Abstract
We congratulate the authors for their systematic review on pancreatic tuberculosis. 1 Although their review focuses on the clinical spectrum and management of pancreatic tuberculosis, it also highlights the difficulties in conducting a scoping review of an uncommon disease. Because of the selection criteria, the authors have excluded the most important studies published on pancreatic tuberculosis. As individual patient data were not available, certain case series with a substantial number of patients have been excluded.2–8 In such a scenario, the authors could have contacted the corresponding authors to retrieve missing information. Further, some of the parameters that have been completely reported may have been included in the systematic review.
The authors of the article have taken efforts to provide an excellent information in the article, but certain features that were not discussed require emphasis. Some patients with nodal tuberculosis of the peripancreatic region may be mis-categorized as pancreatic tuberculosis even after imaging in the form of computed tomography (CT) or endosonography (EUS) and isolated pancreatic tuberculosis is an uncommon entity. Further, as with pancreatic malignancy, involvement of adjacent vasculature has been well described in pancreatic tuberculosis. 9 Histology is crucial for diagnosis and the primary method of tissue acquisition in pre-EUS era was surgery. Many studies included in this systematic review are from the pre-EUS era where a substantial number of patients were diagnosed post-operatively and EUS was performed in only a quarter of patients overall. EUS in the current scenario has become an indispensable tool in patients with focal pancreatic mass or peripancreatic nodes and most of these patients are likely to undergo a diagnostic EUS with Fine needle aspiration/biopsy during initial evaluation. This may substantially increase the diagnostic yield, provide adequate histology and avoid unnecessary surgeries. 8 CA 19-9, in contrast, may be useful with high values suggesting a diagnosis of adenocarcinoma rather than tuberculosis (only few reports suggest elevation of CA 19-9 in pancreatic tuberculosis). 10
This review also provided an excellent opportunity to describe the regime and duration of Antitubercular therapy (ATT) used in patients with pancreatic tuberculosis. Although there is sufficient evidence to suggest multi-drug ATT for 6 months is sufficient in treating patients with abdominal tuberculosis, evidence in isolated pancreatic tuberculosis is lacking. Another dilemma in managing these patients that the study failed to address is a lack of consensus over monitoring for the response to ATT. There are no defined objective criteria, unlike patients with intestinal tuberculosis where mucosal healing on endoscopy suggests clinical response. It may be important to plan timely surgery when a definite tissue diagnosis is not possible. Response on basis of CT findings has been described as complete or partial (at least 50% reduction in volume of involvement). 4 Monitoring using imaging (CT and Positron emission tomography-CT) has been described but EUS may also provide a good modality for follow-up because of the lack of radiation. 4 Cholestasis and jaundice may improve with ATT alone. 10