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Meta-Analysis
. 2015 Mar 19;2015(3):CD007884.
doi: 10.1002/14651858.CD007884.pub3.

Endoscopic or surgical intervention for painful obstructive chronic pancreatitis

Usama Ahmed Ali  1 , Johanna M Pahlplatz, Wiliam H Nealon, Harry van Goor, Hein G Gooszen, Marja A Boermeester
Affiliations
Meta-Analysis

Endoscopic or surgical intervention for painful obstructive chronic pancreatitis

Usama Ahmed Ali et al. Cochrane Database Syst Rev. .

Abstract

Background: Endoscopy and surgery are the treatment modalities of choice for patients with chronic pancreatitis and dilated pancreatic duct (obstructive chronic pancreatitis). Physicians face, without clear consensus, the choice between endoscopy or surgery for this group of patients.

Objectives: To assess and compare the effects and complications of surgical and endoscopic interventions in the management of pain for obstructive chronic pancreatitis.

Search methods: We searched the following databases in The Cochrane Library: CENTRAL (2014, Issue 2), the Cochrane Database of Systematic Reviews (2014, Issue 2), and DARE (2014, Issue 2). We also searched the following databases up to 25 March 2014: MEDLINE (from 1950), Embase (from 1980), and the Conference Proceedings Citation Index - Science (CPCI-S) (from 1990). We performed a cross-reference search. Two review authors independently performed the selection of trials.

Selection criteria: All randomised controlled trials (RCTs) of endoscopic or surgical interventions in obstructive chronic pancreatitis. We included trials comparing endoscopic versus surgical interventions as well as trials comparing either endoscopic or surgical interventions to conservative treatment (i.e. non-invasive treatment modalities). We included relevant trials irrespective of blinding, the number of participants randomised, and the language of the article.

Data collection and analysis: We used standard methodological procedures expected by The Cochrane Collaboration. Two authors independently extracted data from the articles. We evaluated the methodological quality of the included trials and requested additional information from study authors in the case of missing data.

Main results: We identified three eligible trials. Two trials compared endoscopic intervention with surgical intervention and included a total of 111 participants: 55 in the endoscopic group and 56 in the surgical group. Compared with the endoscopic group, the surgical group had a higher proportion of participants with pain relief, both at middle/long-term follow-up (two to five years: risk ratio (RR) 1.62, 95% confidence interval (CI) 1.22 to 2.15) and long-term follow-up (≥ five years, RR 1.56, 95% CI 1.18 to 2.05). Surgical intervention resulted in improved quality of life and improved preservation of exocrine pancreatic function at middle/long-term follow-up (two to five years), but not at long-term follow-up (≥ 5 years). No differences were found in terms of major post-interventional complications or mortality, although the number of participants did not allow for this to be reliably evaluated. One trial, including 32 participants, compared surgical intervention with conservative treatment: 17 in the surgical group and 15 in the conservative group. The trial showed that surgical intervention resulted in a higher percentage of participants with pain relief and better preservation of pancreatic function. The trial had methodological limitations, and the number of participants was relatively small.

Authors' conclusions: For patients with obstructive chronic pancreatitis and dilated pancreatic duct, this review shows that surgery is superior to endoscopy in terms of pain relief. Morbidity and mortality seem not to differ between the two intervention modalities, but the small trials identified do not provide sufficient power to detect the small differences expected in this outcome.Regarding the comparison of surgical intervention versus conservative treatment, this review has shown that surgical intervention in an early stage of chronic pancreatitis is a promising approach in terms of pain relief and pancreatic function. Other trials need to confirm these results because of the methodological limitations and limited number of participants assessed in the present evidence.

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Conflict of interest statement

Usama Ahmed Ali: nothing to declare. Johanna M Pahlplatz: nothing to declare. Wiliam H Nealon: nothing to declare. He is a co‐author of one of the included studies, which was not commercially funded. He did not not participate in the appraising of this study for inclusion or risk of bias, and was not responsible for data extraction. Harry van Goor: Grants received regard innovative medical therapy to reduce pain and normalize pain processing in opioid dependent patients with chronic pancreatitis, which are outside of the scope of this review. Hein G Gooszen: nothing to declare. Marja A Boermeester: nothing to declare. She is a co‐author of one of the included studies, which was not commercially funded. She did not not participate in the appraising of this study for inclusion or risk of bias, and was not responsible for data extraction.

Figures

1
1
Methodological quality summary: review authors' judgements about each methodological quality item for the three included trials
2
2
Flow diagram of selection process
3
3
'Risk of bias graph': review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies
4
4
Forest plot of comparison: 1 Endoscopy versus surgery, outcome: 1.1 Pain relief
5
5
Forest plot of comparison: 1 Endoscopy versus surgery, outcome: 1.4 Endocrine pancreatic insufficiency (new onset)
1.1
1.1. Analysis
Comparison 1 Endoscopy versus surgery, Outcome 1 Pain relief.
1.2
1.2. Analysis
Comparison 1 Endoscopy versus surgery, Outcome 2 Complete pain relief.
1.3
1.3. Analysis
Comparison 1 Endoscopy versus surgery, Outcome 3 Partial pain relief.
1.4
1.4. Analysis
Comparison 1 Endoscopy versus surgery, Outcome 4 Endocrine pancreatic insufficiency (new onset).
See this image and copyright information in PMC

Update of

References

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References to other published versions of this review

Ahmed Ali 2012
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MeSH terms