practice for Chronic Pancreatitis trial, which the researchers hope will further guide the optimal timing for surgical intervention.

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