Download PDF
Endoskopie heute 2003; 16(3): 127-133
DOI: 10.1055/s-2003-44276
Originalarbeit

© Georg Thieme Verlag Stuttgart · New York

Endoskopie versus Chirurgie in der Therapie der chronischen Pankreatitis - Eine prospektive, randomisierte Studie

Endoscopy Versus Surgery for Chronic Pancreatitis - A Prospective, Randomized StudyP. Díte1 , M. Ružicka2 , V. Zboril1 , I. Novotný1
  • 1Dept. of Medicine and Gastroenterology
  • 2Dept. of Surgery, University Hospital, Brno, Czech Republic
Further Information

Publication History

Publication Date:
17 November 2003 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

Die invasive Behandlung des Schmerzsyndroms bei chronischer Pankreatitis kann besonders bei Pankreasgangobstruktionen entweder chirurgisch oder endoskopisch erfolgen. 140 fortlaufende Patienten mit Pankreasgangobstruktion und Schmerzen wurden zur Teilnahme an einer randomisierten Studie eingeladen, die Endotherapie und Chirurgie vergleichen sollte. Patienten, die der Randomisierung nicht zustimmten, wurden dennoch nach dem gleichen Protokoll neu beobachtet. Nur 72 Patienten stimmten der Randomisierung zu. Die Operationen bestanden in einer Resektion (80 %) oder Dränageverfahren (20 %). Die Endotherapie beinhaltete die endoskopische Sphinkterotomie und Stenting (52 %) und/oder Steinentfernung (23 %). In der Gesamtgruppe waren die initialen Erfolgsraten für beide Teilgruppen gleich, aber nach 5 Jahren waren die Patienten in der Operationsgruppe häufiger schmerzfrei (37 vs. 14 %). Eine Schmerzreduktion wurde gleich häufig beobachtet (49 vs. 51 %). Auch in der randomisierten Gruppe wurden ähnliche Resultate beobachtet (Schmerzfreiheit nach Operation in 34 vs. 15 % nach Endotherapie, Schmerzlinderung nach Operation 52 vs. 46 % nach Endotherapie). Die Zunahme des Körpergewichts war ebenfalls ausgeprägter in der Operationsgruppe (20-25 %), ein neu aufgetretener Diabetes wurde in beiden Gruppen in gleicher Frequenz beobachtet (34 -43 %). Auch hier gab es keine Unterschiede zwischen der Gesamtgruppe und der randomisierten Gruppe. Im Langzeitverlauf erwies sich die operative Therapie damit gegenüber der endoskopischen Therapie erfolgreicher im Hinblick auf die Schmerzreduktion bei Patienten mit schmerzhafter obstruktiver Pankreatitis. Wegen der geringeren Invasivität der Endotherapie kann sie dennoch als primäre Therapie angeboten und im Falle des Therapieversagens oder von Schmerzrezidiven durch eine chirurgische Therapie ergänzt werden.

Abstract

Invasive treatment for abdominal pain due to chronic pancreatitis may be either surgical or endoscopic, particularly in cases of ductal obstruction. Consecutive patients with pancreatic duct obstruction and pain were invited to participate in a randomized trial comparing endotherapy and surgery. Patients who did not agree to participation and randomization were also further assessed using the same follow-up protocol. Of 140 eligible patients, only 72 agreed to be randomized. Surgery consisted of resection (80 %) and drainage (20 %) procedures, while endotherapy included sphincterotomy and stenting (52 %) and/or stone removal (23 %). In the entire group, the initial success rates were similar for both groups, but at the 5-year follow-up, complete absence of pain was more frequent after surgery (37 vs. 14 %), with the rate of partial relief being similar (49 vs. 51 %). In the randomised subgroup, results were similar (pain absence 34 after surgery vs. 15 % after endotherapy, relief 52 after surgery vs. 46 % after endotherapy). The increase in body weight was also greater by 20-25 % in the surgical group, while new-onset diabetes developed with similar frequency in both groups (34-43 %), again with no differences between the results for the whole group and the randomised subgroup.
Surgery is superior to endotherapy for long-term pain reduction in patients with painful obstructive chronic pancreatitis. Due to its low degree of invasiveness, however, endotherapy can be offered as a first-line treatment, with surgery being performed in case of failure and/or recurrence.

