Treatment for painful calcified chronic pancreatitis: extracorporeal shock wave lithotripsy versus endoscopic treatment: a randomised controlled trial.
BACKGROUND
In chronic pancreatitis, obstruction of the main pancreatic duct (MPD) may contribute to the pathogenesis of pain. Pilot studies suggest that extracorporeal shock wave lithotripsy (ESWL) alone relieves pain in calcified chronic pancreatitis.


OBJECTIVE
To compare ESWL alone with ESWL and endoscopic drainage of the MPD for treatment of pain in chronic pancreatitis.


METHODS
Patients with uncomplicated painful chronic pancreatitis and calcifications obstructing the MPD.


METHODS
55 patients were randomised to ESWL alone (n = 26) or ESWL combined with endoscopy (n = 29).


RESULTS
2 years after trial intervention, 10 (38%) and 13 (45%) patients of the ESWL alone and ESWL combined with endoscopy group, respectively, had presented pain relapse (primary outcome) (OR 0.77; 95% CI 0.23 to 2.57). In both groups, a similar decrease was seen after treatment in the MPD diameter (mean decrease 1.7 mm; 95% CI 0.9 to 2.6; p<0.001), and in the number of pain episodes/year (mean decrease, 3.7; 95% CI 2.6 to 4.9; p<0.001). Treatment costs per patient were three times higher in the ESWL combined with endoscopy group compared with the ESWL alone group (p = 0.001). The median delay between the onset of chronic pancreatitis and persistent pain relief for both groups was 1.1 year (95% CI 0.7 to 1.6), as compared with 4 years (95% CI 3 to 4) for the natural history of chronic pancreatitis in a reference cohort (p<0.001).


CONCLUSIONS
ESWL is a safe and effective preferred treatment for selected patients with painful calcified chronic pancreatitis. Combining systematic endoscopy with ESWL adds to the cost of patient care, without improving the outcome of pancreatic pain.
Dumonceau
Jean-Marc
JM
Department of Gastroenterology, Erasmus University Hospital, Brussels, Belgium. jmdumonceau@hotmail.com
Costamagna
Guido
G
Tringali
Andrea
A
Vahedi
Kouroche
K
Delhaye
Myriam
M
Hittelet
Axel
A
Spera
Gianluca
G
Giostra
Emiliano
E
Mutignani
Massimiliano
M
De Maertelaer
Viviane
V
Devière
Jacques
J
D015746:Abdominal Pain / Q000209:etiology / Q000628:therapy; D000328:Adult; D002114:Calcinosis / Q000150:complications / Q000191:economics / Q000628:therapy; D002137:Calculi / Q000150:complications / Q000191:economics / Q000628:therapy*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000191:economics; D003131:Combined Modality Therapy; D004322:Drainage / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D017048:Health Care Costs / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008096:Lithotripsy / Q000191:economics; D008297:Male; D008875:Middle Aged; D050500:Pancreatitis, Chronic / Q000150:complications / Q000191:economics / Q000628:therapy*; D012008:Recurrence; D016896:Treatment Outcome