Correspondence

Correction

Chronic Pancreatitis

N Engl J Med 1995; 333:1221-1222November 2, 1995

Article

To the Editor:

In their review of chronic pancreatitis, Steer et al. (June 1 issue)1 imply that the best treatment for pseudocysts due to chronic pancreatitis is laparotomy. Data from several surgical and endoscopic or radiographic series suggest otherwise.

Percutaneous drainage2 was associated with a mortality rate of 2 percent or less, even when the majority of patients had infected pseudocysts.3 Endoscopic drainage4,5 has a mortality rate of 1 percent. These results are equivalent or superior to those from recent reports of surgical repair.6,7 The frequency of recurrence of pseudocysts, hemorrhage, and infection after endoscopic or percutaneous drainage is about the same as that after surgical repair, even though many patients who undergo nonsurgical drainage are acutely ill and are not good candidates for surgery.

William F. Maule, M.D.
Ochsner Clinic of Baton Rouge, Baton Rouge, LA 70816

7 References

1. 1

   Steer ML, Waxman I, Freedman S. Chronic pancreatitis. N Engl J Med 1995;332:1482-1490
   Full Text | Web of Science | Medline

2. 2

   vanSonnenberg E, Wittich GR, Casola G, et al. Percutaneous drainage of infected and noninfected pancreatic pseudocysts: experience in 101 cases. Radiology 1989;170:757-761
   Web of Science | Medline

3. 3

   Freeny PC, Lewis GP, Traverso LW, Ryan JA. Infected pancreatic fluid collections: percutaneous catheter drainage. Radiology 1988;167:435-441
   Web of Science | Medline

4. 4

   Cremer M, Deviere J, Engelholm L. Endoscopic management of cysts and pseudocysts in chronic pancreatitis: long-term follow-up after 7 years of experience. Gastrointest Endosc 1989;35:1-9
   CrossRef | Web of Science | Medline

5. 5

   Liguory C, Lefebvre JF, Vitale GC. Endoscopic drainage of pancreatic pseudocysts. Can J Gastroenterol 1990;4:568-571
   

6. 6

   Vitas GJ, Sarr MG. Selected management of pancreatic pseudocysts: operative versus expectant management. Surgery 1992;111:123-130
   Web of Science | Medline

7. 7

   Newell KA, Liu T, Aranha GV, Prinz RA. Are cystgastrostomy and cystjejunostomy equivalent operations for pancreatic pseudocysts? Surgery 1990;108:635-640
   Web of Science | Medline

To the Editor:

The excellent review by Steer et al. summarizes progress in the treatment of chronic pancreatitis. In our opinion three nonsurgical techniques for the treatment of pancreatic pseudocysts are worth mentioning. Fine-needle puncture under sonographic guidance allows evacuation of the cyst and examination of its contents for the presence of bacteria1 and tumor cells (with the use of cytologic techniques and tumor markers2). Cystogastric drainage under sonographic and gastroscopic guidance, introduced by Hancke and Henriksen3 in 1985, can be used for retrogastric cysts, and success rates of 75 percent have been reported.4 We have observed the successful use of this technique combined with antibiotics even in infected pseudocysts. Treatment with octreotide (Sandostatin, Sandoz Pharmaceuticals) may prevent the refilling of pseudocysts after evacuation in patients at high risk for complications with any kind of drainage. A marked reduction in the secretion volume was demonstrated in externally drained pancreatic pseudocysts.5

Giuliano Ramadori, M.D.
Hans Münke, M.D.
Georg-August Universität Göttingen, 37075 Göttingen, Germany

5 References

1. 1

   Ljubicic N, Bilic A. Inflamed pancreatic pseudocyst: optimization of pseudocyst fluid culture technique. Z Gastroenterol 1993;31:198-200
   Web of Science | Medline

2. 2

   Lewandrowski KB, Southern JF, Pins MR, Compton CC, Warshaw AL. Cyst fluid analysis in the differential diagnosis of pancreatic cysts: a comparison of pseudocysts, serous cystadenomas, mucinous cystic neoplasms, and mucinous cystadenocarcinoma. Ann Surg 1993;217:41-47
   CrossRef | Web of Science | Medline