Schlüsselwörter

Chronische Pankreatitis - Endoskopische Therapie - Operation

Key words

Chronic pancreatitis - endoscopic therapy - operation

Literatur

  • 1 American Diabetes Association . Report of the expert committee on the diagnosis and classification of diabetes mellitus.  Diabetes Care. 1997;  20 1183-1197
    PubMedGoogle Scholar
  • 2 Ammann R W, Muellhaupt B. The natural history of pain in alcoholic chronic pancreatitis.  Gastroenterology. 1999;  116 1132-1140
    PubMedGoogle Scholar
  • 3 Axon A TR, Classen M, Cotton P. et al . Pancreatography in chronic pancreatitis: international definition.  Gut. 1984;  25 1107-1112
    CrossrefPubMedGoogle Scholar
  • 4 Beger H G, Schlosser W, Friess H M. et al . Duodenum-preserving head resection in chronic pancreatitis changes the natural course of the disease.  Ann Surg. 1999;  4 512-523
    PubMedGoogle Scholar
  • 5 Büchler M W, Friess H, MillIer M W. et al . Randomized trial of duodenum-preserving pancreatic head resection versus pylorus-preserving Whipple in chronic pancreatitis.  Am J Surg. 1995;  169 69-70
    PubMedGoogle Scholar
  • 6 Binmoeller K F, Jue P, Seifert H. et al . Endoscopic pancreatic stent drainage in pancreatitis and a dominant stricture: long-term results.  Endoscopy. 1995;  27 638-644
    Article in Thieme ConnectPubMedGoogle Scholar
  • 7 Bittencourt P L, Delhaye M, Devière J. et al . Immediate and long-term results of pancreatic ductal drainage in severe painful chronic pancreatitis.  Gut. 1996;  39 99
    PubMedGoogle Scholar
  • 8 Bradley E L. Long-term results of pancreatojejunostomy in patients with chronic pancreatitis.  Am J Surg. 1987;  153 207-213
    CrossrefPubMedGoogle Scholar
  • 9 Burdick J S, Hogan W J. Chronic pancreatitis: selection of patients for endoscopic therapy.  Endoscopy. 1991;  23 155-160
    PubMedGoogle Scholar
  • 10 Cotton P B. Randomization is not the (only) answer: a plea for structured objective evaluation of endoscopic therapy.  Endoscopy. 2000;  32 402-405
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Cremer M, Deviére J, Delhay M. et al . Stenting in severe chronic pancreatitis: results of medium-term follow-up in 76 patients.  Endoscopy. 1991;  23 171-176
    PubMedGoogle Scholar
  • 12 Díte P, Starý K, Tomanová M. et al . Incidence of chronic pancreatitis in Czech Republic.  Czech Slovak Gastroenterol. 2000;  54 167-171
    PubMedGoogle Scholar
  • 13 Díte P, Zboŗil V, Cikanková E. Endoscopic therapy of chronic pancreatitis.  Hepatogastroenterology. 1996;  43 1633-1637
    PubMedGoogle Scholar
  • 14 Díte P. et al . Endoscopy Versus Surgery for Chronic Pancreatitis.  Endoscopy. 2003;  35 553-558
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 Friess H, Shrikhande S, Büchler M W. Neurotransmitters and nerve growth factors in chronic pancreatitis. In: Bijchier MW, Friess H, Uhl W, Malfertheiner P (eds). Chronic pancreatitis: novel concepts in biology and therapy. Blackwell Science, Oxford 2002
    Google Scholar
  • 16 Glasbrenner B, Adler G. Evaluating pain and the quality of the life inchronic pancreatitis.  IntJ Pancreatol. 1997;  22 163-170
    PubMedGoogle Scholar
  • 17 Hakaim A C, Broughan T A, Vogt D P, Hermann R E. Long-term results of the surgical management of chronic pancreatitis.  Am Surg. 1994;  60 306-308
    PubMedGoogle Scholar
  • 18 Huibregtse K, Schneider B, Vrij A A, Tytgat G NJ. Endoscopic pancreatic drainage in chronic pancreatitis.  Gastrointest Endosc. 1988;  34 8-10
    PubMedGoogle Scholar
  • 19 lzbicki J R, Bloechle C, Broering D C. et al . Extended drainage versus resection in surgery for chronic pancreatitis: a prospective randomizedtrial comparing the longitudinal pancreaticojejunostomy combined with local pancreatic head excision with the pylorus-preserving pancreatoduodenectomy.  Ann Surg. 1998;  228 771-779
    CrossrefPubMedGoogle Scholar
  • 20 Kozarek R A. Pancreatic stents can induce ductal changes consistent with chronic pancreatitis.  Gastrointest Endosc. 1990;  36 93-95
    CrossrefPubMedGoogle Scholar
  • 21 Kozarek R A, Patterson D J, Ball T J, Traverso L W. Endoscopic placement of pancreatic stents and drains in the management of pancreatitis.  Ann Surg. 1989;  209 261-266
    CrossrefPubMedGoogle Scholar
