Diagnosis and treatment in chronic pancreatitis: an international survey and case vignette study

BACKGROUND: The aim of the study was to evaluate the current opinion and clinical decision-making process of international pancreatologists, and to systematically identify key study questions regarding the diagnosis and treatment of chronic pancreatitis (CP) for future research. METHODS: An online survey, including questions regarding the diagnosis and treatment of CP and several controversial clinical case vignettes, was send by e-mail to members of various international pancreatic associations: IHPBA, APA, EPC, ESGE and DPSG. RESULTS: A total of 288 pancreatologists, 56% surgeons and 44% gastroenterologists, from at least 47 countries, participated in the survey. About half (48%) of the specialists used a classification tool for the diagnosis of CP, including the Mayo Clinic (28%), Mannheim (25%), or Buchler (25%) tools. Overall, CT was the preferred imaging modality for evaluation of an enlarged pancreatic head (59%), pseudocyst (55%), calcifications (75%), and peripancreatic fat infiltration (68%). MRI was preferred for assessment of main pancreatic duct (MPD) abnormalities (60%). Total pancreatectomy with auto-islet transplantation was the preferred treatment in patients with parenchymal calcifications without MPD abnormalities and in patients with refractory pain despite maximal medical, endoscopic, and surgical treatment. In patients with an enlarged pancreatic head, 58% preferred initial surgery (PPPD) versus 42% initial endoscopy. In patients with a dilated MPD and intraductal stones 56% preferred initial endoscopic +/- ESWL treatment and 29% preferred initial surgical treatment. CONCLUSION: Worldwide, clinical decision-making in CP is largely based on local expertise, beliefs and disbeliefs. Further development of evidence-based guidelines based on well designed (randomized) studies is strongly encouraged

Natural Course and Treatment of Pancreatic Exocrine Insufficiency in a Nationwide Cohort of Chronic Pancreatitis

Objectives Pancreatic exocrine insufficiency (PEI) is a common complication of chronic pancreatitis. However, little is known about the natural course of PEI and the effect of pancreatic enzyme replacement therapy on symptoms. The aim of this study was to evaluate the natural course and treatment of PEI in a nationwide cohort of patients with chronic pancreatitis. Methods Patients with chronic pancreatitis were selected from the multicenter Dutch Chronic Pancreatitis Registry. Patients were classified in 3 groups: Definite PEI, potential PEI, and no PEI. Definite PEI and no PEI were compared regarding the course of disease, symptoms, treatment, and quality of life. Results Nine hundred eighty-seven patients were included from 29 centers, of which 304 patients (31%) had definite PEI; 451 (46%), potentially PEI; and 232 (24%), no PEI. Patients with definite PEI had significantly more malabsorption symptoms, a lower body mass index, and aberrant defecation. Lowered quality of life was not independently associated with PEI. Of the PEI patients using pancreatic enzyme replacement therapy, 47% still reported steatorrhea. Conclusions Pancreatic exocrine insufficiency is associated with malabsorption symptoms and a lower body mass index. Some form of pancreatic enzyme replacement therapy is reasonably effective in alleviating malabsorption symptoms, but improvement of treatment is needed

Effect of Early Surgery vs Endoscopy-First Approach on Pain in Patients With Chronic Pancreatitis The ESCAPE Randomized Clinical Trial:The ESCAPE Randomized Clinical Trial

IMPORTANCE For patients with painful chronic pancreatitis, surgical treatment is postponed until medical and endoscopic treatment have failed. Observational studies have suggested that earlier surgery could mitigate disease progression, providing better pain control and preserving pancreatic function. OBJECTIVE To determine whether early surgery is more effective than the endoscopy-first approach in terms of clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS The ESCAPE trial was an unblinded, multicenter, randomized clinical superiority trial involving 30 Dutch hospitals participating in the Dutch Pancreatitis Study Group. From April 2011 until September 2016, a total of 88 patients with chronic pancreatitis, a dilated main pancreatic duct, and who only recently started using prescribed opioids for severe pain (strong opioids for INTERVENTIONS There were 44 patients randomized to the early surgery group who underwent pancreatic drainage surgery within 6 weeks after randomization and 44 patients randomized to the endoscopy-first approach group who underwent medical treatment, endoscopy including lithotripsy if needed, and surgery if needed. MAIN OUTCOMES AND MEASURES The primary outcome was pain, measured on the Izbicki pain score and integrated over 18 months (range, 0-100 [increasing score indicates more pain severity]). Secondary outcomes were pain relief at the end of follow-up; number of interventions, complications, hospital admissions; pancreatic function; quality of life (measured on the 36-Item Short Form Health Survey [SF-36]); and mortality. RESULTS Among 88 patients who were randomized (mean age, 52 years; 21 (24%) women), 85 (97%) completed the trial. During 18 months of follow-up, patients in the early surgery group had a lower Izbicki pain score than patients in the group randomized to receive the endoscopy-first approach group (37 vs 49; between-group difference, -12 points [95% CI, -22 to -2]; P = .02). Complete or partial pain relief at end of follow-up was achieved in 23 of 40 patients (58%) in the early surgery vs 16 of 41 (39%)in the endoscopy-first approach group (P = .10). The total number of interventions was lower in the early surgery group (median, 1 vs 3; P <.001). Treatment complications (27% vs 25%), mortality (0% vs 0%), hospital admissions, pancreatic function, and quality of life were not significantly different between early surgery and the endoscopy-first approach. CONCLUSIONS AND RELEVANCE Among patients with chronic pancreatitis, early surgery compared with an endoscopy-first approach resulted in lower pain scores when integrated over 18 months. However, further research is needed to assess persistence of differences over time and to replicate the study findings

