To the Editor: In their review of chronic pancreatitis, Steeret al. (June 1 issue)1 imply that the best treatment for pseudocystsdue to chronic pancreatitis is laparotomy. Data from severalsurgical and endoscopic or radiographic series suggest otherwise.
Percutaneous drainage2 was associated with a mortality rateof 2 percent or less, even when the majority of patients hadinfected pseudocysts.3 Endoscopic drainage4,5 has a mortalityrate of 1 percent. These results are equivalent or superiorto those from recent reports of surgical repair.6,7 The frequencyof recurrence of pseudocysts, hemorrhage, and infection afterendoscopic or percutaneous drainage is about the same as thatafter surgical repair, even though many patients who undergononsurgical drainage are acutely ill and are not good candidatesfor surgery.
William F. Maule, M.D. Ochsner Clinic of Baton Rouge Baton Rouge,LA 70816
References
Steer ML, Waxman I, Freedman S. Chronic pancreatitis. N Engl J Med 1995;332:1482-1490. [Free Full Text]
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. [Free Full Text]
Freeny PC, Lewis GP, Traverso LW, Ryan JA. Infected pancreatic fluid collections: percutaneous catheter drainage. Radiology 1988;167:435-441. [Free Full Text]
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. [Medline]
Liguory C, Lefebvre JF, Vitale GC. Endoscopic drainage of pancreatic pseudocysts. Can J Gastroenterol 1990;4:568-571.
Vitas GJ, Sarr MG. Selected management of pancreatic pseudocysts: operative versus expectant management. Surgery 1992;111:123-130. [Medline]
Newell KA, Liu T, Aranha GV, Prinz RA. Are cystgastrostomy and cystjejunostomy equivalent operations for pancreatic pseudocysts? Surgery 1990;108:635-640. [Medline]
To the Editor: The excellent review by Steer et al. summarizesprogress in the treatment of chronic pancreatitis. In our opinionthree nonsurgical techniques for the treatment of pancreaticpseudocysts are worth mentioning. Fine-needle puncture undersonographic guidance allows evacuation of the cyst and examinationof its contents for the presence of bacteria1 and tumor cells(with the use of cytologic techniques and tumor markers2). Cystogastricdrainage under sonographic and gastroscopic guidance, introducedby Hancke and Henriksen3 in 1985, can be used for retrogastriccysts, and success rates of 75 percent have been reported.4We have observed the successful use of this technique combinedwith antibiotics even in infected pseudocysts. Treatment withoctreotide (Sandostatin, Sandoz Pharmaceuticals) may preventthe refilling of pseudocysts after evacuation in patients athigh risk for complications with any kind of drainage. A markedreduction in the secretion volume was demonstrated in externallydrained pancreatic pseudocysts.5
Ljubicic N, Bilic A. Inflamed pancreatic pseudocyst: optimization of pseudocyst fluid culture technique. Z Gastroenterol 1993;31:198-200. [Medline]
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. [Medline]
Hancke S, Henriksen FW. Percutaneous pancreatic cystogastrostomy guided by ultrasound scanning and gastroscopy. Br J Surg 1985;72:916-917. [Medline]
Heyder N, Günter E, Hahn EG. Endoskopisch-sonographisch geführte zystogastrale Katheterdrainagen pankreatogener Flüssigkeitsansammlungen. Z Gastroenterol 1992;30:553-557. [Medline]
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. [Free Full Text]
To the Editor: In their excellent review of chronic pancreatitis,Steer et al. pointed out the difficulty in identifying patientswho have clinical symptoms and findings on endoscopic retrogradepancreatography suggestive of chronic pancreatitis but who infact have pancreatic carcinoma. Indeed, endoscopic retrogradepancreatography is often not useful and cytologic analysis isnot very sensitive in distinguishing between the two diagnoses.As pointed out, measurement of the tumor marker CA 19-9 is alsonot very useful.
We believe that the detection of c-Ki-ras mutations in fine-needle–biopsyspecimens and pancreatic secretions may be useful in identifyingpatients with early pancreatic carcinoma and may even help identifypremalignant lesions of the pancreas. Mutations at codon 12of the c-Ki-ras gene occur early in the development of pancreaticadenocarcinoma and are present in up to 90 percent of thesecancers. These mutations have been found in premalignant mucous-cellhyperplasia of the pancreas as well.1,2,3 Recently, rapid andsensitive methods of nonradioactive detection have been developedthat can be applied to pancreatic secretions, bile fluid, andfine-needle–biopsy specimens.4,5 Mutations of the c-Ki-rasgene can be detected in pancreatic secretions in cases of mucous-cellhyperplasia of pancreatic ducts, which is thought to be a premalignantlesion.1,2,3 In cases in which a fine-needle biopsy shows onlynecrotic tissue, analysis with the polymerase chain reactioncan confirm the presence of a c-Ki-ras mutation. This noveltest to identify c-Ki-ras mutations may be a step toward theearly identification of patients with carcinoma and extendsthe spectrum of diagnostic tests used to differentiate betweenchronic pancreatitis and cancer when the results of conventionaltests leave uncertainty.
Roland M. Schmid, M.D. Guido Adler, M.D. University of Ulm 89081Ulm, Germany
References
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. [Free Full Text]
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. [Free Full Text]
Trümper LH, Bürger B, von Bonin F, et al. Diagnosis of pancreatic adenocarcinoma by polymerase chain reaction from pancreatic secretions. Br J Cancer 1994;70:278-284. [Medline]
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. [Medline]
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. [Free Full Text]
To the Editor: On page 1484 of "Chronic Pancreatitis," the lastline of the paragraph entitled "Laboratory Tests" states, "anormal diet contains <7 g [of fat] per day." A normal dietcontains 80 to 100 g of fat per day; the value of 7 g per dayis the normal upper limit of fecal fat excretion.
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