A comparative study on Quality of life, between Primary Early Surgery and Late surgery in Chronic Calcific Pancreatitis using the SF-36 Questionnaire – A Prospective Observational Cohort Study

A comparative study on Quality of life, between Primary Early Surgery and Late surgery in Chronic Calcific Pancreatitis using the SF-36 Questionnaire – A Prospective Observational Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A comparative study on Quality of life, between Primary Early Surgery and Late surgery in Chronic Calcific Pancreatitis using the SF-36 Questionnaire – A Prospective Observational Cohort Study Prakash Subramaniam, Somasekar RDR, Kesavan B, Johnson M, Swaminathan R, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7602290/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Nov, 2025 Read the published version in Digestive Diseases and Sciences → Version 1 posted 10 You are reading this latest preprint version Abstract Purpose: We aim to test the hypothesis that “Primary Early surgery (i.e. within 2years from symptoms onset) in Chronic calcific pancreatitis (CCP) has better durable long-term Quality of Life (QOL) than patients undergoing late surgery (> 2 years from symptom onset)” using the SF 36 Questionnaire. Methods: This is a prospective observational study conducted between 2016 to 2025. 162 patients with large duct CCP (MPD diameter ≥ 6mm) underwent either Frey’s procedure or Lateral Pancreatico Jejunostomy. 62/162 patients on regular follow up were included in the study. The 62 patients were grouped into Primary early surgery group (PESG) and Late surgery group (LSG). After long term (> 3year) of follow up, patient’s responses regarding QOL were recorded using the SF36 questionnaire and compared. The primary outcome measures were pain, physical functioning and role limitations due to physical health and the other components on the SF 36 were taken as secondary outcome measures. Results: 27/62 cases were in LSG and 35/62 belonged to PESG. Mann-Whitney U test was used to make group comparisons. 7 out of 8 components namely Pain, Physical Functioning, Role Limitations Due to Physical Health, Role Limitations Due to Emotional Problems, Energy/ Fatigue, Emotional Well Being, Social Functioning had statistically significant difference favouring better QOL in PESG. Conclusion: Primary Early surgery has a positive impact on long term QOL in patients with CCP. However, future RCTs will help to draw solid conclusions to support or refute our observations. Chronic calcific pancreatitis Early surgery Quality of Life Late surgery SF 36 Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Chronic pancreatitis (CP) is a chronic inflammatory condition characterised by chronic pain, progressive loss of pancreatic function and an elevated risk of developing pancreatic cancer[ 1 ]. Chronic inflammation leads to parenchymal fibrosis, atrophy, MPD strictures, intraparenchymal and intraductal calcification leading to progressive endocrine and exocrine insufficiency. The pathophysiology of pain in CP is multifactorial. These include intra-parenchymal and intra-ductal hypertension, abnormal proliferation of peripancreatic nerves, activation of neurons containing pro-inflammatory peptides and hypersensitization of these nerve endings leading to intractable pain[ 2 ]. Ebbehoj et al. demonstrated a correlation between pain severity and intrapancreatic pressure measured before and after surgery, and at one year following MPD drainage. Patients whose pressures stayed low remained free of pain[ 3 ]. The primary goal of treatment in CP is alleviation of pain. There is no treatment modality to halt the progression of the disease till date. The current standard of care generally follows a stepwise approach starting with medical management, progressing to endoscopic interventions and reserving surgery for later stages. The emerging clinical evidence strongly supports the benefits of a Primary early surgical intervention with more effective, sustained pain relief and better QOL. It can potentially preserve pancreatic function for a longer period and aims to delay or mitigate the progression toward irreversible pancreatic insufficiency[ 1 ]. The previous studies in the literature have primarily focused on comparing pain scores and examining differences between various treatment approaches, with relatively limited data available on assessing patients’ QOL after Early surgery[ 4 ]. This study aims to address that gap by evaluating the long-term QOL in individuals who undergo Primary early surgical intervention as compared to those undergoing Late surgery. Methods This was a prospective observational study conducted between 2016 to 2025 in a GI surgery unit in a tertiary care hospital. A total of 522 patients with dilated MPD, parenchymal atrophy, intra-parenchymal or ductal calcifications on a pancreas protocol CECT abdomen were diagnosed as CP between January 2016 to June 2022. Though the predominant etiology of the disease was due to ethanol ingestion, CP due to any cause was included in the study. Of these, 256 patients with an undilated or MPD diameter ≤ 5mm were considered as having small-duct disease and excluded. Another 104 patients with a dilated MPD (≥ 6 mm) had acute inflammatory activity and were managed conservatively. The remaining 162 patients with a dilated MPD (≥ 6 mm) underwent surgical management tailored according to the individuals patho-morphology. Those patients who presented to us within two years of symptom onset and who had not undergone prior medical or endoscopic therapy were classified as PESG (92/162 cases); while those who underwent surgery more than two years after symptom onset and/or undergone prior step-up approach were classified as LSG (70/162 Patients with an atrophic pancreas, dilated MPD with intraductal stones underwent ductal clearance of stones and a lateral pancreatico-jejunostomy[ 5 ]. Those with a head mass underwent a hybrid procedure, the standard Frey’s procedure[ 6 ]. It is our institutional practice to do head coring for non-head mass CP. In the PESG, surgery was done irrespective of the presence or absence of intractable pain. In both groups patients who have lost follow up, not given consent or died due to other causes were excluded. 35/92 cases and 27/70 cases in the early and LSGs respectively were included in the study as detailed in the Fig. 1 . All the patients were followed up on a regular basis and their responses on a SF-36 questionnaire were recorded after 3 years of follow up. We have obtained approval from the institutional ethical committee and an informed consent was obtained from all patients prior to enrolment in the study. The SF-36 consists of 36 multiple-choice questions categorized into eight components namely: Pain, Physical Functioning, Role Limitations Due to Physical Health, Role Limitations Due to Emotional Problems, Energy/Fatigue, Emotional Well-Being, Social Functioning, and General Health. Each answer is assigned a score ranging from 0 to 100 according to the RAND scoring system[ 7 ]. These scores were applied to the patients’ responses, and the average score for each component was calculated and tabulated for both groups. Basic patient characteristics including age, gender, endocrine and exocrine function were compared between the two groups. The primary outcome measures were pain, physical functioning and role limitations due to physical health and the rest of the components of the SF-36 were taken as secondary outcome measures in our study. We used statistical tests to compare the two groups. Results Fisher’s exact test revealed a significant association between group and age (χ² = 9.437, p = 0.021). The LSG had a higher proportion of patients aged 21–30, 31–40, and 51–60 years, while the PESG had more patients in the 41–50 year range (Fig. 2 ). No significant association was found between group and gender (χ² = 0.004, p = 0.953) or group and diabetes (χ² = 1.359, p = 0.244). Gender distribution was nearly identical (PESG: 77.1% male, 22.9% female; LSG: 77.8% male, 22.2% female), while diabetes was present in 17.1% of the PESG and 29.6% of the LSG. All the 8 variables were not normally distributed in the 2 subgroups of the variable Group. Thus, non-parametric tests (Wilcoxon-Mann-Whitney U Test) were used to make group comparisons. The results of basic characteristics and outcomes are summarised in Table 1. The mean (SD) of Pain in the PESG was 78.64 (24.87) and in LSG was 63.98 (21.40). The median (IQR) of Pain in the PESG was 87.5 (77.5–95) and in the LSG was 55 (50-78.75). There was a significant difference between the 2 groups in terms of Pain (W = 653.500, p = 0.010), with the median Pain score being highest in the PESG indicating good pain response in PESG. Strength of Association (Point-Biserial Correlation) = 0.3 (Medium Effect Size). Distribution of pain score in Violin plot is shown in Fig. 2 . The mean (SD) of Physical Functioning in the PESG was 89.14 (11.85) and in LSG was 72.78 (22.07). The median (IQR) of Physical Functioning in the PESG was 90 (87.5–100) and in the LSG was 55 (50-78.75). There was a significant difference between the 2 groups in terms of Physical Functioning (W = 688.500, p = 0.002), with the median Physical Functioning score being highest in the PESG indicating good Physical Functioning in PESG. Strength of Association (Point-Biserial Correlation) = 0.44 (Large Effect Size). Distribution of Physical functioning score in Violin plot is shown in Fig. 3 . The mean (SD) of Role Limitations Due to Physical Health in the PESG was 83.57 (32.05) and in