Author: Siddharth Srivastava
Chronic pancreatitis (CP) is a difficult to treat disease. Three cardinal features include pain, endocrine insufficiency and endocrine insufficiency1. Management of pain is most difficult mainly because pain in CP is due to multiple mechanisms. For endoscopists and surgeon, the focus has been on ductal hypertension as putative mechanism. An ever raging debate is between ERCP and surgery which offers better relief. Issa et al recently published a RCT (ESCAPE trial)comparing early surgery with endoscopy first approach2. They found pain relief is much better in early surgery group with as much as 12-point difference in Izbicki score between both groups over a follow up period of 18 months. Trial has a meticulous methodology and bias was minimized by having a monitoring group which was blinded to trial. Results were in line with previous 2 published RCT. 3,4 However, if we look at patients in whom MPD was completely cleared by ERCP, results of pain score were comparable to early surgery group. 2 Another surprising part was that medical management i.e. analgesics along with enzymes failed to relieve pain in almost all patients.
There are reservations in projecting the results of ESCAPE trial to our population. Alcohol was the most common etiology in this study. In India, the prevalent forms of chronic pancreatitis are Idiopathic and alcohol. The trial is limited to ductal disease and does not focus on parenchymal calcifications. Most patients in India have significant parenchymal calcification. Patients enrolled in ESCAPE trial were not provided optimal medical treatment (as defined by Bharadwaj et al it should include antioxidants with minimum 2 gm of methionine per day).5 Antioxidants have been shown to produce significant benefits in Indian patients with chronic pancreatitis especially in patients who have parenchymal calcification and high stone load.6,7 Therefore in Indian patients a tailor-made approach consisting of optimal medical therapy followed by either surgery or endoscopic therapy may be a better option.
References:
1. Forsmark CE. Management of Chronic Pancreatitis. Gastroenterology. 2013 May;144(6):1282-1291.e3.
2. Issa Y, Kempeneers MA, Bruno MJ, Fockens P, Poley J-W, Ahmed Ali U, et al. Effect of Early Surgery vs Endoscopy-First Approach on Pain in Patients With Chronic Pancreatitis The ESCAPE Randomized Clinical Trial. JAMA. 2020;323(3):237–47.
3. Cahen DL, Gouma DJ, Nio Y, Rauws EAJ, Boermeester MA, Busch OR, et al. Endoscopic versus Surgical Drainage of the Pancreatic Duct in Chronic Pancreatitis. N Engl J Med. 2007 Feb 15;356(7):676–84.
4. A Prospective, Randomized Trial Comparing Endoscopic and Surgical Therapy for Chronic Pancreatitis. Endoscopy. 2003 Jul;35(7):553–8.
5. Bhardwaj P, Garg PK, Maulik SK, Saraya A, Tandon RK, Acharya SK. A randomized controlled trial of antioxidant supplementation for pain relief in patients with chronic pancreatitis. Gastroenterology. 2009 Jan;136(1):149-159.e2.
6. Bhardwaj P, Garg PK, Maulik SK, Saraya A, Tandon RK, Acharya SK. A randomized controlled trial of antioxidant supplementation for pain relief in patients with chronic pancreatitis. Gastroenterology. 2009 Jan;136(1):149-159.e2.
7. Talukdar R, Lakhtakia S, Nageshwar Reddy D, Rao GV, Pradeep R, Banerjee R, et al. Ameliorating effect of antioxidants and pregabalin combination in pain recurrence after ductal clearance in chronic pancreatitis: Results of a randomized, double blind, placebo-controlled trial. J Gastroenterol Hepatol. 2016 Sep;31(9):1654–62.