title: The inflammatory pancreatic head mass: significant differences in the anatomic pathology of German and American patients with chronic pancreatitis determine very different surgical strategies.
abstract: 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.
authors.affiliation: Department of Surgery and Radiology, University of Freiburg, Germany.
authors.forename: Tobias
authors.initials: T
authors.lastname: Keck
authors.forename: Goran
authors.initials: G
authors.lastname: Marjanovic
authors.forename: Carlos
authors.initials: C
authors.lastname: Fernandez-del Castillo
authors.forename: Frank
authors.initials: F
authors.lastname: Makowiec
authors.forename: Arndt Oliver
authors.initials: AO
authors.lastname: Schäfer
authors.forename: J Ruben
authors.initials: JR
authors.lastname: Rodriguez
authors.forename: Oswaldo
authors.initials: O
authors.lastname: Razo
authors.forename: Ulrich Theodor
authors.initials: UT
authors.lastname: Hopt
authors.forename: Andrew L
authors.initials: AL
authors.lastname: Warshaw
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D005858:Germany; D006801:Humans; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy / Q000379:methods*; D050500:Pancreatitis, Chronic / Q000150:complications / Q000473:pathology* / Q000601:surgery*; D014481:United States; D055815:Young Adult