LSG was 44.44 (47.20). The median (IQR) of Role Limitations Due to Physical Health in the PESG was 100 (87.5–100) and in the LSG was 25 (0-100). There was a significant difference between the 2 groups in terms of Role Limitations Due to Physical Health (W = 683.000, p = 0.001), with the median Role Limitations Due to Physical Health score being highest in the PESG indicating lesser Role Limitations Due to Physical Health in PESG. Strength of Association (Point-Biserial Correlation) = 0.45 (Large Effect Size). The significance in primary objectives in PESG are depicted in Table 2. Distribution of Role limitation to Physical health score in Violin plot in Fig. 4 . The mean (SD) of Role Limitations Due to Emotional Problems in the PESG was 96.19 (13.46) and in LSG was 77.78 (32.03). The median (IQR) of Role Limitations Due to Emotional Problems in the PESG was 100 (100–100) and in the LSG was 100 (33.33–100). There was a significant difference between the 2 groups in terms of Role Limitations Due to Emotional Problems (W = 598.500, p = 0.009), with the median Role Limitations Due to Emotional Problems score being highest in the PESG indicating lesser Role Limitations Due to Emotional Problems in PESG. Strength of Association (Point-Biserial Correlation) = 0.37 (Large Effect Size) The mean (SD) Energy/Fatigue score was 69.29 (21.39) in the PESG and 52.59 (22.55) in the LSG. A significant difference was found (W = 668.500, p = 0.005), with higher median scores in the PESG, indicating a positive impact on Energy/Fatigue. The mean (SD) Emotional Well-Being score was 71.77 (15.00) in the PESG and 57.19 (17.32) in the LSG. A significant difference was observed (W = 696.000, p = 0.001), with higher median scores in the PESG, indicating better Emotional Well-Being. The mean (SD) Social Functioning score was 78.50 (22.58) in the PESG and 63.70 (25.85) in the LSG. A significant difference was found (W = 647.000, p = 0.012), with higher median scores in the PESG, indicating better Social Functioning. The mean (SD) of General Health in the PESG was 59.69 (25.70) and in LSG was 50.22 (21.80). There was no significant difference between the groups in terms of General Health (W = 574.000, p = 0.150). Table.1 Comparison summary of basic characteristics and the outcomes between PESG and LSGs Parameters Group p value Early (n = 35) Late (n = 27) Age (Years) 44.26 ± 6.26 40.63 ± 9.90 0.103 1 Age*** 0.021 2 21–30 Years 0 (0.0%) 4 (14.8%) 31–40 Years 9 (25.7%) 10 (37.0%) 41–50 Years 20 (57.1%) 7 (25.9%) 51–60 Years 6 (17.1%) 6 (22.2%) Gender 0.953 3 Male 27 (77.1%) 21 (77.8%) Female 8 (22.9%) 6 (22.2%) Diabetic (Yes) 6 (17.1%) 8 (29.6%) 0.244 3 Exocrine Insufficiency (Yes) 3 (8.6%) 4 (14.8%) 0.689 2 Pain*** 78.64 ± 24.87 63.98 ± 21.40 0.010 4 Physical Functioning*** 89.14 ± 11.85 72.78 ± 22.07 0.002 4 Role Limitations Due To Physical Health*** 83.57 ± 32.05 44.44 ± 47.20 0.001 4 Role Limitations Due To Emotional Problems*** 96.19 ± 13.46 77.78 ± 32.03 0.009 4 Energy/ Fatigue*** 69.29 ± 21.39 52.59 ± 22.55 0.005 4 Emotional Well Being*** 71.77 ± 15.00 57.19 ± 17.32 0.001 4 Social Functioning*** 78.50 ± 22.58 63.70 ± 25.85 0.012 4 General Health 59.69 ± 25.70 50.22 ± 21.80 0.150 4 ***Significant at p < 0.05, 1: t-test, 2: Fisher's Exact Test, 3: Chi-Squared Test, 4: Wilcoxon-Mann-Whitney U Test Table.2 Primary objectives and their comparisons . Pain Group Wilcoxon-Mann-Whitney U Test Early Late W p value Mean (SD) 78.64 (24.87) 63.98 (21.40) 653.500 0.010 Median (IQR) 87.5 (77.5–95) 55 (50-78.75) Min - Max 10–100 32.5–100 Physical Functioning Group Wilcoxon-Mann-Whitney U Test Early Late W p value Mean (SD) 89.14 (11.85) 72.78 (22.07) 688.500 0.002 Median (IQR) 90 (87.5–100) 80 (45–90) Min - Max 45–100 40–100 Role Limitations Due to Physical Health Group Wilcoxon-Mann-Whitney U Test Early Late W p value Mean (SD) 83.57 (32.05) 44.44 (47.20) 683.000 0.001 Median (IQR) 100 (87.5–100) 25 (0-100) Min - Max 0–100 0–100 Discussion Chronic pancreatitis (CP) is a progressive inflammatory disorder with multiple causes, most often linked to alcohol use. The exact pathophysiology remains uncertain. It generally begins with acinar cell injury triggering the inflammation. While some cases resolve with repair, others progress to persistent inflammation due to persisting or intermittent exposure to noxious stimuli, leading to activation of pancreatic stellate cells. These cells drive fibrosis and irreversible structural changes, forming the hallmark of CP[ 8 ]. Chronic pancreatitis (CP) is now understood as a multifactorial disease shaped by genetic predisposition and modifying factors. Variants in PRSS1, SPINK1, and CFTR show the strongest associations, while CTRC and CASR contribute more modestly. These genetic influences highlight the role of inherited susceptibility in disease onset, progression, and variability among patients[ 9 ]. Hereditary pancreatitis (HP) presents in childhood or adolescence, progresses rapidly to end-stage chronic pancreatitis with exocrine and endocrine failure, and carries a substantially increased lifetime risk of pancreatic adenocarcinoma[ 9 ]. In our study, alcohol was identified as the predominant etiological factor, accounting for nearly 80% of cases (32% in LSG and 48% in PESG), while the remaining were attributed to idiopathic causes, often presenting with early onset during adolescence. In a recent study, the age distribution of patients ranged from 40 to 62 years. The Indian cohort demonstrated the youngest mean age and showed no significant overall difference in age between eastern and western populations[ 10 ]. In our study, the mean age was 44.26 years in the PESG and 40.63 years in the LSG. The LSG cohort had more patients in the 21–30, 31–40, and 51–60-year ranges, while the PESG was concentrated in the 41–50-year range, showing a statistically significant age distribution difference. A higher proportion of younger patients in the LSG suggests their symptoms began in adolescence but were mild, overlooked, or untreated, leading to delayed presentation beyond two years. By then, the pancreas had often progressed to an atrophic state, reducing the benefits of surgery. As a result, their postoperative QOL was less favorable compared with the PESG, who underwent intervention before extensive pancreatic damage developed. Despite the predominance of a younger population in the LSG, it did not translate into a better QOL. The gender distribution between the two groups is also comparable. The age group comparisons are depicted in Fig. 5 . The reason why some patients present as large-duct CP (LDCP) and others with small-duct CP (SDCP) during their index presentation is not known. But early presentation as LDCP is probably a favorable patho-morphology as it prompts timely intervention. In LDCP, surgery effectively relieves intraductal and probably intra-parenchymal hypertension. As the head of the pancreas is considered a pace-maker of pain, head-coring procedures effectively provide durable results. It is our institutional practice to do head-coring even in non-head mass CP. We advocate primary early surgical management in LDCP irrespective of the intractability of pain. As for acute pancreatitis, a step-up approach is advocated for CP in the existing literature. But evolving evidence goes in favour of primary Early surgery in CP. Two randomized controlled trials in patients with painful obstructive chronic pancreatitis compared Step Up approach with surgical intervention. In both studies, surgery demonstrated clear and durable superiority, providing more effective long-term pain relief, better QOL outcomes and improved results across multiple clinical endpoints[ 11 ]. Current evidence indicates that surgery generally offers superior outcomes compared to interventional endoscopy. However, endoscopy remains a valuable option for selected patients, particularly those who may benefit from its less invasive nature or as a bridging or alternative therapy when surgery is not feasible [ 12 ]. In our study, approximately 44% of patients in the LSG had already undergone a step-up approach elsewhere, with surgery ultimately performed in our institution as a salvage treatment option. It is established in the ESCAPE trial that Early surgery rather than initial endoscopic management had a better pain response in the short-term. Although the ESG reported lower pain scores during follow-up, there was no significant difference in overall QOL when compared with the LSG[ 13 ]. Cahen et al. demonstrated that surgery offers superior long-term pain relief in chronic pancreatitis, with 75% of surgical patients reporting relief at midterm versus 32% with endoscopy, and 80% versus 38% at long-term follow-up, establishing it as the stronger therapeutic option[ 14 ], [ 15 ].Ali et al. showed that Early surgery offers better outcomes, with three independent predictors of improved postoperative pain relief: pain duration of three years or less (P = .03), no preoperative opioid use (P = .006), and five or fewer endoscopic procedures before surgery (P = .04). These findings emphasize the value of timely surgical intervention, avoiding opioid use and repeated endoscopic treatments to optimize long-term results in chronic pancreatitis[ 16 ]. We selectively practice the step-up approach only for very high-risk surgical patients and those not willing for surgery. In long-standing disease, neuroplastic changes in the central nervous system leads to somatic hyperalgesia and limits the benefit of surgery or endotherapy[ 17 ]. Prior opioid exposure and repeated endoscopic procedures before