Pain relapses in the first 10 years of chronic pancreatitis

Smoking Is Associated with Worse Clinical Outcomes in Chronic Pancreatitis

BACKGROUND

Tobacco smoking is a known risk factor for progression of chronic pancreatitis (CP).

AIM

We compare clinical outcomes of CP patients with current or former smoking with those who have never smoked.

METHODS

We reviewed all patients with followed at our Pancreas Center from 2016 to 2021, comparing the demographics, clinical features, comorbidities, outcomes, and resource utilization between smokers and non-smokers.

RESULTS

Of 439 CP patients, 283 were smokers (125 current, 158 former). Significantly more smokers were men (58.3% vs 40.4%), with alcoholic CP (45.5% vs 12.1%), chronic abdominal pain (77.7% vs 65.4%), anxiety and depression (22.6% vs 14.1% and 38.9% vs 23.1%), and with more local pancreatic complications [splanchnic vein thrombosis (15.7% vs 5.13%), pseudocyst (42.7% vs 23.7%), biliary obstruction (20.5% vs 5.88%)], exocrine pancreatic insufficiency (65.8% vs 46.2%), hospitalizations (2.59 vs 1.75 visits), and emergency department visits (8.96% vs 3.25%). Opioid and neuromodulator use were significantly higher (59.2% vs 30.3% and 58.4% vs 31.2%). Current smokers had worse outcomes than former smokers. Multivariate analysis controlling for multiple factors identified smoking as an independent predictor of chronic abdominal pain (OR 2.49, CI 1.23-5.04, p = 0.011), opioid (OR 2.36, CI 1.35-4.12, p = 0.002), neuromodulators (OR 2.55, CI 1.46-4.46, p = 0.001), and non-opioid-controlled medications (OR 2.28, CI 1.22-4.30, p = 0.01) use, as well as splanchnic vein thromboses (OR 2.65, CI 1.02-6.91, p = 0.045) and biliary obstruction (OR 4.12, CI 1.60-10.61, p = 0.003).

CONCLUSION

CP patients who smoke or formerly smoked have greater morbidity and worse outcomes than non-smokers.

Diagnosis and Management of Chronic Pancreatitis: A Review

IMPORTANCE

Chronic pancreatitis (CP) is a chronic inflammatory and fibrotic disease of the pancreas with a prevalence of 42 to 73 per 100 000 adults in the United States.

OBSERVATIONS

Both genetic and environmental factors are thought to contribute to the pathogenesis of CP. Environmental factors associated with CP include alcohol abuse (odds ratio [OR], 3.1; 95% CI, 1.87-5.14) for 5 or more drinks per day vs abstainers and light drinkers as well as smoking (OR, 4.59; 95% CI, 2.91-7.25) for more than 35 pack-years in a case-control study involving 971 participants. Between 28% to 80% of patients are classified as having "idiopathic CP." Up to 50% of these individuals have mutations of the trypsin inhibitor gene (SPINK1) or the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Approximately 1% of people diagnosed with CP may have hereditary pancreatitis, associated with cationic trypsinogen (PRSS1) gene mutations. Approximately 80% of people with CP present with recurrent or chronic upper abdominal pain. Long-term sequelae include diabetes in 38% to 40% and exocrine insufficiency in 30% to 48%. The diagnosis is based on pancreatic calcifications, ductal dilatation, and atrophy visualized by imaging with computed tomography, magnetic resonance imaging, or both. Endoscopic ultrasound can assist in making the diagnosis in patients with a high index of suspicion such as recurrent episodes of acute pancreatitis when imaging is normal or equivocal. The first line of therapy consists of advice to discontinue use of alcohol and smoking and taking analgesic agents (nonsteroidal anti-inflammatory drugs and weak opioids such as tramadol). A trial of pancreatic enzymes and antioxidants (a combination of multivitamins, selenium, and methionine) can control symptoms in up to 50% of patients. Patients with pancreatic ductal obstruction due to stones, stricture, or both may benefit from ductal drainage via endoscopic retrograde cholangiopancreatography (ERCP) or surgical drainage procedures, such as pancreaticojejunostomy with or without pancreatic head resection, which may provide better pain relief among people who do not respond to endoscopic therapy.

CONCLUSIONS AND RELEVANCE

Chronic pancreatitis often results in chronic abdominal pain and is most commonly caused by excessive alcohol use, smoking, or genetic mutations. Treatment consists primarily of alcohol and smoking cessation, pain control, replacement of pancreatic insufficiency, or mechanical drainage of obstructed pancreatic ducts for some patients.

10 Fr S-Type Plastic Pancreatic Stents in Chronic Pancreatitis Are Effective for the Treatment of Pancreatic Duct Strictures and Pancreatic Stones

AIM

Endoscopic pancreatic stenting for refractory pancreatic duct strictures associated with impacted pancreatic stones in chronic pancreatitis cases has yielded conflicting results. We retrospectively evaluated the efficacy of endoscopic treatment in chronic pancreatitis patients with pancreatic duct strictures.

