Early surgery versus endoscopic therapy in chronic pancreatitis: toward an evidence-based paradigm shift
DOI:
https://doi.org/10.18203/2349-2902.isj20261592Keywords:
Chronic pancreatitis, Early surgery, Endoscopic therapy, Obstructive disease, Pain managementAbstract
Chronic pancreatitis (CP) is a progressive inflammatory disease leading to irreversible pancreatic damage, exocrine and endocrine insufficiency and chronic debilitating pain. Traditional management follows a step-up approach: medical therapy, endoscopic intervention, then surgery for refractory cases. Emerging evidence challenges this sequence, especially for patients with obstructive disease. This review evaluates comparative evidence of endoscopic versus surgical interventions in CP, emphasizing pain relief, durability and timing. Endoscopic therapy including pancreatic duct stenting, stricture dilation and extracorporeal shock wave lithotripsy offers meaningful short-term relief in selected patients with ductal obstruction. However, long-term efficacy is limited; 3–5 years sustained pain relief occurs in only 30–50% of patients, often requiring repeated procedures. In contrast, surgical approaches (pancreaticojejunostomy, Frey or Beger procedures) address both ductal obstruction and inflammatory mass, resulting in more durable outcomes. Randomized trials, including long-term data from the ESCAPE trial (~8-year follow-up), demonstrate superior pain control with early surgery: complete pain relief was achieved in 45% of early surgery patients versus 20% in endoscopy-first patients, with fewer cumulative interventions and higher patient satisfaction. Delayed surgery following repeated endoscopic therapy is associated with reduced efficacy, likely due to central sensitization and neural remodelling. Accumulating evidence supports a paradigm shift toward early, individualized surgical intervention in selected patients with obstructive chronic pancreatitis. While endoscopic therapy retains a role in carefully selected cases, prolonged step-up approaches may compromise long-term outcomes. Timely surgical referral, guided by disease morphology and symptom duration, is critical to optimizing pain relief and quality of life.
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