surgery were linked to reduced pain relief, whereas patients who underwent surgical intervention earlier in the course of the disease experienced more favorable outcomes[ 18 ]. Moreover, endotherapy is not feasible in all cases and increases the chances of post-operative infectious complications. An experimental study in piglets showed that early surgical drainage preserved pancreatic histology and function better than delayed surgery, supporting intervention before irreversible damage occurs[ 19 ]. Early surgery helps to relieve chronic intraductal and intra-parenchymal hypertension and preserves the remaining parenchyma from further damage. Ke et al. conducted a retrospective analysis comparing pain scores and pancreatic function in patients who underwent either early surgery (< 3 years from diagnosis) or late surgery (≥ 3 years from diagnosis). The study concluded that early surgical intervention was associated with significantly higher rates of pain relief and better preservation of pancreatic function compared with delayed surgery. Among the different surgical techniques, the Frey and Berne procedures demonstrated superior outcomes compared with other operative approaches[ 20 ]. In the above study, among the PESG and LSG 23% and 30% have undergone Frey’s procedure respectively. A meta-analysis of eight randomized controlled trials ranked the Frey procedure as the most effective surgical option for chronic pancreatitis, demonstrating superior outcomes in terms of postoperative QOL, lower readmission rates and reduced incidence of exocrine insufficiency compared with other surgical techniques[ 21 ]. In our study the distribution of the type of procedure is comparable between the two groups, with the standard Frey’s procedure done in 53% and 46% of cases in PESG and LSG respectively. Longitudinal Pancreaticojejunostomy was done in the remaining cases and no resectional procedures were done. This eliminates the type of procedure as a confounding factor and strengthens the results of our study. In 2025 ESCOPA study, QOL following surgery for CP was evaluated using The Pancreatitis QOL Instrument (PANQOLI) and the 12-Item Short-Form Survey (SF-12). The SF-12 further provided two summary measures—the Physical Component Summary (PCS) score and the Mental Component Summary (MCS) score—allowing assessment of both physical and mental health outcomes after surgery[ 22 ]. Patients undergoing pancreatic duct drainage procedures typically report better postoperative QOL than those treated with resectional surgeries, as drainage effectively relieves symptoms while preserving pancreatic tissue and function.[ 23 ]. There are about 41 instruments for QOL assessment, with only 10 that are abdomen specific. Among all instrument’s, SF 36 ranks second in place with usage in17.2% studies next to EORTC QLQ-30 questionnaire. No instrument had all eight psychometric properties evaluated; however, GIQLI, PAN-PROMISE, and SF-36 were the only tools in which seven properties were assessed[ 24 ]. In our analysis, among the SF 36 components Pain, Emotional Well Being, Social Functioning had average score difference of 14 to 15 with better significance in PESG. Physical functioning and energy/fatigue had score difference of 16.4(p = 0.002) and 16.7(p = 0.005) respectively with third best significance in PESG. Major difference in scores of about 18.4 was seen in Role Limitations Due to Emotional Problems and highest score difference is seen in Role Limitations Due to Physical Health with 39.13 with p value < 0.001 as shown in Fig. 6 . The only component that has very low score difference of 9.4 is General health which is not statistically significant. This can probably be attributed to extrinsic and other multifactorial causes not related to the disease. Thus, in our analysis early surgery has a major positive impact on Role Limitations Due to Physical Health and Emotional Problems. The Score comparison between the components of SF 36 is shown in Fig. 7 . In a study assessing QOL in Early surgery using the SF-36 questionnaire, ESG (within 3 years of symptom onset) showed higher scores across all scales except Physical Functioning. Similarly, analysis with the EORTC QLQ-30 revealed that the ESG had superior average scores on all functional scales compared to the LSG, except for Cognitive Functioning.[ 25 ]. In our observation except for “General health “in SF 36 all other components have reached significant positive effects in PESG. With our thorough literature search we found, no studies have focused on the concept of primary early surgery. Across the existing literature, QOL—encompassing emotional well-being, the effect of pain on daily activities, social functioning, physical health and mental health—have not been thoroughly evaluated following early surgery. In this study, however, nearly all components of QOL were assessed, providing stronger evidence that early surgery exerts a significant long-term positive impact on patients’ overall well-being. Conclusion This is the first study to emphasize the concept of Primary early surgery in CP. Primary Early surgery for LDCP at the index presentation yields better long term QOL as compared to the traditional step-up approach. There is better QOL in terms of Pain control, Role Limitations Due to Physical Health and emotional problems in the PESG. Though the outcome of our study is encouraging and promising, it has a limitation in not being a randomized controlled trial (RCT), which restricts the strength of inferences. Further, future RCTs with a larger sample size will help to validate the results of our study. Declarations Authors have no financial or non-financial interests that are directly or indirectly related to the work submitted for publication. Author Contribution P. Data collection , compilation, statistical analysis and manuscript draftingSo. Analyzing results , Manuscript editing and revisionsK.J. and Sw. Manuscript revision and supervisionSi. Finalizing Manuscript and Guiding the research References C. J. 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Cite Share Download PDF Status: Published Journal Publication published 27 Nov, 2025 Read the published version in Digestive Diseases and Sciences → Version 1 posted Editorial decision: Revision requested 06 Oct, 2025 Reviewers agreed at journal 21 Sep, 2025 Reviews received at journal 16 Sep, 2025 Reviewers agreed at journal 16 Sep, 2025 Reviews received at journal 16 Sep, 2025 Reviewers agreed at journal 16 Sep, 2025 Reviewers invited by journal 15 Sep, 2025 Editor assigned by journal 15 Sep, 2025 Submission checks completed at journal 13 Sep, 2025 First submitted to journal 12 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7602290","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":518182327,"identity":"3ab63c6a-177b-4279-b80e-0bf5f543896b","order_by":0,"name":"Prakash Subramaniam","email":"","orcid":"","institution":"Government Mohan Kumaramangalam Medical College Hospital","correspondingAuthor":false,"prefix":"","firstName":"Prakash","middleName":"","lastName":"Subramaniam","suffix":""},{"id":518182328,"identity":"3cc76c00-ebdc-4574-89f7-09f2787f002c","order_by":1,"name":"Somasekar RDR","email":"","orcid":"","institution":"Government Mohan 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1","display":"","copyAsset":false,"role":"figure","size":87944,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlow diagram for enrolment and follow-up\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7602290/v1/1fd2ed196e7bbd816afe9bfb.png"},{"id":92053088,"identity":"4998c96b-7903-4d4e-8b25-2d9e825e26a3","added_by":"auto","created_at":"2025-09-24 06:21:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":34357,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of pain score in Violin plot\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7602290/v1/1e9ca7bd02ca645556b40223.png"},{"id":92054371,"identity":"8815adc9-13ac-4a78-bca9-7305b07e3e61","added_by":"auto","created_at":"2025-09-24 06:37:08","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":35643,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of Physical functioning score in Violin plot\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7602290/v1/7718cdd14d06a02ff0c0925f.png"},{"id":92054072,"identity":"62bdc8e9-b92f-4587-b83e-678ddbc382ec","added_by":"auto","created_at":"2025-09-24 06:29:08","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":36597,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of Role limitation to Physical health score in Violin plot\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7602290/v1/45e6a657dae4228029c2567b.png"},{"id":92053096,"identity":"2285a250-93d6-4e9f-aa71-35e214b1edac","added_by":"auto","created_at":"2025-09-24 06:21:09","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":89386,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAge group comparison in Pie chart\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7602290/v1/394f3cb49a9a059425d228dd.png"},{"id":92054077,"identity":"a517234d-fd74-491c-a0d0-9af8313f2ae0","added_by":"auto","created_at":"2025-09-24 06:29:09","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":34672,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eScores of Role limitations due to Physical health\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-7602290/v1/fd256dbae8ba70f8d486ffec.png"},{"id":92053093,"identity":"9f9baba0-ed60-42db-84b2-f03a4a67774f","added_by":"auto","created_at":"2025-09-24 06:21:09","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":16741,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eScore comparison between the components of SF 36\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-7602290/v1/f4a813c459fb567b261e934b.png"},{"id":97178807,"identity":"b46a8801-eddd-4e0d-9806-12dbebcbfddf","added_by":"auto","created_at":"2025-12-01 16:13:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1167577,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7602290/v1/7794ea24-6949-4fd8-93d6-ca193fb3b813.