METHODS

Pancreatic sphincterotomy, dilatation procedures, pancreatic brush cytology, and pancreatic juice cytology were routinely performed, and malignant diseases were excluded. After gradual dilatation, a 10 Fr plastic pancreatic stent was inserted. The stents were replaced every 3 months and removed after the strictures were dilated. Statistical analyses were performed to determine the risk of main pancreatic duct restenosis.

RESULTS

Endoscopic pancreatic stents were successfully placed in 41 of a total of 59 patients (69.5%). The median duration of pancreatic stenting was 276 days. Pain relief was obtained in 37 of 41 patients (90.2%). Seventeen patients (41.5%) had recurrence of main pancreatic duct stricture, and restenting was performed in 16 patients (average placement period 260 days). During the follow-up period, pancreatic cancer developed in three patients (5.1%). Multivariate analysis revealed that the presence of remnant stones after stenting treatment was significantly associated with a higher rate of main pancreatic duct restenosis (p = 0.03).

CONCLUSION

The use of 10 Fr S-type plastic pancreatic stents with routine exchange was effective for both short-term and long-term outcomes in chronic pancreatitis patients with benign pancreatic duct strictures and impacted pancreatic stones.

Diagnostic and therapeutic recommendations for chronic pancreatitis. Recommendations of the Working Group of the Polish Society of Gastroenterology and the Polish Pancreas Club

This article describes the latest diagnostic and therapeutic recommendations in chronic pancreatitis, developed by the Working Group of the Polish Society of Gastroenterology and the Polish Pancreas Club. The recommendations refer to the diagnosis of chronic pancreatitis, autoimmune pancreatitis, conservative management, treatment of pain, and exocrine and endocrine pancreatic insufficiency, treatment of chronic pancreatitis by endoscopic and surgical methods, and oncological surveillance of chronic pancreatitis. This paper refers to the Polish recommendations published in 2011, which have been updated and supplemented. All recommendations were voted by experts of the Polish Society of Gastroenterology and the Polish Pancreas Club, who evaluated them each time on a five-degree scale, where I meant full acceptance, II – acceptance with some reservation, III – acceptance with serious reservation, IV – rejection with some reservation and V – full rejection. The results of the voting, together with a brief commentary, have been included with each recommendation put to the vote. In addition, the expert group assessed the value of clinical studies on which the statements are based, on a scale where A means high (based on meta-analyses and randomised clinical trials), B means medium (based on clinical trials and observational studies), and C means low (based mainly on expert opinion).

Incidence and predictors of 30-day readmissions in patients hospitalized with chronic pancreatitis: A nationwide analysis

BACKGROUND

Patients with chronic pancreatitis are prone to frequent readmissions. The aim of this study is to evaluate the rate and predictors of 30-day readmissions in patients with chronic pancreatitis using the Nationwide Readmission Database (NRD).

METHODS

We performed a retrospective analysis of all adult patients with the principal discharge diagnosis of chronic pancreatitis from 2010 through 2014. We excluded patients who died during the hospitalization. Multivariate Cox proportional hazard regression was performed to identify demographic, clinical, and hospital factors that associated with 30-day unplanned readmissions.

RESULTS

During the study period, 25,259 patients had the principal discharge diagnosis of chronic pancreatitis and survived the index hospitalization. Of these, 6477 (26.7%) were readmitted within 30 days. Younger age group, males, length of stay >5 days, admission to a large, metropolitan hospital, and several comorbidities (renal failure, rheumatic disease, chronic anemia, heart failure, depression, drug abuse, psychosis, and diabetes) were independently associated with increased risk of 30-day readmission. ERCP, pancreatic surgery, and obesity were associated with lower risk. The most common reasons for readmissions were acute pancreatitis (30%), chronic pancreatitis (17%), pseudocyst (2%), and abdominal pain (6%).

CONCLUSIONS

One in four patients with chronic pancreatitis is readmitted within 30 days (26.7%). Pancreatic disease accounts for at least half of all readmissions. Several baseline comorbidities and characteristics are associated with 30-day readmission risk after index admission. Knowledge of these predictors can help design interventions to target high-risk patients and reduce readmissions and costs of care.

Medical Management of Pain in Chronic Pancreatitis

The medical management of pain in chronic pancreatitis continues to pose significant challenges for clinicians caring for these patients. There are increasing data, suggesting that pain in chronic pancreatitis is largely due to peripheral and central sensitization that evolves, over time, as a result of nociceptive afferent associated with chronic inflammation and fibrosis of the pancreas. In many instances, patients rapidly progress to requiring opioid analgesics for the adequate treatment of pain despite the unequivocal risks associated with the long-term use of these drugs. Centrally acting drugs, such as gabapentinoids, appear to be effective means of treating pain due to their inhibition of neurotransmitters involved in central sensitization, but side effects limit their use. The present review explores the evidence for various non-pharmacologic and pharmacologic treatments for pain in chronic pancreatitis.