3. 3

   Hancke S, Henriksen FW. Percutaneous pancreatic cystogastrostomy guided by ultrasound scanning and gastroscopy. Br J Surg 1985;72:916-917
   CrossRef | Web of Science | Medline

4. 4

   Heyder N, Gunter E, Hahn EG. Endoskopisch-sonographisch geführte zystogastrale Katheterdrainagen pankreatogener Flüssigkeitsansammlungen. Z Gastroenterol 1992;30:553-557
   Web of Science | Medline

5. 5

   D'Agostino HB, vanSonnenberg E, Sanchez RB, Goodacre BW, Villaveiran RG, Lyche K. Treatment of pancreatic pseudocysts with percutaneous drainage and octreotide: work in progress. Radiology 1993;187:685-688
   Web of Science | Medline

To the Editor:

In their excellent review of chronic pancreatitis, Steer et al. pointed out the difficulty in identifying patients who have clinical symptoms and findings on endoscopic retrograde pancreatography suggestive of chronic pancreatitis but who in fact have pancreatic carcinoma. Indeed, endoscopic retrograde pancreatography is often not useful and cytologic analysis is not very sensitive in distinguishing between the two diagnoses. As pointed out, measurement of the tumor marker CA 19-9 is also not very useful.

We believe that the detection of c-Ki-ras mutations in fine-needle–biopsy specimens and pancreatic secretions may be useful in identifying patients with early pancreatic carcinoma and may even help identify premalignant lesions of the pancreas. Mutations at codon 12 of the c-Ki-ras gene occur early in the development of pancreatic adenocarcinoma and are present in up to 90 percent of these cancers. These mutations have been found in premalignant mucous-cell hyperplasia of the pancreas as well.1-3 Recently, rapid and sensitive methods of nonradioactive detection have been developed that can be applied to pancreatic secretions, bile fluid, and fine-needle–biopsy specimens.4,5 Mutations of the c-Ki-ras gene can be detected in pancreatic secretions in cases of mucous-cell hyperplasia of pancreatic ducts, which is thought to be a premalignant lesion.1-3 In cases in which a fine-needle biopsy shows only necrotic tissue, analysis with the polymerase chain reaction can confirm the presence of a c-Ki-ras mutation. This novel test to identify c-Ki-ras mutations may be a step toward the early identification of patients with carcinoma and extends the spectrum of diagnostic tests used to differentiate between chronic pancreatitis and cancer when the results of conventional tests leave uncertainty.

Roland M. Schmid, M.D.
Guido Adler, M.D.
University of Ulm, 89081 Ulm, Germany

5 References

1. 1

   Yanagisawa A, Ohtake K, Ohashi K, et al. Frequent c-Ki-ras oncogene activation in mucous cell hyperplasias of pancreas suffering from chronic inflammation. Cancer Res 1993;53:953-956
   Web of Science | Medline

2. 2

   Caldas C, Hahn SA, Hruban RH, Redston MS, Yeo CJ, Kern SE. Detection of K-ras mutations in the stool of patients with pancreatic adenocarcinoma and pancreatic ductal hyperplasia. Cancer Res 1994;54:3568-3573
   Web of Science | Medline

3. 3

   Trumper LH, Burger B, von Bonin F, et al. Diagnosis of pancreatic adenocarcinoma by polymerase chain reaction from pancreatic secretions. Br J Cancer 1994;70:278-284
   CrossRef | Web of Science | Medline

4. 4

   Kahn SM, Jiang W, Culbertson TA, et al. Rapid and sensitive nonradioactive detection of mutant K-ras genes via “enriched” PCR amplification. Oncogene 1991;6:1079-1083
   Web of Science | Medline

5. 5

   Tada M, Omata M, Kawai S, et al. Detection of ras gene mutations in pancreatic juice and peripheral blood of patients with pancreatic adenocarcinoma. Cancer Res 1993;53:2472-2474
   Web of Science | Medline

To the Editor:

On page 1484 of “Chronic Pancreatitis,” the last line of the paragraph entitled “Laboratory Tests” states, “a normal diet contains <7 g [of fat] per day.” A normal diet contains 80 to 100 g of fat per day; the value of 7 g per day is the normal upper limit of fecal fat excretion.

Dieter Seidler, M.D.
Schneeheide 50, 21149 Hamburg, Germany