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A comparative study on Quality of life, between Primary Early Surgery and Late surgery in Chronic Calcific Pancreatitis using the SF-36 Questionnaire – A Prospective Observational Cohort Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChronic pancreatitis (CP) is a chronic inflammatory condition characterised by chronic pain, progressive loss of pancreatic function and an elevated risk of developing pancreatic cancer[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Chronic inflammation leads to parenchymal fibrosis, atrophy, MPD strictures, intraparenchymal and intraductal calcification leading to progressive endocrine and exocrine insufficiency. The pathophysiology of pain in CP is multifactorial. These include intra-parenchymal and intra-ductal hypertension, abnormal proliferation of peripancreatic nerves, activation of neurons containing pro-inflammatory peptides and hypersensitization of these nerve endings leading to intractable pain[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Ebbehoj et al. demonstrated a correlation between pain severity and intrapancreatic pressure measured before and after surgery, and at one year following MPD drainage. Patients whose pressures stayed low remained free of pain[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe primary goal of treatment in CP is alleviation of pain. There is no treatment modality to halt the progression of the disease till date. The current standard of care generally follows a stepwise approach starting with medical management, progressing to endoscopic interventions and reserving surgery for later stages. The emerging clinical evidence strongly supports the benefits of a Primary early surgical intervention with more effective, sustained pain relief and better QOL. It can potentially preserve pancreatic function for a longer period and aims to delay or mitigate the progression toward irreversible pancreatic insufficiency[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe previous studies in the literature have primarily focused on comparing pain scores and examining differences between various treatment approaches, with relatively limited data available on assessing patients\u0026rsquo; QOL after Early surgery[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This study aims to address that gap by evaluating the long-term QOL in individuals who undergo Primary early surgical intervention as compared to those undergoing Late surgery.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis was a prospective observational study conducted between 2016 to 2025 in a GI surgery unit in a tertiary care hospital. A total of 522 patients with dilated MPD, parenchymal atrophy, intra-parenchymal or ductal calcifications on a pancreas protocol CECT abdomen were diagnosed as CP between January 2016 to June 2022. Though the predominant etiology of the disease was due to ethanol ingestion, CP due to any cause was included in the study. Of these, 256 patients with an undilated or MPD diameter\u0026thinsp;\u0026le;\u0026thinsp;5mm were considered as having small-duct disease and excluded. Another 104 patients with a dilated MPD (\u0026ge;\u0026thinsp;6 mm) had acute inflammatory activity and were managed conservatively. The remaining 162 patients with a dilated MPD (\u0026ge;\u0026thinsp;6 mm) underwent surgical management tailored according to the individuals patho-morphology. Those patients who presented to us within two years of symptom onset and who had not undergone prior medical or endoscopic therapy were classified as PESG (92/162 cases); while those who underwent surgery more than two years after symptom onset and/or undergone prior step-up approach were classified as LSG (70/162 Patients with an atrophic pancreas, dilated MPD with intraductal stones underwent ductal clearance of stones and a lateral pancreatico-jejunostomy[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Those with a head mass underwent a hybrid procedure, the standard Frey\u0026rsquo;s procedure[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. It is our institutional practice to do head coring for non-head mass CP. In the PESG, surgery was done irrespective of the presence or absence of intractable pain.\u003c/p\u003e\u003cp\u003eIn both groups patients who have lost follow up, not given consent or died due to other causes were excluded. 35/92 cases and 27/70 cases in the early and LSGs respectively were included in the study as detailed in the Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. All the patients were followed up on a regular basis and their responses on a SF-36 questionnaire were recorded after 3 years of follow up. We have obtained approval from the institutional ethical committee and an informed consent was obtained from all patients prior to enrolment in the study.\u003c/p\u003e\u003cp\u003eThe SF-36 consists of 36 multiple-choice questions categorized into eight components namely: Pain, Physical Functioning, Role Limitations Due to Physical Health, Role Limitations Due to Emotional Problems, Energy/Fatigue, Emotional Well-Being, Social Functioning, and General Health. Each answer is assigned a score ranging from 0 to 100 according to the RAND scoring system[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. These scores were applied to the patients\u0026rsquo; responses, and the average score for each component was calculated and tabulated for both groups. Basic patient characteristics including age, gender, endocrine and exocrine function were compared between the two groups. The primary outcome measures were pain, physical functioning and role limitations due to physical health and the rest of the components of the SF-36 were taken as secondary outcome measures in our study. We used statistical tests to compare the two groups.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFisher\u0026rsquo;s exact test revealed a significant association between group and age (χ\u0026sup2; = 9.437, p\u0026thinsp;=\u0026thinsp;0.021). The LSG had a higher proportion of patients aged 21\u0026ndash;30, 31\u0026ndash;40, and 51\u0026ndash;60 years, while the PESG had more patients in the 41\u0026ndash;50 year range (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). No significant association was found between group and gender (χ\u0026sup2; = 0.004, p\u0026thinsp;=\u0026thinsp;0.953) or group and diabetes (χ\u0026sup2; = 1.359, p\u0026thinsp;=\u0026thinsp;0.244). Gender distribution was nearly identical (PESG: 77.1% male, 22.9% female; LSG: 77.8% male, 22.2% female), while diabetes was present in 17.1% of the PESG and 29.6% of the LSG.\u003c/p\u003e\u003cp\u003eAll the 8 variables were not normally distributed in the 2 subgroups of the variable Group. Thus, non-parametric tests (Wilcoxon-Mann-Whitney U Test) were used to make group comparisons. The results of basic characteristics and outcomes are summarised in Table\u0026nbsp;1.\u003c/p\u003e\u003cp\u003eThe mean (SD) of Pain in the PESG was 78.64 (24.87) and in LSG was 63.98 (21.40). The median (IQR) of Pain in the PESG was 87.5 (77.5\u0026ndash;95) and in the LSG was 55 (50-78.75). There was a significant difference between the 2 groups in terms of Pain (W\u0026thinsp;=\u0026thinsp;653.500, p\u0026thinsp;=\u0026thinsp;0.010), with the median Pain score being highest in the PESG indicating good pain response in PESG. Strength of Association (Point-Biserial Correlation)\u0026thinsp;=\u0026thinsp;0.3 (Medium Effect Size). Distribution of pain score in Violin plot is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe mean (SD) of Physical Functioning in the PESG was 89.14 (11.85) and in LSG was 72.78 (22.07). The median (IQR) of Physical Functioning in the PESG was 90 (87.5\u0026ndash;100) and in the LSG was 55 (50-78.75). There was a significant difference between the 2 groups in terms of Physical Functioning (W\u0026thinsp;=\u0026thinsp;688.500, p\u0026thinsp;=\u0026thinsp;0.002), with the median Physical Functioning score being highest in the PESG indicating good Physical Functioning in PESG. Strength of Association (Point-Biserial Correlation)\u0026thinsp;=\u0026thinsp;0.44 (Large Effect Size). Distribution of Physical functioning score in Violin plot is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe mean (SD) of Role Limitations Due to Physical Health in the PESG was 83.57 (32.05) and in LSG was 44.44 (47.20). The median (IQR) of Role Limitations Due to Physical Health in the PESG was 100 (87.5\u0026ndash;100) and in the LSG was 25 (0-100). There was a significant difference between the 2 groups in terms of Role Limitations Due to Physical Health (W\u0026thinsp;=\u0026thinsp;683.000, p\u0026thinsp;=\u0026thinsp;0.001), with the median Role Limitations Due to Physical Health score being highest in the PESG indicating lesser Role Limitations Due to Physical Health in PESG. Strength of Association (Point-Biserial Correlation)\u0026thinsp;=\u0026thinsp;0.45 (Large Effect Size). The significance in primary objectives in PESG are depicted in Table\u0026nbsp;2. Distribution of Role limitation to Physical health score in