Mechanisms of primary operative failure and results of remedial operation in patients with chronic pancreatitis

INTRODUCTION

Resection and drainage operations achieve long-term pain relief in approximately 85% of patients with chronic pancreatitis (CP). In patients who develop recurrent pain, a few data exist on the long-term results of remedial operations.

MATERIALS AND METHODS

Over an 18-year period (1988-2006), 316 patients with CP had primary resection or drainage operations at our institution. Thirty-nine developed recurrent pain and were treated by a remedial resection or drainage operation. Patient demographics, time to symptom recurrence, radiographic anatomic abnormalities, type of remedial operation, postoperative morbidity, and long-term outcomes were analyzed.

RESULTS

Thirty-nine patients, 56% female with a mean age of 41 years (range 16-61 years) had either remedial resection: total pancreatectomy (TP; N = 8), pancreaticoduodenectomy (PD; N = 6), distal pancreatectomy (DP; N = 5), or drainage operation: duodenal preserving pancreatic head resection (DPPHR; N = 8), revision of pancreaticojejunostomy (N = 12). TP achieved pain relief in 88% with postoperative complications greater than or equal to grade III in 38% and diabetes in 100%. Drainage operations achieved pain relief in 67% of patients with postoperative complications greater than or equal to grade III in only 8%. Partial parenchymal resections (DPPHR, PD, DP) as a remedial procedure achieved pain relief <50% of the time.

CONCLUSION

Drainage procedures, when anatomically feasible, are the preferred reoperation to treat patients with recurrent pain after failed primary operation for chronic pancreatitis.

Smoking cessation at the clinical onset of chronic pancreatitis and risk of pancreatic calcifications

OBJECTIVE

Cigarette smoking is associated with a higher risk of developing chronic pancreatitis (CP) and increases the likelihood of developing pancreatic calcifications. The aim of this study was to know whether smoking cessation modifies the course of the disease.

METHODS

Patients with CP who had been followed up for more than 6 years from clinical onset and who had not developed calcifications after 5 years were analyzed. We studied smokers, never-smokers, and patients who had given up smoking within 5 years. For actuarial analysis, the sixth year was considered as time 0.

RESULTS

Of the 360 patients, there were 43 women and 317 men (88.1%) with a mean age of 38.7 years. The median follow-up was 19.0 years. Chronic pancreatitis was alcohol-associated in 255 patients, hereditary in 10, obstructive in 54, and idiopathic in 41. There were 317 smokers (88.1%) and 259 alcohol drinkers (71.9%). At the end of the follow-up, 212 patients (59.8%) developed calcifications. Concerning the risk of calcifications, never-smokers and ex-smokers had similar actuarial curves, and these were significantly different from the curve for smokers (P < 0.003). Considering never-smokers as the reference class, ex-smokers had an odds ratio (OR) of 0.56 (95.0% confidence interval [CI], 0.2-1.4; P = not significant), patients smoking 1 to 10 cigarettes per day had an OR of 1.95 (95.0% CI, 1.1-3.4; P < 0.019), patients smoking 11 to 20 cigarettes per day had an OR of 1.76 (95.0% CI, 1.1-2.8; P < 0.0018), and those smoking more than 20 cigarettes per day had an OR of 1.79 (95.0% CI, 1.1-2.9; P < 0.019). Alcohol cessation seems to have no influence.

CONCLUSIONS

Smoking cessation in the first years from the clinical onset of CP reduces the risk of developing pancreatic calcifications.

Quality of life in patients with chronic pancreatitis

INTRODUCTION

Health-related quality of life is becoming a major issue in the evaluation of any therapeutic intervention in patients with chronic or hard to cure diseases.

AIMS

To assess the quality of life in patients with chronic pancreatitis, the majority of whom have had the disease for a long time, and to evaluate which factors linked to the disease are able to influence the quality of life.

SUBJECTS AND METHODS

A total of 190 consecutive patients (157 males, 33 females; mean age 58.6+/-12.7 years, range 18-92 years) with proven chronic pancreatitis were enrolled. The SF-36 questionnaire was used for assessing the health-related quality of life.

RESULTS

The z-scores of the eight domains of the patients with chronic pancreatitis were significantly negative indicating an overall impairment of the quality of life when compared to the Italian normative sample. Pancreatic pain was the unique clinical variable able to significantly impair all eight domains of the SF-36, while Wirsung dilation and diabetes were negatively related to some physical and mental domains. The body mass index was the unique variable positively related with some SF-36 domains.

