To the Editor:
We read with interest the article by Branum et al, 1 in which the authors investigated postoperative and long-term results in 50 patients after surgery for necrotizing pancreatitis. The reported mortality of 12% is impressively low and represents an excellent result. However, the incidence rates of endocrine (40%) and exocrine (23%) insufficiencies 40 months after surgery seem high and justify a few remarks.
1. The detection of exocrine and endocrine insufficiencies is heavily influenced by the sensitivity of diagnostic tests applied. Oral glucose tolerance tests, serum insulin or c-peptide levels and pancreatic exocrine function tests as the secretin-cholecystokinin test yield much higher rates of impaired function than fasting serum glucose levels or the clinical evidence of steatorrhea. The authors did not indicate by which methods pancreatic insufficiencies were diagnosed.
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2. The development of exocrine or endocrine insufficiencies after surgery depends on the amount of functioning pancreatic tissue preserved, and is determined by the following factors:
a. Pancreatic function before surgery: In the reported series, 20% of patients presented with diabetes and 12% with exocrine insufficiency before treatment indicating a history of previous bouts of acute or chronic pancreatitis leading to parenchymal destruction;
b. Amount of necrosis and tissues debrided: In a study we found significantly higher rates of diabetes in patients in whom partial pancreatic resections had to be performed due to the extension of necrosis compared to patients after debridement only 2;
c. Length of the interval between surgery and follow-up: Doepel and associates 3 demonstrated increasing rates of diabetes depending on duration of follow-up (50% after 6 years); and
d. Rate of recurrent attacks of pancreatitis mainly due to ethanol intake leading to further destruction of pancreatic tissue.
According to data presented by Branum et al, 1 Broome et al, 4 and our own experience, 2,5 however, exocrine and endocrine insufficiencies after surgical treatment of necrotizing pancreatitis may be easily treated in the great majority of patients and do not adversely affect the good long-term results.
August 4, 1998
Stephan Kriwanek MD
Michael Gschwantler MD
Christian Armbruster MD
References
- 1.Branum G, Galloway J, Hirchowitz W, et al. Pancreatic necrosis results of necrosectomy, packing, and ultimate closure over drains. Ann Surg 1998; 227: 870–877. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Kriwanek S, Armbruster C, Dittrich K, et al. Long-term results after surgery for acute necrotizing pancreatitis. Chirurgie 1996; 67: 244–248. [PubMed] [Google Scholar]
- 3.Doepel M, Eriksson J, Halme L, et al. Good long-term results in patients surviving severe acute pancreatitis. Br J Surg 1993; 80: 1583–1585. [DOI] [PubMed] [Google Scholar]
- 4.Broome AH, Eisen GM, Harland RC, et al. Quality of life after treatment for pancreatitis. Ann Surg 1996; 223: 665–672. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Kriwanek S, Armbruster C, Dittrich K, et al. Long-term outcome after open treatment of severe intra-abdominal infection and pancreatic necrosis. Arch Surg 1998; 1233: 140–144. [DOI] [PubMed] [Google Scholar]