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• W2068809009 abstract "The four cardinal manifestations of chronic pancreatitis (CP) are recurrent or protracted abdominal pain, diabetes, steatorrhea, and pancreatic calculi. 1 Abdominal pain is the dominant feature of chronic pancreatitis that initially brings most of the patients to the physician's attention. The intractable pain, which is quite debilitating, disrupts lifestyle and leads to functional incapacity, drug and alcohol dependency, and drug-seeking behavior and pushes the desperate patient to suicidal tendencies. It is unusual for a patient with CP not to have pain, although painless CP has been observed in nearly 5% to 10% of patients. 2 Pain in CP is considered to be multifactorial. The current thoughts are centered around increased intraductal pressure, increased pancreatic tissue pressure (interstitial hypertension), pancreatitis-associated neuritis, pancreatic ischemia, and ongoing pancreatic injury or complications of CP, and presence of an inflammatory mass in the head of the pancreas considered to be the peacemaker location by some for pain in CP. Pain in CP as the disease progresses to pancreatic exocrine and endocrine insufficiency is unpredictable in an individual case. Levrat et al., 3 reporting on a longitudinal study of 113 patients followed for 4 years, observed that the pain decreased in 42%, was stable in 32%, and worsened in 26%. The often quoted study of Amman et al. 2 from Switzerland concluded that 85% of patients obtain lasting relief from pain at a median of 4.5 years from the onset of disease. In this issue of the Journal, Thuluvath et al. 4 have evaluated the natural history of CP, with a major goal being pain relief. Retrospective data was collected for 193 consecutive patients, who had at least one hospitalization for the control of pain or a complication of CP during a 10-year period (1979–1989) through a mailed questionnaire and/or telephone interview. Complete follow-up information was available in only 107 (56%) of patients. Of these 107 patients, 27 (25%) died during the follow-up. A majority (56%) of deaths occurred within the first 5 years of diagnosis, and the most common cause of death was cancer (29%). Mortality was not significantly different in the surgically treatment group (21%) or in those managed without surgery (34%); however, mortality was influenced by etiology being significantly higher in alcoholic CP than nonalcoholic CP (35% vs. 10%). Pain was graded using a scale of 0 to 10. Pain was considered better when there was an improvement of 5 or more points, worse when there was deterioration by 5 or more points, and unchanged when the score was within 5 points of either side of the initial score. Satisfactory information regarding pain control was available in only 80 patients. Only 39 patients (20% of total sample) scored the pain on a scale of 1 to 10; others reported pain as improved, unchanged, or worse. Of these 80 patients, 41 had surgery for pain relief, 7 had sphincter ablation, 9 had surgery for complications, and 23 were treated conservatively with no surgery. Long-term pain control was seen in 83% of patients who had surgery for pain, in 57% who had sphincter ablation, in 78% who had surgery for complications, and in 75% who had conservative treatment, suggesting that long-term improvement of pain is similar in patients who undergo surgery and in those treated conservatively. Also, long-term pain relief was similar in patients with alcoholic and nonalcoholic CP. After surgery, relief of pain was observed in 70% of patients in the immediate postoperative period. In contrast in the conservatively treated patients, pain relief was more gradual, reaching a plateau around 4 years from the onset of symptoms. Similarly, decrease in mean pain score was higher in patients who had surgery than in those who did not have surgery (7 vs. 4.6 points). Besides being retrospective, the study has several limitations. Not only it is difficult to assess the severity of pain but the assessment is also often clouded by addiction to alcohol and narcotic analgesics, as well as by the personality disorders underlying these dependencies. This study did not have a formal assessment of pain at the onset of treatment or surgery and does not provide information regarding addiction to narcotics, continued use of alcohol, or measures of quality of life. Pain was considered to be better or worse when there was a change of five or more points. This appears to be a very arbitrary distinction, as most patients would consider a decrease in pain from a 4 to 0 extremely gratifying. The authors also rightly point that their results could have been influenced by recall bias, and correctly acknowledge that this study provides only a gross estimation or perception of pain. In their review of the charts, the authors could not find a viable explanation why certain patients underwent operation while others were managed conservatively. A selection bias for those treated surgically cannot be excluded. Chronic pancreatitis patients undergoing surgery can be divided into two broad groups: those with “large duct” disease (main pancreatic duct measures 6 mm or more) or “small duct” disease (main pancreatic duct is <6 mm in diameter). Patients with large duct disease are the best candidates who are likely to benefit most from ductal drainage or lateral pancreaticojejunostomy (a Puestow-type operation). In contrast, CP patients with small duct disease are difficult to manage, and the surgical alternative is pancreatic resection. Resections generally involve one of the following procedures: pancreaticoduodenectomy (Whipple procedure or pylorus-preserving), duodenum preserving resection of the pancreatic head, and subtotal or distal pancreatectomy. In the series by Thuluvath et al., 4 distal pancreatectomy was the most common surgical procedure performed in 40 (21%) patients, followed by pancreaticojejunostomy in 32 (17%) and Whipple's procedure in only 11 (6%). Review of the literature indicates that distal pancreatectomy alone has poor results unless the disease is largely confined to the body and tail of pancreas. 5 Resection of the head of the pancreas can now be done with very low mortality and is the procedure of choice for small duct disease and for patients with an inflammatory mass in the head of the pancreas. An important observation of this study is that patients who had sphincter ablation (endoscopically or surgically) had the worst results. The attractive feature of endoscopic drainage procedures is that they offer an alternative to surgical management. The types of endoscopic procedures currently available include splincterotomy, internal drainage of pancreatic cysts, extraction of pancreatic duct stones, and dilatations of strictures with placement of stents. Not withstanding the enthusiasm among interventional endoscopists, the risk of pancreatic stenting is beginning to be appreciated, specifically the risk of causing damage to the duct and parenchyma in up to 50% to 80% of patients. Additional studies are needed to validate the results of endoscopic therapy before they can be recommended for general use. 5 It is now generally recognized that CP is a risk factor for pancreatic carcinoma. 6 The overall incidence of pancreatic cancer is this series was 3%. However, an important but not appreciated finding of this study is that patients with CP also have a high incidence of extrapancreatic malignancy, which was observed in 5% of patients. The incidence of extrapancreatic cancer was similar in both alcoholic and nonalcoholic CP and can be outside the upper aerodigestive tract. The authors need to be commended for undertaking this difficult study. The extreme variability in the natural history of CP, pathology, influence of numerous significant factors, and lack of standard objective criteria for pain assessment makes it a Herculean task to perform a prospective randomized study. Despite their limitations, the authors have made several important contributions by showing that long-term pain relief was similar in patients with alcoholic and nonalcoholic CP, and improvement in pain was similar between those who underwent surgery and those who had conservative mangement. However, in an individual case, no one can predict how long it will take to reach a pain-free stage of CP or whether that individual will ever get a “burned out pancreas.” Surgical management cannot be delayed with the hope that spontaneous relief would ever occur. Furthermore, surgical management is not associated with an increased mortality. Management of pain in CP is a team approach. The gastroenterologist, a surgeon, a radiologist, and a psychiatrist should work together to achieve success. Evaluation for surgery must be individualized and should take into consideration such matters as frequent hospitalizations, disruption of employment and social life, nutritional status, depression or other psychiatric manifestations, and drug dependence. Patients with CP also have a higher incidence of both pancreatic and extrapancreatic malignancy and should have long-term cancer surveillance." @default.
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• W2068809009 title "Management of Pain in Chronic Pancreatitis" @default.
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