Morphology-Based Surgery for Chronic Pancreatitis Across Europe: Toward the Next Generation of Unified Guidelines
Abstract
OBJECTIVE: To evaluate the use and impact of current surgical guidelines for chronic pancreatitis (CP) across Europe. SUMMARY BACKGROUND DATA: Current guidelines recommend morphology-based surgery for CP, but international studies evaluating their use and impact are lacking. METHODS: Post hoc analysis of the prospective multicenter ESCOPA study, including patients undergoing surgery for symptomatic CP at 22 centers in 13 countries (June 2021-November 2022), with 6-month follow-up. Patients were stratified by morphologic subtype: "isolated dilated main pancreatic duct (MPD)," "isolated enlarged pancreatic head (PH)," "combined dilated MPD and enlarged PH," and "small duct disease." Treatment was based on the European HaPanEU and International IAP-APA-JPS-EPC guidelines. Primary outcomes were 90-day major morbidity, mortality, and pain relief at 6 months. Practice variation was assessed, including a case-based survey. RESULTS: Overall, 207 patients were included following surgery for CP, with 1.4% 90-day mortality and 72.6% pain relief. The surgical approach varied widely by morphologic subtype: duodenum-preserving pancreatic head resections (DPPHR) were most common for "combined dilated MPD and enlarged PH" (46.8%, P=0.016); whereas formal pancreatectomy predominated for "isolated dilated MPD" (63.3%, P=0.040) and "small duct disease" (66.0%, P=0.004). Guideline-concordant surgery (66%) was not associated with improved rates of major morbidity (12.9% vs. 18.8%, P=0.387), mortality (1.6% vs. 1.6%, P>0.999), or pain relief (75.3% vs. 66.7%, P=0.468). Outcomes were also comparable between drainage/parenchyma-preserving surgery and formal pancreatectomy. Survey findings confirmed practice variation, including the use of formal and V-shaped pancreatectomy for small duct disease. CONCLUSION: The substantial variation in surgical practice for CP across Europe highlights the need for unified guidelines with clear recommendations, particularly regarding formal and V-shaped pancreatectomy.
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Authors: Charlotte L. van Veldhuisen, C. Leseman, Fleur E.M. De Rijk, Joana C. Marques-Antunes, Fabio Ausania, Orlin Belyaev, Frederik Berrevoet, Marja Boermeester, Ugo Boggi, Stefan A. Bouwense, Marco J. Bruno, Olivier R. Busch, Kevin C. Conlon, Safi Dokmak, Massimo Falconi, Poya Ghorbani, Filip Gryspeerdt, Roel Haen, Arturan İbrahimli, Jakob R. Izbicki, Christina Krikke, Arto Kokkola, Lancelot Marique, JSD Mieog, Gennaro Nappo, Janis Pavulans, Haralds Plaudis, Geert Roeyen, Pasquale Scognamiglio, Domenico Tamburrino, Tore Tholfsen, Marie Toschka, Faik G. Uzunoglu, Susan van Dieren, Casper H.J. Van Eijck, Jeanin E. van Hooft, Hjalmar C. Van Santvoort, Robert C. Verdonk, Rogier P. Voermans, Anne Waage, Marc G. Besselink
Institutions: University Medical Center Groningen, University of Groningen, Leiden University Medical Center, University of Helsinki, Amsterdam University Medical Centers, Inserm, Karolinska University Hospital, Maastricht University, Ghent University Hospital, University of Amsterdam, Université Paris Cité, Hôpital Beaujon, Helsinki University Hospital, Universität Hamburg, Erasmus MC, Assistance Publique – Hôpitaux de Paris, Ruhr University Bochum, Humanitas University, University of Pisa, Vita-Salute San Raffaele University, Erasmus MC Cancer Institute, Antwerp University Hospital, University Medical Center Utrecht, Oslo University Hospital, St. Josef-Hospital, Instituto de Investigación Sanitaria de Santiago, Trinity College Dublin, Azerbaijan Medical University, St. Antonius Ziekenhuis, Hospital de Santa Maria, Centre de Recherche sur l'Inflammation, Tallaght University Hospital, Riga East University Hospital