Violin plot in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe mean (SD) of Role Limitations Due to Emotional Problems in the PESG was 96.19 (13.46) and in LSG was 77.78 (32.03). The median (IQR) of Role Limitations Due to Emotional Problems in the PESG was 100 (100\u0026ndash;100) and in the LSG was 100 (33.33\u0026ndash;100). There was a significant difference between the 2 groups in terms of Role Limitations Due to Emotional Problems (W\u0026thinsp;=\u0026thinsp;598.500, p\u0026thinsp;=\u0026thinsp;0.009), with the median Role Limitations Due to Emotional Problems score being highest in the PESG indicating lesser Role Limitations Due to Emotional Problems in PESG. Strength of Association (Point-Biserial Correlation)\u0026thinsp;=\u0026thinsp;0.37 (Large Effect Size)\u003c/p\u003e\u003cp\u003eThe mean (SD) Energy/Fatigue score was 69.29 (21.39) in the PESG and 52.59 (22.55) in the LSG. A significant difference was found (W\u0026thinsp;=\u0026thinsp;668.500, p\u0026thinsp;=\u0026thinsp;0.005), with higher median scores in the PESG, indicating a positive impact on Energy/Fatigue. The mean (SD) Emotional Well-Being score was 71.77 (15.00) in the PESG and 57.19 (17.32) in the LSG. A significant difference was observed (W\u0026thinsp;=\u0026thinsp;696.000, p\u0026thinsp;=\u0026thinsp;0.001), with higher median scores in the PESG, indicating better Emotional Well-Being. The mean (SD) Social Functioning score was 78.50 (22.58) in the PESG and 63.70 (25.85) in the LSG. A significant difference was found (W\u0026thinsp;=\u0026thinsp;647.000, p\u0026thinsp;=\u0026thinsp;0.012), with higher median scores in the PESG, indicating better Social Functioning.\u003c/p\u003e\u003cp\u003eThe mean (SD) of General Health in the PESG was 59.69 (25.70) and in LSG was 50.22 (21.80). There was no significant difference between the groups in terms of General Health (W\u0026thinsp;=\u0026thinsp;574.000, p\u0026thinsp;=\u0026thinsp;0.150).\u003c/p\u003e\u003cp\u003e\u003cb\u003eTable.1 Comparison summary of basic characteristics and the outcomes between PESG and LSGs\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eParameters\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ep value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEarly\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLate\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge (Years)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44.26\u0026thinsp;\u0026plusmn;\u0026thinsp;6.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40.63\u0026thinsp;\u0026plusmn;\u0026thinsp;9.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.103\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge***\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.021\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e21\u0026ndash;30 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (14.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e31\u0026ndash;40 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (25.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (37.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e41\u0026ndash;50 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (57.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (25.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e51\u0026ndash;60 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (17.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (22.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.953\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27 (77.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (77.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (22.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (22.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDiabetic (Yes)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (17.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (29.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.244\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eExocrine Insufficiency (Yes)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (8.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (14.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.689\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePain***\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e78.64\u0026thinsp;\u0026plusmn;\u0026thinsp;24.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63.98\u0026thinsp;\u0026plusmn;\u0026thinsp;21.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.010\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePhysical Functioning***\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e89.14\u0026thinsp;\u0026plusmn;\u0026thinsp;11.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72.78\u0026thinsp;\u0026plusmn;\u0026thinsp;22.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.002\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRole Limitations Due To Physical Health***\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e83.57\u0026thinsp;\u0026plusmn;\u0026thinsp;32.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44.44\u0026thinsp;\u0026plusmn;\u0026thinsp;47.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.001\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRole Limitations Due To Emotional Problems***\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e96.19\u0026thinsp;\u0026plusmn;\u0026thinsp;13.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e77.78\u0026thinsp;\u0026plusmn;\u0026thinsp;32.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.009\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEnergy/ Fatigue***\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e69.29\u0026thinsp;\u0026plusmn;\u0026thinsp;21.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52.59\u0026thinsp;\u0026plusmn;\u0026thinsp;22.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.005\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEmotional Well Being***\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e71.77\u0026thinsp;\u0026plusmn;\u0026thinsp;15.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.19\u0026thinsp;\u0026plusmn;\u0026thinsp;17.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.001\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSocial Functioning***\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e78.50\u0026thinsp;\u0026plusmn;\u0026thinsp;22.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63.70\u0026thinsp;\u0026plusmn;\u0026thinsp;25.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.012\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGeneral Health\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59.69\u0026thinsp;\u0026plusmn;\u0026thinsp;25.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50.22\u0026thinsp;\u0026plusmn;\u0026thinsp;21.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.150\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003e***Significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, 1: t-test, 2: Fisher's Exact Test, 3: Chi-Squared Test, 4: Wilcoxon-Mann-Whitney U Test\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTable.2\u003c/b\u003e \u003cb\u003ePrimary objectives and their comparisons\u003c/b\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e\u003ccolgroup cols=\"17\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c17\" colnum=\"17\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" morerows=\"1\" nameend=\"c3\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003ePain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c9\" namest=\"c4\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c15\" namest=\"c10\"\u003e\u003cp\u003eWilcoxon-Mann-Whitney U Test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003eEarly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u003cp\u003eLate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e\u003cp\u003eW\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c15\" namest=\"c13\"\u003e\u003cp\u003ep value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003e78.64 (24.87)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u003cp\u003e63.98 (21.40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" morerows=\"2\" nameend=\"c12\" namest=\"c10\" rowspan=\"3\"\u003e\u003cp\u003e653.500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" morerows=\"2\" nameend=\"c15\" namest=\"c13\" rowspan=\"3\"\u003e\u003cp\u003e0.010\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eMedian (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003e87.5 (77.5\u0026ndash;95)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u003cp\u003e55 (50-78.