Background: In chronic pancreatitis (CP), obstruction of the main pancreatic duct (MPD) may participate in the pathogenesis of pain. Pilot studies suggest that extracorporeal shock wave lithotripsy (ESWL) alone relieves pain in calcified CP.
Aims: We compared ESWL alone with ESWL plus endoscopic drainage of the MPD for the treatment of pain in CP.
Subjects: Patients with uncomplicated painful CP and calcification(s) obstructing the MPD.
Methods: Fifty-five patients were randomized to ESWL alone (n=26) or ESWL plus endoscopy (n=29).
Results: Two years after trial intervention, 10 (38%) and 13 (45%) patients of the ESWL alone and ESWL plus endoscopy group, respectively, had presented pain relapse (primary outcome) (odds ratio 0.77; 95% CI, 0.23, 2.57). In both groups there was a similar decrease after treatment in the MPD diameter (mean decrease, 1.7 mm; 95% CI, 0.9-2.6; P=0.0002), and in the number of pain attacks/year (mean decrease, 3.7; 95% CI, 2.6-4.9; P<0.0001). Treatment costs per patient were 3 times higher in the ESWL plus endoscopy compared to the ESWL alone group (P=0.001). The median delay between the onset of CP and persistent pain relief for both groups was 1.1 year (95% CI, 0.7-1.6), as compared to 4 years (95% CI, 3- 4) for the natural history of CP in a reference cohort (P<0.0001).
Conclusions: ESWL is a safe and effective first line therapy for selected patients with painful calcified CP. Adding systematic endoscopy on top of ESWL adds to the cost of patient care without improving outcome of pancreatic pain.
- chronic pancreatitis