Editorial: Does ESWL-ERCP for pancreatic duct stone removal change the natural course of symptomatic chronic calcific pancreatitis? Authors' reply

Abstract

We would like to thank Dr Kozarek for his very interesting editorial¹ on our study entitled ‘Long-term Clinical Outcomes of Extracorporeal Shockwave Lithotripsy and Endoscopic Retrograde Cholangiopancreatography for Pancreatic Duct Stone Treatment in Patients with Chronic Pancreatitis’² that aimed to explore the short- and long-term efficacies of extracorporeal shockwave lithotripsy for pancreatic stones (P-ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) for painful chronic pancreatitis (CP). We totally agree that the efficacy of P-ESWL and ERCP seemed better than several previous studies.^3-6 The discordance should be attributed to the several factors. First of all, the heterogeneity in treatment protocols across different studies may lead to variations in therapeutic efficacy. We have treated patients with CP according to the guidelines as much as possible,^{7, 8} yet some studies have not.^{4, 5} For instance, the stone diameter was bigger in these studies, which represented the difficulty of P-ESWL and ERCP.^{4, 5} The frequent stent exchanges performed every 2–4 months⁶ could also influence the efficacy since the guidelines suggest treating painful patients with a single plastic stent for one uninterrupted year.^{7, 8} The unified treatment protocol may help the comparison of the efficacy in the future. Next, the studies including Dr Kozarek's et al.'s³ study and several randomized controlled trials (RCTs)^4-6 shared a common feature in that they only included patients with severe pain. Patients with severe pain may be experiencing refractory pain with central sensitization. However, patients with CP in our country have different pain patterns compared with other countries. The majority of patients suffered from recurrent acute pancreatitis, recurrent acute pancreatitis and recurrent pain, and <5% of patients complained of chronic pain. The proportion of analgesics usage was much lower than in western countries, which also proved the low rate of chronic pain in our centre. In our analysis, we included all patients experiencing pain who had indication for P-ESWL and ERCP, including those with mild to severe pain. This broader inclusion may be the major reason for the higher pain relief rate observed compared to the aforementioned studies. Furthermore, the proportion of patients who smoke and drink in these studies was much higher than in our centre, leading to differences in treatment efficacy. As reported in a recent study, consumption of alcohol and tobacco were independent predictors of persistent pain after successful ESWL.⁹ Dr Kozarek et al.³ also reported smoking cessation could improve narcotic pain medication use. Although our study did not yield positive results regarding smoking cessation improving abdominal pain, we believe that a more rigorously designed RCT with a longer follow-up period may potentially reach this conclusion. Ultimately, as for the lower rate of further invasive treatment in our centre, the end of follow-up in this study does not mean the end of further treatment. We encouraged patients to seek additional treatment at the appropriate time.

In conclusion, our study reflected the efficacy of P-ESWL and ERCP for painful patients with CP. While, large-scale RCTs with long-term follow-up are needed to evaluate the specific efficacy of these treatments.

Yu Liu: Conceptualization; writing – original draft; writing – review and editing. Liang-Hao Hu: Conceptualization; writing – original draft; writing – review and editing.

None.

The authors declare no conflicts of interest.

This article is linked to Liu et al papers. To view these articles, visit https://doi.org/10.1111/apt.18224 and https://doi.org/10.1111/apt.18253