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Is early surgery better for painful chronic pancreatitis?

Researchers compared levels of pain between patients with chronic pancreatitis who had surgery less than, or more than, three years from their diagnosis.

The pancreas is an organ within the abdomen involved in regulating blood sugar levels and digestion. To aid in digestion, the pancreas produces types of proteins called enzymes that help break down the food we eat into an absorbable form. A duct leads from the pancreas to a part of the intestine that follows the stomach, delivering the enzymes to food that has just exited the stomach.

What is pancreatitis?

The term pancreatitis literally means inflammation of the pancreas. The inflammation can occur as an acute form, as a one-time event, or as a chronic form, with recurring symptoms and bouts of inflammation. The inflammation leads to a build-up of enzymes within the pancreas. Without good drainage, the enzymes start breaking down the pancreas itself, just like they would food. This perpetuates the cycle of inflammation, leading to a chronic process. The causes are varied, but in chronic pancreatitis, alcohol abuse is most often the inciting cause.

Chronic pancreatitis is characterized by pain that is difficult to control, and a poor quality of life. A number of medical and surgical treatment options exist for controlling the level of pain. Medical professionals have traditionally adhered to what is called a step-up approach in the management of pain. This means that the various medical options are worked through before any surgical options are offered to the patient.

Researchers based in China, working with English and New Zealand surgical teams, have questioned the step-up approach, and designed a research project to determine whether offering surgery earlier would provide better pain control. They also wanted to know if earlier surgery could preserve the function of the pancreas in patients with chronic pancreatitis. They recently published their findings in Medicine. 

The purpose of surgery

The purpose of surgery can be two-fold, and the surgical approaches have evolved significantly over the years. In some situations, part of the pancreas itself is permanently removed from the abdomen, and this is termed resection. In other patients, a drainage procedure alone, to enhance the delivery of the destructive enzymes from the pancreas into the intestines is carried out. Additionally, both drainage and partial resection can be carried out at the same time.

The researchers looked back at the medical and surgical records of 297 patients from one hospital in China who had surgery for painful chronic pancreatitis over a period of five years. They looked only at patients who had a diagnosis of chronic pancreatitis made by laboratory analysis of the pancreas histopathologically (under the microscope).

To be included in the study, patients must not have had a prior pancreatic surgery. Researchers placed patients in the early surgery group if they had undergone resection alone, drainage alone, or resection and drainage together, within the three years following their diagnosis of chronic pancreatitis. They categorized patients into the late surgery group if the same procedures were carried out longer than three years after their diagnosis. They followed all of the patients for at least three years following their surgery to determine their level of pain and the functioning ability of their pancreas. They also determined the quality of life of each patient through a questionnaire.

Early surgery provided better pain relief

The results of the study showed that patients who underwent early surgery had significantly better pain relief following surgery than those that had surgery later. Additionally, the ability of the pancreas to regulate blood sugar levels and effectively deliver digestive enzymes to the intestine was better in the early surgery group compared to the late surgery group.

The surgical procedures that showed the best results in the early surgery group were from those patients who had both resection and drainage surgery combined, compared with resection or drainage alone.

One complication that was more predominant in the early surgical group, however, was the incidence of pancreatic fistulae occurring in the period following surgery. This occurs when a small hole in the duct develops that allows leakage of enzymes from the duct into the abdomen. The researchers speculate that this most likely occurred in the early surgical group because the pancreas was of a softer texture than the late surgical group, having been subjected to the chronic inflammatory process for a shorter period: researchers have already demonstrated that fistulae are more likely in the softer pancreas.

The researchers discuss that one possible reason for the reduced pain in the patients who underwent surgery early is the avoidance of an over-sensitization of the nerve endings. Recent research has shown that patients who undergo repeated episodes of pancreatic inflammation are more likely to develop sensitization to pain, meaning that even a small amount of inflammation induces a large degree of pain, resulting in a state of chronic pain.

Clinical trials necessary to confirm study findings

In addition to improving quality of life more rapidly, early surgery can also help prevent the amount of narcotic analgesia that patients require. The researchers discuss that this would help avoid further detrimental symptoms of addiction that may develop, and it would need to be taken into account whether this also could justify an early major surgery.

The researchers conclude that while their data demonstrates the benefit of early surgery, a study designed to provide a higher quality of evidence through a clinical trial would be necessary to confirm the findings.

Written by Nicola Cribb, VetMB DVSc Dip.ACVS

References:

(1) Ke N, Jia D, Huang W, et al. Earlier surgery improves outcomes from painful chronic pancreatitis. Medicine. 2018;97(19):e0651. DOI:10.1097/MD.0000000000010651.
(2) D‘Haese, Jan G. Cahen, Djuna L. Werner, Jens. (2016). Current Surgical Treatment Options in Chronic Pancreatitis. Pancreapedia: Exocrine Pancreas Knowledge Base, DOI: 10.3998/panc.2016.26

Nicola Cribb
Nicola Cribb
Nicola obtained her Veterinary and Master’s degrees from the University of Cambridge, UK, and Doctor of Veterinary Science from the University of Guelph, Canada. She is board-certified in surgery and has research interests in minimally-invasive surgery. She has worked in a clinical setting, as well as research and teaching disciplines for the past 16 years at the University of Guelph, where she is currently Adjunct Faculty. She is a freelance medical writer and reviews, authors, and co-authors publications and reviews in scientific journals and books.
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