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

Importance Patients with painful chronic pancreatitis and a dilated pancreatic duct can be treated by early surgery or an endoscopy-first approach. Objective To 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 Participants Between 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. Exposure Patients with chronic pancreatitis were randomly assigned to early surgery or an endoscopy-first approach. Main Outcomes and Measures The 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. Results In 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 Relevance In 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.