Early surgery versus optimal current step-up practice for chronic pancreatitis (ESCAPE): design and rationale of a randomized trial

Usama Ahmed Ali,Robin Timmer,Paul Fockens,Hjalmar Van Santvoort,Harry Van Goor,Yama Issa,Frank P Vleggaar ,O H G Wilder‐Smith ,Peter D Siersema ,Vincent B Nieuwenhuijs ,Hein G Gooszen ,Marco J Bruno ,Marc G Besselink ,Yolande C.a Keulemans ,Dirk J Gouma ,Marcel G W Dijkgraaf ,Jeanin E Van Hooft ,Cornelis H C Dejong ,Olivier R Busch ,Jan Werner Poley ,Hendrik M Van Dullemen ,Casper H Van Eijck ,Marja A Boermeester

doi:10.1186/1471-230x-13-49

Abstract

BackgroundIn current practice, patients with chronic pancreatitis undergo surgical intervention in a late stage of the disease, when conservative treatment and endoscopic interventions have failed. Recent evidence suggests that surgical intervention early on in the disease benefits patients in terms of better pain control and preservation of pancreatic function. Therefore, we designed a randomized controlled trial to evaluate the benefits, risks and costs of early surgical intervention compared to the current stepwise practice for chronic pancreatitis.Methods/designThe ESCAPE trial is a randomized controlled, parallel, superiority multicenter trial. Patients with chronic pancreatitis, a dilated pancreatic duct (≥ 5 mm) and moderate pain and/or frequent flare-ups will be registered and followed monthly as potential candidates for the trial. When a registered patient meets the randomization criteria (i.e. need for opioid analgesics) the patient will be randomized to either early surgical intervention (group A) or optimal current step-up practice (group B). An expert panel of chronic pancreatitis specialists will oversee the assessment of eligibility and ensure that allocation to either treatment arm is possible. Patients in group A will undergo pancreaticojejunostomy or a Frey-procedure in case of an enlarged pancreatic head (≥ 4 cm). Patients in group B will undergo a step-up practice of optimal medical treatment, if needed followed by endoscopic interventions, and if needed followed by surgery, according to predefined criteria. Primary outcome is pain assessed with the Izbicki pain score during a follow-up of 18 months. Secondary outcomes include complications, mortality, total direct and indirect costs, quality of life, pancreatic insufficiency, alternative pain scales, length of hospital admission, number of interventions and pancreatitis flare-ups. For the sample size calculation we defined a minimal clinically relevant difference in the primary endpoint as a difference of at least 15 points on the Izbicki pain score during follow-up. To detect this difference a total of 88 patients will be randomized (alpha 0.05, power 90%, drop-out 10%).DiscussionThe ESCAPE trial will investigate whether early surgery in chronic pancreatitis is beneficial in terms of pain relief, pancreatic function and quality of life, compared with current step-up practice.Trial registrationISRCTN: ISRCTN45877994

Highlights

In current practice, patients with chronic pancreatitis undergo surgical intervention in a late stage of the disease, when conservative treatment and endoscopic interventions have failed
The ESCAPE trial will investigate whether early surgery in chronic pancreatitis is beneficial in terms of pain relief, pancreatic function and quality of life, compared with current step-up practice
In patients with chronic pancreatitis (CP), the most important clinical problem is the management of pain, which often occurs daily and is disabling [1,2]

Summary

Introduction

Patients with chronic pancreatitis undergo surgical intervention in a late stage of the disease, when conservative treatment and endoscopic interventions have failed. Surgical intervention is kept as an option of last resort when other treatments have failed and the severity of disease has increased substantially and pain becomes unmanageable [6,7]. This approach is based on the so called ‘burnout hypothesis’, assuming that CP is a ‘self-limiting’ disease in which pain will resolve spontaneously due to progressive parenchymal destruction of the pancreas [3]. The main argument against the burnout hypothesis is the long time it takes for pain to subside; e.g. after 5 years of the onset of the disease about 60% of the patients will still experience substantial pain, and that in many reports complete insufficiency (‘burnout’) of the gland does not guarantee pain relief [4,8]

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