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eMin - Max\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003e10\u0026ndash;100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u003cp\u003e32.5\u0026ndash;100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" morerows=\"1\" nameend=\"c3\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003ePhysical Functioning\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c9\" namest=\"c4\"\u003e\u003cp\u003e\u003cb\u003eGroup\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c15\" namest=\"c10\"\u003e\u003cp\u003e\u003cb\u003eWilcoxon-Mann-Whitney U Test\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003e\u003cb\u003eEarly\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u003cp\u003e\u003cb\u003eLate\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e\u003cp\u003e\u003cb\u003eW\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c15\" namest=\"c13\"\u003e\u003cp\u003e\u003cb\u003ep value\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003e89.14 (11.85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u003cp\u003e72.78 (22.07)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" morerows=\"2\" nameend=\"c12\" namest=\"c10\" rowspan=\"3\"\u003e\u003cp\u003e688.500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" morerows=\"2\" nameend=\"c15\" namest=\"c13\" rowspan=\"3\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eMedian (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003e90 (87.5\u0026ndash;100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u003cp\u003e80 (45\u0026ndash;90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eMin - Max\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003e45\u0026ndash;100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u003cp\u003e40\u0026ndash;100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" morerows=\"1\" nameend=\"c3\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eRole Limitations Due to Physical Health\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c9\" namest=\"c4\"\u003e\u003cp\u003e\u003cb\u003eGroup\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c15\" namest=\"c10\"\u003e\u003cp\u003e\u003cb\u003eWilcoxon-Mann-Whitney U Test\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003e\u003cb\u003eEarly\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u003cp\u003e\u003cb\u003eLate\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e\u003cp\u003e\u003cb\u003eW\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c15\" namest=\"c13\"\u003e\u003cp\u003e\u003cb\u003ep value\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003e83.57 (32.05)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u003cp\u003e44.44 (47.20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" morerows=\"2\" nameend=\"c12\" namest=\"c10\" rowspan=\"3\"\u003e\u003cp\u003e683.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" morerows=\"2\" nameend=\"c15\" namest=\"c13\" rowspan=\"3\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eMedian (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003e100 (87.5\u0026ndash;100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u003cp\u003e25 (0-100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eMin - Max\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003e0\u0026ndash;100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u003cp\u003e0\u0026ndash;100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eChronic pancreatitis (CP) is a progressive inflammatory disorder with multiple causes, most often linked to alcohol use. The exact pathophysiology remains uncertain. It generally begins with acinar cell injury triggering the inflammation. While some cases resolve with repair, others progress to persistent inflammation due to persisting or intermittent exposure to noxious stimuli, leading to activation of pancreatic stellate cells. These cells drive fibrosis and irreversible structural changes, forming the hallmark of CP[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Chronic pancreatitis (CP) is now understood as a multifactorial disease shaped by genetic predisposition and modifying factors. Variants in PRSS1, SPINK1, and CFTR show the strongest associations, while CTRC and CASR contribute more modestly. These genetic influences highlight the role of inherited susceptibility in disease onset, progression, and variability among patients[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Hereditary pancreatitis (HP) presents in childhood or adolescence, progresses rapidly to end-stage chronic pancreatitis with exocrine and endocrine failure, and carries a substantially increased lifetime risk of pancreatic adenocarcinoma[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In our study, alcohol was identified as the predominant etiological factor, accounting for nearly 80% of cases (32% in LSG and 48% in PESG), while the remaining were attributed to idiopathic causes, often presenting with early onset during adolescence.\u003c/p\u003e\u003cp\u003eIn a recent study, the age distribution of patients ranged from 40 to 62 years. The Indian cohort demonstrated the youngest mean age and showed no significant overall difference in age between eastern and western populations[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In our study, the mean age was 44.26 years in the PESG and 40.63 years in the LSG. The LSG cohort had more patients in the 21\u0026ndash;30, 31\u0026ndash;40, and 51\u0026ndash;60-year ranges, while the PESG was concentrated in the 41\u0026ndash;50-year range, showing a statistically significant age distribution difference. A higher proportion of younger patients in the LSG suggests their symptoms began in adolescence but were mild, overlooked, or untreated, leading to delayed presentation beyond two years. By then, the pancreas had often progressed to an atrophic state, reducing the benefits of surgery. As a result, their postoperative QOL was less favorable compared with the PESG, who underwent intervention before extensive pancreatic damage developed. Despite the predominance of a younger population in the LSG, it did not translate into a better QOL. The gender distribution between the two groups is also comparable. The age group comparisons are depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe reason why some patients present as large-duct CP (LDCP) and others with small-duct CP (SDCP) during their index presentation is not known. But early presentation as LDCP is probably a favorable patho-morphology as it prompts timely intervention. In LDCP, surgery effectively relieves intraductal and probably intra-parenchymal hypertension. As the head of the pancreas is considered a pace-maker of pain, head-coring procedures effectively provide durable results. It is our institutional practice to do head-coring even in non-head mass CP. We advocate primary early surgical management in LDCP irrespective of the intractability of pain. As for acute pancreatitis, a step-up approach is advocated for CP in the existing literature. But evolving evidence goes in favour of primary Early surgery in CP.\u003c/p\u003e\u003cp\u003eTwo randomized controlled trials in patients with painful obstructive chronic pancreatitis compared Step Up approach with surgical intervention. In both studies, surgery demonstrated clear and durable superiority, providing more effective long-term pain relief, better QOL outcomes and improved results across multiple clinical endpoints[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Current evidence indicates that surgery generally offers superior outcomes compared to interventional endoscopy. However, endoscopy remains a valuable option for selected patients, particularly those who may benefit from its less invasive nature or as a bridging or alternative therapy when surgery is not feasible [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In our study, approximately 44% of patients in the LSG had already undergone a step-up approach elsewhere, with surgery ultimately performed in our institution as a salvage treatment option.\u003c/p\u003e\u003cp\u003eIt is established in the ESCAPE trial that Early surgery rather than initial endoscopic management had a better pain response in the short-term. Although the ESG reported lower pain scores during follow-up, there was no significant difference in overall QOL when compared with the LSG[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Cahen et al. demonstrated that surgery offers superior long-term pain relief in chronic pancreatitis, with 75% of surgical patients reporting relief at midterm versus 32% with endoscopy, and 80% versus 38% at long-term follow-up, establishing it as the stronger therapeutic option[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].Ali et al. showed that Early surgery offers better outcomes, with three independent predictors of improved postoperative pain relief: pain duration of three years or less (P\u0026thinsp;=\u0026thinsp;.03), no preoperative opioid use (P\u0026thinsp;=\u0026thinsp;.006), and five or fewer endoscopic procedures before surgery (P\u0026thinsp;=\u0026thinsp;.04). These findings emphasize the value of timely surgical intervention, avoiding opioid use and repeated endoscopic treatments to optimize long-term results in chronic pancreatitis[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. We selectively practice the step-up approach only for very high-risk surgical patients and those not willing for surgery.\u003c/p\u003e\u003cp\u003eIn long-standing disease, neuroplastic changes in the central nervous system leads to somatic hyperalgesia and limits the benefit of surgery or endotherapy[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Prior opioid exposure and repeated endoscopic procedures before surgery were linked to reduced pain relief, whereas patients who underwent surgical intervention earlier in the course of the disease experienced more favorable outcomes[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Moreover, endotherapy is not feasible in all cases and increases the chances of post-operative infectious complications. An experimental study in piglets showed that early surgical drainage preserved pancreatic histology and function better than delayed surgery, supporting intervention before irreversible damage occurs[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Early surgery helps to relieve chronic intraductal and intra-parenchymal hypertension and preserves the remaining parenchyma from further damage.