1074
Letters
4. Donati M, Stavrou GA, Basile F, et al. Combination of in situ split and portal ligation: lights and shadows of a new surgical procedure. Ann Surg 2012;256:e11ee12. 5. Oldhafer KJ, Donati M, Maghsoudi T, et al. Integration of 3D volumetry, portal vein transection and in situ split procedure: a new surgical strategy for inoperable liver metastasis. J Gastrointest Surg 2012;16:415e416. 6. Machado MA, Makdissi FF, Surjan RC. ALPPS procedure with the use of pneumoperitoneum. Ann Surg Oncol 2013;20: 1491e1493.
Disclosure Information: Nothing to disclose.
Early Detection of Potentially Severe Acute Pancreatitis Ahmet Ziya Balta, MD, Yavuz Ozdemir, MD, Ilker Sucullu, MD, Mehmet Levhi Akin, MD, FACS Istanbul, Turkey Sezai Demirbas, Ankara, Turkey
MD, FACRS
We read with great interest the article entitled ‘‘Early Angiopoietin-2 Levels after Onset Predict the Advent of Severe Pancreatitis, Multiple Organ Failure, and Infectious Complications in Patients with Acute Pancreatitis’’ by Buddingh and colleagues.1 The study aimed to determine whether early plasma angiopoietin-2 (Ang-2) level is associated with adverse outcomes in patients with predicted severe acute pancreatitis (SAP). They concluded that increased Ang-2 level is associated with the severity of the disease course and its complications. However, body mass index of the patients was not considered as a notable factor that can affect the disease course. Several clinical investigations showed that obesity rates are rising in the world with the increasing consumption of a Western diet. Obesity affects the severity of the disease by favoring local complications within the pancreas and injuries in remote organs and, as a result, increases the mortality rate.2 Obese patients have fatty infiltration in the visceral organs and this situation leads to a generalized pro-inflammatory milieu and subsequent organ dysfunction due to severe inflammatory response. Many epidemiologic studies have clearly shown obesity to be an independent risk factor for SAP developing.3 In addition, Silha and colleagues4 demonstrated that angiogenic factors, including Ang-2, are elevated in overweight and obese individuals, and this might explain why SAP develops in some patients. Recently, we have been working on an experimental model of L-arginine induced SAP. According to our unpublished data, although serum Ang-2 levels are markedly
J Am Coll Surg
elevated in obese rats, adiponectin levels are decreased, and we found a ratio between adiponectin and Ang-2 that shows disease severity. We believe that not only increased serum Ang-2 level affects the disease course, but also decreased adiponectin levels. Increased serum Ang-2 levels lead to vascular leak syndrome and are associated with disease complications, such as remote organ dysfunction and infectious complications, as the authors mentioned in their article. But several biochemical factors and mechanisms play roles in SAP, and Ang-2 is only one of these factors. There is still uncertainty about the exact mechanism of SAP in some patients. The main problem is the early prediction of the prognosis of the patients who have SAP. In addition to biochemical markers such as Ang-2 and adiponectin, several scoring systems have been developed for the prediction of disease severity. Ranson Criteria was the first prognostic scoring system developed in 1974 for acute pancreatitis. Afterward, numerous scoring systems were developed, including Glasgow/Imrie, APACHE II, Multiple Organ Dysfunction Score, and many others.5 Although these biochemical markers or scoring systems are useful in estimation of the prognosis of acute pancreatitis, we still need more sensitive and specific markers. Recent studies focused on serum biomarkers, including Ang-2 and adiponectin.6 In conclusion, we believe that new scoring systems, including both physiologic parameters, such as body mass index, and biochemical markers are needed, and future studies evaluating markers like Ang-2 and adiponectin are necessary. The circulating concentrations of inflammatory mediators are closely related to obesity and the severity of pancreatitis. REFERENCES 1. Buddingh KT, Koudstaal LG, van Santvoort HC, et al. Early angiopoietin-2 levels after onset predict the advent of severe pancreatitis, multiple organ failure, and infectious complications in patients with acute pancreatitis. J Am Coll Surg 2014;218:26e32. 2. Frossard JL, Lescuyer P, Pastor CM. Experimental evidence of obesity as a risk factor for severe acute pancreatitis. World J Gastroenterol 2009;15:5260e5265. 3. Al-Azzawi HH, Wade TE, Swartz-Basile DA, et al. Acute pancreatitis in obesity: adipokines and dietary fish oil. Dig Dis Sci 2011;56:2318e2325. 4. Silha JV, Krsek M, Sucharda P, Murphy LJ. Angiogenic factors are elevated in overweight and obese individuals. Int J Obes (Lond) 2005;29:1308e1314. 5. Dambrauskas Z, Gulbinas A, Pundzius J, Barauskas G. Value of the different prognostic systems and biological markers for predicting severity and progression of acute pancreatitis. Scand J Gastroenterol 2010;45:959e970. 6. Demirci S, Akbal E, Koc¸ak E, et al. Adipokine levels in the course of mild biliary pancreatitis. Ann Nutr Metab 2012;61:271e274.
Disclosure Information: Nothing to disclose.