Chronic pancreatitis: Novel concepts in diagnostics and treatment

Chronic pancreatitis (CP) is an inflammatory disease of the pancreas. The most prominent symptom is abdominal pain, which often leads to recurrent hospitalizations, absence of work, multiple interventions, and opioid addiction. Ten years after onset of the disease, more than half of the patients are still suffering from pain. The ongoing inflammation often leads to fibrosis and pancreatic function loss. Within 5 years, 50% of the patients becomes endocrine insufficient and 80% exocrine insufficient. This thesis is divided in three parts. The first part focuses on the diagnostics in CP, in which we describe the diagnostic accuracy of imaging modalities for the diagnosis of CP, compare CT with MRI in patients with CP, and compare diagnostic tools for CP. The second part explores the natural course of CP. We describe the nationwide prospective Dutch Chronic Pancreatitis Registry (CARE), and the long-term outcomes in terms of recurrent pancreatitis and progression to CP in a large cohort of patients with a first acute pancreatitis episode. The third part evaluates the treatment of CP, where we evaluate the role of preoperative opioid use on the success of thoracoscopic splanchnicectomy in terms of long-term pain relief, and describe a randomized controlled multicenter trial, which evaluates the benefits, risks and costs of early surgical intervention: the Early Surgery versus Optimal Current Step-up Practice for Chronic Pancreatitis (ESCAPE) – trial

Better pain management in chronic pancreatitis through early surgery?

The most important symptom in patients with chronic pancreatitis is pain. This is often difficult to treat. The current treatment consists of, successively, optimal medical treatment, endoscopic intervention and finally surgical intervention. Previous research has indicated that early surgical intervention leads to better pain management and preservation of pancreatic function. Recently, the randomised multicentre 'Early surgery versus optimal current step up practice for chronic-pancreatitis' (ESCAPE) trial was started in order to evaluate whether early surgery provides better reduction of pain in comparison with present treatment. In addition, serious complications, mortality, cost-effectiveness, quality of life, pancreas insufficiency, alternative pain scores, hospital admissions and the number of interventions will be assessed.</p

Early laboratory biomarkers for severity in acute pancreatitis; A systematic review and meta-analysis

Background/Objectives: Acute pancreatitis is complicated by local and systemic complications in 20–30% of the patients. Accurate prediction of severity may be important for clinical decision making. Our aim is to identify and compare the accuracy of laboratory biomarkers that predict severity and complications in adult patients. Methods: Medline, EMBASE, Web of Science and Cochrane Library (1993 to August 2020) were searched for studies with an unselected population of patients with acute pancreatitis, that contains accuracy data for ≥1 laboratory biomarker(s) and/or APACHE-II score for the prediction of a patient outcomes of interest during the first 48 h of admission. The primary outcome is moderate severe or severe acute pancreatitis (MSAP/SAP). Secondary outcomes are severe acute pancreatitis, pancreatic necrosis and organ failure. Risk of bias was assed using QUADAS-2. Biomarkers extracted from ≥3 unique sources, were analyzed using hierarchical summary receiver operating characteristic (HSROC) and bivariate model analysis. Results: In total, 181 studies were included in the qualitative analysis reporting on 29 biomarkers. For the primary outcome at admission, summary sensitivities and specificities were, respectively, 87% (95% CI 69–95%) and 88% (95% CI 80–93%) for IL-6 at a threshold of >50 pg/ml, 72% (95% CI 64–79%) and 76% (95% CI 67–84%) for an APACHE-II score of ≥8, and 53% (95% CI 35–71%) and 82% (95% CI 74–88%) for CRP >150 mg/l. HSROC curve analysis confirmed these results. Conclusion: This study indicates superiority of IL-6 for the early prediction of MSAP/SAP and may be used for to guide clinical decision making