\u003c/p\u003e\u003cp\u003eKe et al. conducted a retrospective analysis comparing pain scores and pancreatic function in patients who underwent either early surgery (\u0026lt;\u0026thinsp;3 years from diagnosis) or late surgery (\u0026ge;\u0026thinsp;3 years from diagnosis). The study concluded that early surgical intervention was associated with significantly higher rates of pain relief and better preservation of pancreatic function compared with delayed surgery. Among the different surgical techniques, the Frey and Berne procedures demonstrated superior outcomes compared with other operative approaches[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In the above study, among the PESG and LSG 23% and 30% have undergone Frey\u0026rsquo;s procedure respectively.\u003c/p\u003e\u003cp\u003eA meta-analysis of eight randomized controlled trials ranked the Frey procedure as the most effective surgical option for chronic pancreatitis, demonstrating superior outcomes in terms of postoperative QOL, lower readmission rates and reduced incidence of exocrine insufficiency compared with other surgical techniques[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In our study the distribution of the type of procedure is comparable between the two groups, with the standard Frey\u0026rsquo;s procedure done in 53% and 46% of cases in PESG and LSG respectively. Longitudinal Pancreaticojejunostomy was done in the remaining cases and no resectional procedures were done. This eliminates the type of procedure as a confounding factor and strengthens the results of our study.\u003c/p\u003e\u003cp\u003eIn 2025 ESCOPA study, QOL following surgery for CP was evaluated using The Pancreatitis QOL Instrument (PANQOLI) and the 12-Item Short-Form Survey (SF-12). The SF-12 further provided two summary measures\u0026mdash;the Physical Component Summary (PCS) score and the Mental Component Summary (MCS) score\u0026mdash;allowing assessment of both physical and mental health outcomes after surgery[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Patients undergoing pancreatic duct drainage procedures typically report better postoperative QOL than those treated with resectional surgeries, as drainage effectively relieves symptoms while preserving pancreatic tissue and function.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThere are about 41 instruments for QOL assessment, with only 10 that are abdomen specific. Among all instrument\u0026rsquo;s, SF 36 ranks second in place with usage in17.2% studies next to EORTC QLQ-30 questionnaire. No instrument had all eight psychometric properties evaluated; however, GIQLI, PAN-PROMISE, and SF-36 were the only tools in which seven properties were assessed[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn our analysis, among the SF 36 components Pain, Emotional Well Being, Social Functioning had average score difference of 14 to 15 with better significance in PESG. Physical functioning and energy/fatigue had score difference of 16.4(p\u0026thinsp;=\u0026thinsp;0.002) and 16.7(p\u0026thinsp;=\u0026thinsp;0.005) respectively with third best significance in PESG. Major difference in scores of about 18.4 was seen in Role Limitations Due to Emotional Problems and highest score difference is seen in Role Limitations Due to Physical Health with 39.13 with p value\u0026thinsp;\u0026lt;\u0026thinsp;0.001 as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e. The only component that has very low score difference of 9.4 is General health which is not statistically significant. This can probably be attributed to extrinsic and other multifactorial causes not related to the disease. Thus, in our analysis early surgery has a major positive impact on Role Limitations Due to Physical Health and Emotional Problems. The Score comparison between the components of SF 36 is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn a study assessing QOL in Early surgery using the SF-36 questionnaire, ESG (within 3 years of symptom onset) showed higher scores across all scales except Physical Functioning. Similarly, analysis with the EORTC QLQ-30 revealed that the ESG had superior average scores on all functional scales compared to the LSG, except for Cognitive Functioning.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In our observation except for \u0026ldquo;General health \u0026ldquo;in SF 36 all other components have reached significant positive effects in PESG. With our thorough literature search we found, no studies have focused on the concept of primary early surgery.\u003c/p\u003e\u003cp\u003eAcross the existing literature, QOL\u0026mdash;encompassing emotional well-being, the effect of pain on daily activities, social functioning, physical health and mental health\u0026mdash;have not been thoroughly evaluated following early surgery. In this study, however, nearly all components of QOL were assessed, providing stronger evidence that early surgery exerts a significant long-term positive impact on patients\u0026rsquo; overall well-being.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis is the first study to emphasize the concept of Primary early surgery in CP. Primary Early surgery for LDCP at the index presentation yields better long term QOL as compared to the traditional step-up approach. There is better QOL in terms of Pain control, Role Limitations Due to Physical Health and emotional problems in the PESG. Though the outcome of our study is encouraging and promising, it has a limitation in not being a randomized controlled trial (RCT), which restricts the strength of inferences. Further, future RCTs with a larger sample size will help to validate the results of our study.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAuthors have no financial or non-financial interests that are directly or indirectly related to the work submitted for publication.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eP. Data collection , compilation, statistical analysis and manuscript draftingSo. Analyzing results , Manuscript editing and revisionsK.J. and Sw. Manuscript revision and supervisionSi. Finalizing Manuscript and Guiding the research\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eC. J. Yang \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Systematic Review of Early Surgery for Chronic Pancreatitis: Impact on Pain, Pancreatic Function, and Re-intervention,\u0026rdquo; \u003cem\u003eJ. Gastrointest. Surg.\u003c/em\u003e, vol. 18, no. 10, pp. 1863\u0026ndash;1869, Oct. 2014, doi: 10.1007/s11605-014-2571-8.\u003c/li\u003e\n\u003cli\u003eD. K. Andersen and C. F. Frey, \u0026ldquo;The Evolution of the Surgical Treatment of Chronic Pancreatitis,\u0026rdquo; \u003cem\u003eAnn. Surg.\u003c/em\u003e, vol. 251, no. 1, p. 18, Jan. 2010, doi: 10.1097/SLA.0b013e3181ae3471.\u003c/li\u003e\n\u003cli\u003eA. K. Sharma, G. K. Pande, P. Sahni, and S. Nundy, \u0026ldquo;Surgery for nonalcoholic chronic pancreatitis,\u0026rdquo; \u003cem\u003eWorld J. Surg.\u003c/em\u003e, vol. 22, no. 3, pp. 236\u0026ndash;239; discussion 239-240, Mar. 1998, doi: 10.1007/s002689900376.\u003c/li\u003e\n\u003cli\u003eS.-Z. Li \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Quality of life after pancreatic surgery,\u0026rdquo; \u003cem\u003eWorld J. Gastroenterol.\u003c/em\u003e, vol. 30, no. 8, pp. 943\u0026ndash;955, Feb. 2024, doi: 10.3748/wjg.v30.i8.943.\u003c/li\u003e\n\u003cli\u003e\u0026ldquo;Longitudinal Pancreaticojejunostomy (Puestow Procedure) Technique: Approach Considerations, Incision and Exploration, Exposure of Anterior Surface of Pancreas.\u0026rdquo; Accessed: Aug. 22, 2025. [Online]. Available: https://emedicine.medscape.com/article/1892781-technique\u003c/li\u003e\n\u003cli\u003eJ. Gonz\u0026aacute;lez, D. Ayala, N. Caballero, C. E. Rey Chaves, D. Conde, and J. C. Sabogal Olarte, \u0026ldquo;Outcomes after Frey\u0026rsquo;s procedure for chronic pancreatitis: a 8-year single-center experience in Colombia,\u0026rdquo; \u003cem\u003eBMC Surg.\u003c/em\u003e, vol. 22, no. 1, p. 424, Dec. 2022, doi: 10.1186/s12893-022-01839-x.\u003c/li\u003e\n\u003cli\u003e\u0026ldquo;36-Item Short Form Survey from the RAND Medical Outcomes Study.\u0026rdquo; Accessed: Aug. 22, 2025. [Online]. Available: https://www.rand.org/health-care/surveys_tools/mos/36-item-short-form.html\u003c/li\u003e\n\u003cli\u003eJ. Kalivarathan, K. Yadav, W. Bataller, N. W. Brigle, and M. A. Kanak, \u0026ldquo;Chapter 1 - Etiopathogenesis and pathophysiology of chronic pancreatitis,\u0026rdquo; in \u003cem\u003eTransplantation, Bioengineering, and Regeneration of the Endocrine Pancreas\u003c/em\u003e, G. Orlando, L. Piemonti, C. Ricordi, R. J. Stratta, and R. W. G. Gruessner, Eds., Academic Press, 2020, pp. 5\u0026ndash;32. doi: 10.1016/B978-0-12-814831-0.00001-4.\u003c/li\u003e\n\u003cli\u003eA. Pham and C. Forsmark, \u0026ldquo;Chronic pancreatitis: review and update of etiology, risk factors, and management,\u0026rdquo; \u003cem\u003eF1000Research\u003c/em\u003e, vol. 7, p. F1000 Faculty Rev-607, May 2018, doi: 10.12688/f1000research.12852.1.\u003c/li\u003e\n\u003cli\u003eN. Desai, T. Kaura, M. Singh, F. F. Willingham, S. Rana, and S. Chawla, \u0026ldquo;Epidemiology and Characteristics of Chronic Pancreatitis\u0026mdash;Do the East and West Meet?,\u0026rdquo; \u003cem\u003eGastro Hep Adv.\u003c/em\u003e, vol. 1, no. 6, pp. 942\u0026ndash;949, Jan. 2022, doi: 10.1016/j.gastha.2022.07.013.\u003c/li\u003e\n\u003cli\u003eS. A. W. Bouwense \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Surgery in Chronic Pancreatitis: Indication, Timing and Procedures,\u0026rdquo; \u003cem\u003eVisc. Med.