Letters
4. Donati M, Stavrou GA, Basile F, et al. Combination of in situ split and portal ligation: lights and shadows of a new surgical procedure. Ann Surg 2012;256:e11ee12. 5. Oldhafer KJ, Donati M, Maghsoudi T, et al. Integration of 3D volumetry, portal vein transection and in situ split procedure: a new surgical strategy for inoperable liver metastasis. J Gastrointest Surg 2012;16:415e416. 6. Machado MA, Makdissi FF, Surjan RC. ALPPS procedure with the use of pneumoperitoneum. Ann Surg Oncol 2013;20: 1491e1493.
Disclosure Information: Nothing to disclose.
Early Detection of Potentially Severe Acute Pancreatitis Ahmet Ziya Balta, MD, Yavuz Ozdemir, MD, Ilker Sucullu, MD, Mehmet Levhi Akin, MD, FACS Istanbul, Turkey Sezai Demirbas, Ankara, Turkey
MD, FACRS
We read with great interest the article entitled ‘‘Early Angiopoietin-2 Levels after Onset Predict the Advent of Severe Pancreatitis, Multiple Organ Failure, and Infectious Complications in Patients with Acute Pancreatitis’’ by Buddingh and colleagues.1 The study aimed to determine whether early plasma angiopoietin-2 (Ang-2) level is associated with adverse outcomes in patients with predicted severe acute pancreatitis (SAP). They concluded that increased Ang-2 level is associated with the severity of the disease course and its complications. However, body mass index of the patients was not considered as a notable factor that can affect the disease course. Several clinical investigations showed that obesity rates are rising in the world with the increasing consumption of a Western diet. Obesity affects the severity of the disease by favoring local complications within the pancreas and injuries in remote organs and, as a result, increases the mortality rate.2 Obese patients have fatty infiltration in the visceral organs and this situation leads to a generalized pro-inflammatory milieu and subsequent organ dysfunction due to severe inflammatory response. Many epidemiologic studies have clearly shown obesity to be an independent risk factor for SAP developing.3 In addition, Silha and colleagues4 demonstrated that angiogenic factors, including Ang-2, are elevated in overweight and obese individuals, and this might explain why SAP develops in some patients. Recently, we have been working on an experimental model of L-arginine induced SAP. According to our unpublished data, although serum Ang-2 levels are markedly
J Am Coll Surg
elevated in obese rats, adiponectin levels are decreased, and we found a ratio between adiponectin and Ang-2 that shows disease severity. We believe that not only increased serum Ang-2 level affects the disease course, but also decreased adiponectin levels. Increased serum Ang-2 levels lead to vascular leak syndrome and are associated with disease complications, such as remote organ dysfunction and infectious complications, as the authors mentioned in their article. But several biochemical factors and mechanisms play roles in SAP, and Ang-2 is only one of these factors. There is still uncertainty about the exact mechanism of SAP in some patients. The main problem is the early prediction of the prognosis of the patients who have SAP. In addition to biochemical markers such as Ang-2 and adiponectin, several scoring systems have been developed for the prediction of disease severity. Ranson Criteria was the first prognostic scoring system developed in 1974 for acute pancreatitis. Afterward, numerous scoring systems were developed, including Glasgow/Imrie, APACHE II, Multiple Organ Dysfunction Score, and many others.5 Although these biochemical markers or scoring systems are useful in estimation of the prognosis of acute pancreatitis, we still need more sensitive and specific markers. Recent studies focused on serum biomarkers, including Ang-2 and adiponectin.6 In conclusion, we believe that new scoring systems, including both physiologic parameters, such as body mass index, and biochemical markers are needed, and future studies evaluating markers like Ang-2 and adiponectin are necessary. The circulating concentrations of inflammatory mediators are closely related to obesity and the severity of pancreatitis. REFERENCES 1. Buddingh KT, Koudstaal LG, van Santvoort HC, et al. Early angiopoietin-2 levels after onset predict the advent of severe pancreatitis, multiple organ failure, and infectious complications in patients with acute pancreatitis. J Am Coll Surg 2014;218:26e32. 2. Frossard JL, Lescuyer P, Pastor CM. Experimental evidence of obesity as a risk factor for severe acute pancreatitis. World J Gastroenterol 2009;15:5260e5265. 3. Al-Azzawi HH, Wade TE, Swartz-Basile DA, et al. Acute pancreatitis in obesity: adipokines and dietary fish oil. Dig Dis Sci 2011;56:2318e2325. 4. Silha JV, Krsek M, Sucharda P, Murphy LJ. Angiogenic factors are elevated in overweight and obese individuals. Int J Obes (Lond) 2005;29:1308e1314. 5. Dambrauskas Z, Gulbinas A, Pundzius J, Barauskas G. Value of the different prognostic systems and biological markers for predicting severity and progression of acute pancreatitis. Scand J Gastroenterol 2010;45:959e970. 6. Demirci S, Akbal E, Koc¸ak E, et al. Adipokine levels in the course of mild biliary pancreatitis. Ann Nutr Metab 2012;61:271e274.
Disclosure Information: Nothing to disclose.
