Controversies on the endoscopic and surgical management of pain in patients with chronic pancreatitis: pros and cons!

Pain is the dominating symptom of chronic pancreatitis (CP) causing impairment of quality of life, decreased activity, unemployment and major healthcare costs.1 Opinions differ on the best strategy to treat CP-related pain. These differences are fuelled by the lack of a clear correlation between the severity of complaints and the presence and extent of morphological abnormalities, lack of a comprehensive pain assessment tools, deficiency in the knowledge about the natural course of CP and the presence of (changes in) both peripheral and central nervous system pain mechanisms. Analgesics are the cornerstone of pancreatic pain management, but when opioids are used, it may lead to dependency and opioid-induced hyperalgesia.2 When analgesic therapy fails, invasive treatments including endoscopic pancreatic duct clearance (with or without extracorporeal shock wave lithotripsy (ESWL)) or pancreatic duct stenting and surgery (resection and/or ductal decompression) are used. The rationale for invasive treatments is that reducing ductal pressure by restoring pancreatic juice flow and/or resecting an inflammatory pancreatic mass will result in pain relief. However, there is also a neuropathic basis for pain in most patients, for which invasive treatments may not be effective or even harmful. While there are many clinical studies that support invasive treatments, there is a paucity of high-quality randomised controlled trials (RCTs). As a result, the current guidelines for endoscopic and surgical treatments for painful CP are inconsistent and tend to reflect a specialty bias.3 For example, the German guidelines4 recommend surgery as the most effective treatment of pain, whereas the European Society of Gastrointestinal Endoscopy5 and the international evidence-based (HaPanEU) guidelines1 advice a ‘step-up approach’ incorporating both conservative, endoscopic and surgical treatment. These contradictions allow historic bias and a significant variation in clinical practice. Gut received a review article on the treatment of pain in CP that …