\u003c/em\u003e, vol. 35, no. 2, pp. 110\u0026ndash;118, Apr. 2019, doi: 10.1159/000499612.\u003c/li\u003e\n\u003cli\u003e\u0026ldquo;United European Gastroenterology evidence‐based guidelines for the diagnosis and therapy of chronic pancreatitis (HaPanEU) - L\u0026ouml;hr - 2017 - United European Gastroenterology Journal - Wiley Online Library.\u0026rdquo; Accessed: Aug. 26, 2025. [Online]. Available: https://onlinelibrary.wiley.com/doi/10.1177/2050640616684695\u003c/li\u003e\n\u003cli\u003eY. Issa \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Effect of Early Surgery vs Endoscopy-First Approach on Pain in Patients With Chronic Pancreatitis,\u0026rdquo; \u003cem\u003eJAMA\u003c/em\u003e, vol. 323, no. 3, pp. 237\u0026ndash;247, Jan. 2020, doi: 10.1001/jama.2019.20967.\u003c/li\u003e\n\u003cli\u003eD. L. Cahen \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Long-term Outcomes of Endoscopic vs Surgical Drainage of the Pancreatic Duct in Patients With Chronic Pancreatitis,\u0026rdquo; \u003cem\u003eGastroenterology\u003c/em\u003e, vol. 141, no. 5, pp. 1690\u0026ndash;1695, Nov. 2011, doi: 10.1053/j.gastro.2011.07.049.\u003c/li\u003e\n\u003cli\u003eD. L. Cahen \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Endoscopic versus Surgical Drainage of the Pancreatic Duct in Chronic Pancreatitis,\u0026rdquo; \u003cem\u003eN. Engl. J. Med.\u003c/em\u003e, vol. 356, no. 7, pp. 676\u0026ndash;684, Feb. 2007, doi: 10.1056/NEJMoa060610.\u003c/li\u003e\n\u003cli\u003eU. A. Ali \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Clinical Outcome in Relation to Timing of Surgery in Chronic Pancreatitis: A Nomogram to Predict Pain Relief,\u0026rdquo; \u003cem\u003eArch. Surg.\u003c/em\u003e, vol. 147, no. 10, pp. 925\u0026ndash;932, Oct. 2012, doi: 10.1001/archsurg.2012.1094.\u003c/li\u003e\n\u003cli\u003e\u0026ldquo;Neural plasticity in pancreatitis and pancreatic cancer | Nature Reviews Gastroenterology \u0026amp; Hepatology.\u0026rdquo; Accessed: Aug. 16, 2025. [Online]. Available: https://www.nature.com/articles/nrgastro.2015.166\u003c/li\u003e\n\u003cli\u003eU. Ahmed Ali \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Clinical outcome in relation to timing of surgery in chronic pancreatitis: a nomogram to predict pain relief,\u0026rdquo; \u003cem\u003eArch. Surg. Chic. Ill 1960\u003c/em\u003e, vol. 147, no. 10, pp. 925\u0026ndash;932, Oct. 2012, doi: 10.1001/archsurg.2012.1094.\u003c/li\u003e\n\u003cli\u003eB. Lamme \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Early versus late surgical drainage for obstructive pancreatitis in an experimental model,\u0026rdquo; \u003cem\u003eBr. J. Surg.\u003c/em\u003e, vol. 94, no. 7, pp. 849\u0026ndash;854, Jul. 2007, doi: 10.1002/bjs.5722.\u003c/li\u003e\n\u003cli\u003eN. Ke \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Earlier surgery improves outcomes from painful chronic pancreatitis,\u0026rdquo; \u003cem\u003eMedicine (Baltimore)\u003c/em\u003e, vol. 97, no. 19, p. e0651, May 2018, doi: 10.1097/MD.0000000000010651.\u003c/li\u003e\n\u003cli\u003eC. B. B. Ratnayake \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;A Network Meta-analysis of Surgery for Chronic Pancreatitis: Impact on Pain and Quality of Life,\u0026rdquo; \u003cem\u003eJ. Gastrointest. Surg.\u003c/em\u003e, vol. 24, no. 12, pp. 2865\u0026ndash;2873, Dec. 2020, doi: 10.1007/s11605-020-04718-z.\u003c/li\u003e\n\u003cli\u003eC. L. van Veldhuisen \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Surgery for chronic pancreatitis across Europe (ESCOPA): prospective multicentre study,\u0026rdquo; \u003cem\u003eBJS\u003c/em\u003e, vol. 112, no. 4, p. znaf068, Apr. 2025, doi: 10.1093/bjs/znaf068.\u003c/li\u003e\n\u003cli\u003eE. S. van Loo, M. C. P. M. van Baal, H. G. Gooszen, R. J. Ploeg, and V. B. Nieuwenhuijs, \u0026ldquo;Long-term quality of life after surgery for chronic pancreatitis,\u0026rdquo; \u003cem\u003eBr. J. Surg.\u003c/em\u003e, vol. 97, no. 7, pp. 1079\u0026ndash;1086, Jul. 2010, doi: 10.1002/bjs.7103.\u003c/li\u003e\n\u003cli\u003eM. Kawka \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Quality of life instruments in acute and chronic pancreatitis: a consensus-based standards for the selection of health measurement instruments (COSMIN) approach,\u0026rdquo; \u003cem\u003eHPB\u003c/em\u003e, vol. 26, no. 7, pp. 859\u0026ndash;872, Jul. 2024, doi: 10.1016/j.hpb.2024.04.004.\u003c/li\u003e\n\u003cli\u003eM. Iurii, Y. Volodymyr, S. Vasyl, B. Oleksandr, and S. Oleh, \u0026ldquo;Optimal management of early surgery of chronic pancreatitis,\u0026rdquo; \u003cem\u003eInt. J. Health Sci.\u003c/em\u003e, vol. 5, no. 3, pp. 373\u0026ndash;385, Oct. 2021, doi: 10.53730/ijhs.v5n3.1638.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"digestive-diseases-and-sciences","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ddsj","sideBox":"Learn more about [Digestive Diseases and Sciences](http://link.springer.com/journal/10620)","snPcode":"10620","submissionUrl":"https://submission.nature.com/new-submission/10620/3","title":"Digestive Diseases and Sciences","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Chronic calcific pancreatitis, Early surgery, Quality of Life, Late surgery, SF 36","lastPublishedDoi":"10.21203/rs.3.rs-7602290/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7602290/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cu\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e\u003c/u\u003e We aim to test the hypothesis that “Primary Early surgery (i.e. within 2years from symptoms onset) in Chronic calcific pancreatitis (CCP) has better durable long-term Quality of Life (QOL) than patients undergoing late surgery (\u0026gt; 2 years from symptom onset)” using the SF 36 Questionnaire.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/u\u003e This is a prospective observational study conducted between 2016 to 2025. 162 patients with large duct CCP (MPD diameter ≥ 6mm) underwent either Frey’s procedure or Lateral Pancreatico Jejunostomy. 62/162 patients on regular follow up were included in the study. The 62 patients were grouped into Primary early surgery group (PESG) and Late surgery group (LSG). After long term (\u0026gt; 3year) of follow up, patient’s responses regarding QOL were recorded using the SF36 questionnaire and compared. The primary outcome measures were pain, physical functioning and role limitations due to physical health and the other components on the SF 36 were taken as secondary outcome measures.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/u\u003e27/62 cases were in LSG and 35/62 belonged to PESG. Mann-Whitney U test was used to make group comparisons. 7 out of 8 components namely Pain, Physical Functioning, Role Limitations Due to Physical Health, Role Limitations Due to Emotional Problems, Energy/ Fatigue, Emotional Well Being, Social Functioning had statistically significant difference favouring better QOL in PESG.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/u\u003e Primary Early surgery has a positive impact on long term QOL in patients with CCP. However, future RCTs will help to draw solid conclusions to support or refute our observations.\u003c/p\u003e","manuscriptTitle":"A comparative study on Quality of life, between Primary Early Surgery and Late surgery in Chronic Calcific Pancreatitis using the SF-36 Questionnaire – A Prospective Observational Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-24 06:21:04","doi":"10.21203/rs.3.rs-7602290/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-06T18:33:19+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"234815821100791759131092345461339310956","date":"2025-09-21T06:11:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-16T09:29:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74464693712150117731835910118138181743","date":"2025-09-16T07:45:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-16T07:23:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"14043299594828590519442110619690853215","date":"2025-09-16T06:14:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-15T23:44:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-15T23:16:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-13T12:47:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"Digestive Diseases and Sciences","date":"2025-09-12T16:10:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"digestive-diseases-and-sciences","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ddsj","sideBox":"Learn more about [Digestive Diseases and Sciences](http://link.springer.com/journal/10620)","snPcode":"10620","submissionUrl":"https://submission.nature.com/new-submission/10620/3","title":"Digestive Diseases and Sciences","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"d287d8a6-e40a-4ea1-8c1a-f4f2cf5cbf64","owner":[],"postedDate":"September 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:07:21+00:00","versionOfRecord":{"articleIdentity":"rs-7602290","link":"https://doi.org/10.1007/s10620-025-09584-w","journal":{"identity":"digestive-diseases-and-sciences","isVorOnly":false,"title":"Digestive Diseases and Sciences"},"publishedOn":"2025-11-27 15:58:07","publishedOnDateReadable":"November 27th, 2025"},"versionCreatedAt":"2025-09-24 06:21:04","video":"","vorDoi":"10.1007/s10620-025-09584-w","vorDoiUrl":"https://doi.org/10.1007/s10620-025-09584-w","workflowStages":[]},"version":"v1","identity":"rs-7602290","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7602290","identity":"rs-7602290","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}