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The Inflammatory Pancreatic Head Mass: Significant Differences in the Anatomic Pathology of German and American Patients With Chronic Pancreatitis Determine Very Different Surgical Strategies

Keck, Tobias MD*; Marjanovic, Goran MD*; Fernandez-del Castillo, Carlos MD; Makowiec, Frank MD*; Schäfer, Arndt Oliver MD*; Rodriguez, J Ruben MD; Razo, Oswaldo MD; Hopt, Ulrich Theodor MD*; Warshaw, Andrew L. MD

doi: 10.1097/SLA.0b013e31818ef078
Original Articles

Background: The indications for surgery and the surgical strategy selected for chronic pancreatitis (CP) vary widely, perhaps because of unaccounted characteristics of different patient populations such as the “inflammatory mass” in the head of the pancreas, commonly described in Europe but not in America.

Methods: We compared the pancreatic morphology, anatomic complications, indications leading to intervention, and the operation performed in 93 consecutive patients with CP operated upon either at a German (n = 48) or an American (n = 45) center specializing in pancreatic surgery. Pretreatment computed tomography/magnetic resonance imaging scans were reevaluated by 2 independent radiologists, especially to measure the anterior-posterior diameter of the pancreatic head (the inflammatory mass).

Results: The prevalence of endocrine and exocrine insufficiency was not significantly different. The median diameter of the pancreatic head mass was significantly larger in the German group (4.5 vs. 2.6 cm, P < 0.001). Inflammatory mass-dependent symptoms [gastric outlet obstruction (9/48 vs. 1/45; P = 0.02) and hemorrhage (7/48 vs. 0/45; P = 0.013)] were more frequent in the German group. Bile duct stenosis (19/48 vs. 11/43; P = 0.18) and suspicion of malignancy (5/48 vs. 11/43; P = 0.10) were comparable, whereas chronic pain (15/48 vs. 28/43; P = 0.001) was a more frequent indication for surgery in the US group. Splenic or portal vein thrombosis was found only in the German group. The duration of nonoperative therapy was significantly longer in the German group (median 56 vs. 26 months; P = 0.02). In the US group, a pancreatoduodenectomy with antrectomy was performed in most (89%) cases, whereas in the German group a duodenum-preserving head resection was preferred in more than half (25/47) of the cases (P < 0.001).

Conclusions: Symptoms, duration of conservative therapy, and selection of surgical treatment all differed significantly between German and American patients with CP. These differences seem to be dependent upon surprising but unexplained disparities in the pathologic pancreatic anatomy between the 2 populations.

An inflammatory mass in the pancreatic head is common in German patients but not in American patients with chronic pancreatitis. This previously unrecognized difference in pathology, although unexplained, leads to very different anatomic consequences and surgical treatment.

From the *Departments of Surgery and Radiology, University of Freiburg, Germany; and the †Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Reprints: Andrew L. Warshaw, MD, Surgeon-in-Chief, W. Gerald Austen Professor of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street WHT 506, Boston, MA 02114. E-mail:

© 2009 Lippincott Williams & Wilkins, Inc.