Long-Term Outcomes of Early Surgery vs Endoscopy First in Chronic Pancreatitis
Authors: van Veldhuisen Charlotte L. , Kempeneers Marinus A. , de Rijk Florence E. M. , Bouwense Stefan A. , Bruno Marco J. , Fockens Paul , Poley Jan W. , Ali Usama Ahmed , Bollen Thomas L. , Busch Olivier R. , van Duijvendijk Peter , van Dullemen Hendrik M. , van Eijck Casper H. , Van Goor Harry , Hadithi Muhammed , Haveman Jan-Willem , Keulemans Yolande , Nieuwenhuijs Vincent B. , Poen Alexander C. , Voermans Rogier P. , Tan Adriaan C. , Thijs Willem , Verdonk Robert C. , Witteman Ben J. , van Hooft Jeanin E. , van Santvoort Hjalmar C. , Dijkgraaf Marcel G. , Besselink Marc G. , Boermeester Marja A. , Issa Yama ,   Dutch Pancreatitis Study Group, Honkoop Pieter , Thijssen Annemieke Y , Kooistra Tessa , Balkema Sebastiaan , Bekkali Noor , Boparai Karam S , Kager Liesbeth M , Kloek Jaap J , Rauws Erik A , Takkenberg R Bart , Gouma Dirk J , van Gulik Thomas M , Bemelman Willem A , Zwinderman A H (Koos) , Bodelier Alexander G L , Seerden Tom C J , van Enckevort Conny , van Gils Nienke , Schoon Erik , Vogelaar Lauran , de Vries Roland S , Voorburg Annet M , Heisterkamp Joos , Bezemer Geert , Braat Henri , Didden Paul , Farahani Neda , Flink Hajo J , Koch Arjun D , Postma Cindy , van Putten Paul G , Reijnders Jurriën G P , Roomer Robert , Wiersema Ubbo , Homans G Lieneke , Mares Wout G N , Meiland Ruby , Erkelens G Willemien , van Maanen Hans , Muller Gudrun , van Geenen Erwin , Perk Lars E , de Raaf Johan , Fransen Karin , Hoedemaker Reinier , Meijssen Maarten A C , Oude Hergelink Dorien , van Munster Ivo P , Römkes Tessa E H , Braat Anries E , Schaapherder A F M (Sandro) , Kubben Frank J G M , Hoge Chantal , de Maat M , Masclee Ad , Stassen Laurents P S , Brink Menno A , van Vlerken Lotte , Kolkman Jeroen J , Venneman Niels G , Houdijk A P J  (Lex) , van der Spek Bas , Jansen Jeroen M , The Olle , Gehards Michael F , Gooszen Hein G , Wilder-Smith Oliver , Hoekstra Jildou , Josemanders Daniëlle F G M , Spanier B W Marcel , de Boer Sybrand Y , de Vries Edith , Al-toma Abdulbaqi , van Ramshorst Bert , Weusten Bas  L A M , Boerma Djamila , Bijlsma A (Rina) , Festen Eleonora A M , Kerkhof Ilona P , Kleibeuker Jan H , Kouw Eva , Hofker H Sijbrand , Ploeg R , Beese Ulrich , Siersema Peter D , Vleggaar Frank P , Molenaar I Quintus , Aktas Huseyin , van Guchelaar Iris 
Published: November 2024

ImportancePatients with painful chronic pancreatitis and a dilated pancreatic duct can be treated by early surgery or an endoscopy-first approach.ObjectiveTo compare long-term clinical outcomes of early surgery vs an endoscopy-first approach using follow-up data from the ESCAPE randomized clinical trial.Design, Setting, and ParticipantsBetween April 2011 and September 2018, 88 patients with painful chronic pancreatitis were randomly assigned to early surgery or an endoscopy-first approach in 30 hospitals in the Netherlands collaborating in the Dutch Pancreatitis Study Group as part of the ESCAPE randomized clinical trial. For the present cohort study, long-term clinical data were collected after the initial 18-month follow-up. Follow-up was completed in June 2022, and data analysis was performed in June 2023.ExposurePatients with chronic pancreatitis were randomly assigned to early surgery or an endoscopy-first approach.Main Outcomes and MeasuresThe primary end point was pain, assessed by the Izbicki pain score; secondary end points included patient-reported complete pain relief and satisfaction. Predefined subgroups included patients who progressed from endoscopy to surgery and those with ductal clearance obtained by endoscopy. Analysis was performed according to the intention-to-treat principle.ResultsIn this cohort study, 86 of 88 overall patients could be evaluated, with a mean (SD) follow-up period of 98 (16) months. Of 88 initial patients, 21 patients (24%) were female, and mean (SD) patient age was 61 (10) years. At the end of long-term follow-up, the mean (SD) Izbicki pain score was significant lower (33 [31] vs 51 [31]) in the early surgery group, as was the rate of patient-reported complete pain relief (14 of 31 patients [45%] vs 6 of 30 patients [20%]), compared to the endoscopy-first group. After the initial 18-month follow-up, 11 of 43 patients in the early surgery group (26%) underwent reinterventions vs 19 of 43 patients in the endoscopy-first group (44%). At the end of follow-up, more patients in the early surgery group were “very satisfied” with their treatment (22 of 31 patients [71%] vs 10 of 30 patients [33%]). Patients who progressed from endoscopy to surgery (22 of 43 patients [51%]) had significantly worse mean (SD) Izbicki pain scores (33 [31] vs 52 [24]) compared to the early surgery group and had a lower rate of complete pain relief (55% for early surgery vs 12% for endoscopy first). In the endoscopy-first group, patients with endoscopic ductal clearance had similar mean (SD) Izbicki pain scores as the remaining patients (49 [34] vs 53 [28]).Conclusions and RelevanceIn this cohort study evaluating long-term outcomes of the ESCAPE randomized clinical trial, after approximately 8 years of follow-up, early surgery was superior to an endoscopy-first approach in patients with painful chronic pancreatitis and a dilated main pancreatic duct in pain scores and patient satisfaction. Notably, patients who progressed from endoscopy to surgery had worse outcomes compared to patients undergoing early surgery, and obtaining endoscopic ductal clearance did not improve outcomes.