  • 22 Layer P, Yamamoto H, Kalthoff L. et al . The different courses of earlyand late-onset idiopathic and alcoholic chronic pancreatitis.  Gastroenterology. 1994;  107 1481-1487
    CrossrefPubMedGoogle Scholar
  • 23 Lankisch P G, Löhr-Happe A, Otto J, Creutzfeldt W. Natural course in chronic pancreatitis.  Digestion. 1993;  54 148-155
    CrossrefPubMedGoogle Scholar
  • 24 Melzack R. The McGill Pain Questionnaire: major properties and scoring methods.  Pain. 1975;  1 277-299
    CrossrefPubMedGoogle Scholar
  • 25 McHale A, Buechter K, Cohn I, O'Leary J P. Surgical management of chronic pain from chronic pancreatitis.  Am Surg. 1997;  63 1119-1122
    PubMedGoogle Scholar
  • 26 Miyake H, Harada H, Kunichika K. et al . Clinical course and prognosis of chronic pancreatitis.  Pancreas. 1987;  2 378-385
    CrossrefPubMedGoogle Scholar
  • 27 Müller M W, Friess H, Beger H G. et al . Gastric emptying following pylorus-preserving Whipple and duodenum-preserving pancreatic head resection in patients with chronic pancreatitis.  Am J Surg. 1997;  173 257-263
    CrossrefPubMedGoogle Scholar
  • 28 Okolo P, Pasricha P J, Kalloo A N. What are the long-term results of endoscopic pancreatic sphincterotomy?.  Gastrointest Endosc. 2000;  52 15-19
    Google Scholar
  • 29 Pitchumoni C S. Chronic pancreatitis: pathogenesis and management of pain.  J Clin Gastroenterol. 1998;  27 101-107
    CrossrefPubMedGoogle Scholar
  • 30 Ponchon T, Bory R M, Hedelius F. et al . Endoscopic stenting for pain relief in chronic pancreatitis: results of a standardized protocol.  Gastrointest Endosc. 1995;  42 452-456
    Google Scholar
  • 31 Prinz R A. Pancreatic duct drainage. In: Beger HG, Warshaw AL, Büchler MW et al. (eds). The pancreas. Blackwell Science, Oxford 1998; 829-836
    Google Scholar
  • 32 Prinz R A. Surgical drainage procedures. In: Howard JM, Idezuki Y, Ihse I, Prinz RA (eds). Surgical diseases of the pancreas. 3rd ed. Williams and Wilkins, Baltimore 1998; 359-366
    Google Scholar
  • 33 Prinz R A, Greenlee H B. Pancreatic duct drainage in chronic pancreatitis.  Hepatogastroenterology. 1990;  37 295-300
    PubMedGoogle Scholar
  • 34 Provansal-Cheylan M, Bernard J P, Mariani A. et al . Occluded pancreatic endoprostheses: analysis of the clogging material.  Endoscopy. 1989;  21 63-69
    PubMedGoogle Scholar
  • 35 Rösch T, Daniel S, Scholz M. et al . Endoscopic treatment of chronic pancreatitis: a multicenter study of 1 000 patients with long-term follow-up.  Endoscopy. 2002;  34 765-771
    Google Scholar
  • 36 Ružicka M, Díte P, Kala Z. Our approach to the surgical treatment of chronic pancreatitis.  Hepatogastroenterology. 1997;  44 1472-1476
    PubMedGoogle Scholar
  • 37 Sarles J C, Nacchiero M, Garani F. et al . Surgical treatment of chronic pancreatitis.  Am J Surg. 1982;  144 317-321
    CrossrefPubMedGoogle Scholar
  • 38 Sarr M G, Sakorafas G H. Incapacitating pain of chronic pancreatitis: a surgical perspective of what is known and what needs to be known.  Gastrointest Endosc. 1999;  49 85-89
    PubMedGoogle Scholar
  • 39 Schmalz M J, Geenen J E. Therapeutic pancreatic endoscopy.  Endoscopy. 1999;  31 88-94
    Article in Thieme ConnectPubMedGoogle Scholar
  • 40 Sherman S, Alvarez C, Robert M. et al . Polyethylene pancreatic duct stent-induced changes in the normal dog pancreas.  Gastrointest Endosc. 1993;  39 658-664
    CrossrefPubMedGoogle Scholar
  • 41 Smits M E, Rauws E A, Tytgat G N. et al . Endoscopic treatment of pancreatic stones in patients with chronic pancreatitis.  Gastrointest Endosc. 1996;  43 556-560
    PubMedGoogle Scholar
  • 42 Tuech J J, Duplessis R, Villapadierna F. et al . Anastomose pancréatojéjunale ou pancréaticogastrique après duodénopancréatectomie céphalique: étude comparative retrospective.  Chirurgie. 1998;  123 450-455
    CrossrefPubMedGoogle Scholar
  • 43 Zhao P, Tu J, Penninckx F. et al . Early derivation operation can restore the pancreas histology and function in chronic obstructive pancreatitis in the cat.  Hepatogastroenterology. 1998;  45 1849-1854
    PubMedGoogle Scholar

Prof. Dr. H J Schulz

Oskar-Ziethen-Krankenhaus

Paritätisches Krankenhaus Berlin-Lichtenberg

Klinik für Innere Medizin

Fanningerstraße 32

10365 Berlin

Phone: 030/55 18 22 10

Fax: 030/55 18 22 50

Email: schulz@khl-Berlin.de

      >