CONCLUSIONS

Pain may be considered the most important factor affecting the quality of life of chronic pancreatitis patients; moreover, alimentary and metabolic factors deserve more attention in improving the quality of life of these subjects.

Long-term clinical outcome after endoscopic pancreatic ductal drainage for patients with painful chronic pancreatitis

BACKGROUND & AIMS

Endotherapy for patients with painful chronic pancreatitis (CP) gives early and midterm clinical results comparable with those of conventional surgery. The authors evaluated long-term clinical outcome after endoscopic pancreatic ductal drainage, focusing on pain and pancreatic endocrine/exocrine functions.

METHODS

Of 110 patients with painful CP endoscopically treated between October 1987 and December 1989, 56 long-surviving patients were followed-up for 14.4 years (SD, .6 y); 40 patients died and 14 patients were lost to follow-up evaluation. Technical results included decreased ductal dilation and stone clearance. Clinical results included the rate of hospitalizations for pain before and after endotherapy, the need for surgery, the course of endocrine/exocrine insufficiencies, and late mortality.

RESULTS

Complete or partial technical success initially was obtained in 48 of 56 long-surviving patients. Long-term clinical success (< or =5 hospitalizations for pain during follow-up evaluation, without surgery) was obtained for 37 of 56 patients. At a mean follow-up time of 14.4 years, 44 patients had avoided surgery and the annual rate of hospitalizations for pain decreased significantly (before endotherapy: 0.98 [+/-1.36] vs 0.40 [+/-0.51] for the 3 years thereafter vs 0.14 [+/-0.22] for the last 11 years of follow-up evaluation; P < .001). Short duration of disease before initial therapy and absence of smoking at the last follow-up evaluation were associated with long-term clinical success.

CONCLUSIONS

Endotherapy provides long-term benefits for about two thirds of patients with painful CP. Good clinical outcome was associated with cessation or absence of smoking, whereas alcohol abuse increased the risks for diabetes mellitus, steatorrhea, and mortality.

Alcohol intake, cigarette smoking, and body mass index in patients with alcohol-associated pancreatitis

The differential diagnosis between acute and chronic alcohol-associated pancreatitis is often difficult or impossible at onset of the disease. A study was conducted to determine possible relationships between patients suffering from a first episode of acute alcoholic pancreatitis and patients with unequivocal chronic alcoholic pancreatitis, comparing age, drinking and smoking habits, and body mass index (BMI). Two groups of men were considered. The first group consisted of 67 patients with a diagnosis of acute alcohol-associated pancreatitis in the absence of other potential pathogenic factors; in this group, 48 of the 56 patients surviving the acute attack were submitted to imaging studies for a median period of 9 years. The second group consisted of 396 patients with chronic alcoholic pancreatitis with a median follow-up period of 12 years. The variables that differed significantly in the two groups were BMI (p < 0.009) and number of smokers (p < 0.001). Logistic regression analysis selected only BMI with an odds ratio of 1.19 (95% CI, 1.07-1.33; p < 0.00015) in favor of acute alcoholic pancreatitis. In male patients, from an epidemiologic standpoint, only smoking habits and BMI are significant differences at clinical onset between the two types of pancreatitis.

Incidence of cancer in the course of chronic pancreatitis

OBJECTIVE

Chronic pancreatitis patients appear to present an increased incidence of pancreatic cancer. The aim of the study was to compare the incidence of cancer, whether pancreatic or extrapancreatic, in our chronic pancreatitis cases with that in the population of our region.

METHODS

We analyzed 715 cases of chronic pancreatitis with a median follow-up of 10 yr (7287 person-years); during this observation period they developed 61 neoplasms, 14 of which were pancreatic cancers. The cancer incidence rates were compared, after correction for age and gender, with those of a tumour registry.

RESULTS

We documented a significant increase in incidence of both extrapancreatic (Standardized Incidence Ratio [SIR], 1.5; 95% confidence interval [CI], 1.1-2.0; p <0.003) and pancreatic cancer (SIR, 18.5; 95% CI, 10-30; p <0.0001) in chronic pancreatitis patients. Even when excluding from the analysis the four cases of pancreatic cancer that occurred within 4 yr of clinical onset of chronic pancreatitis, the SIR is 13.3 (95% CI, 6.4-24.5; p <0.0001). If we exclude these early-onset cancers, there would appear to be no increased risk of pancreatic cancer in nonsmokers, whereas in smokers this risk increases 15.6-fold.

CONCLUSIONS

The risks of pancreatic and nonpancreatic cancers are increased in the course of chronic pancreatitis, the former being significantly higher than the latter. The very high incidence of pancreatic cancer in smokers probably suggests that, in addition to cigarette smoking, some other factor linked to chronic inflammation of the pancreas may be responsible for the increased risk.