TRANSATLANTIC DIFFERENCES IN THE SURGICAL TREATMENT OF CHRONIC PANCREATITIS

Abstract

Hypothesis: The indications for surgical resection and the operation chosen in chronic pancreatitis (CP) may vary in Europe vs. America. Methods: We compared the morphology and circumstances that precipitated surgical therapy in either a German or US centre for pancreatic surgery. Retrospective analysis compared the serum biochemical values, morphological parameters, and clinical indications in 93 consecutive patients. CT scans were evaluated for the AP diameter of the pancreatic head, pancreatic duct dilation, and obstruction of the bile duct or duodenum. Symptoms were categorized as objective gastric outlet obstruction, obstructive jaundice, and haemorrhage versus subjective chronic pain. Differences were evaluated by Chi square, Wilcoxon and Fisher's exact tests. Results: 48 consecutive patients were studied from the German and 45 from the US centre. The prevalence of diabetes, exocrine insufficiency and chronic pain were not significantly different. The average maximal AP diameter of the pancreatic head mass was significantly greater in the German group (4.81 vs. 1.69 cm; p < 0.001). Symptoms of gastric outlet obstruction (9/48 vs. 1/45; p = 0.016) and haemorrhage (7/48 vs. 0/45; p = 0.013) significantly correlated with the larger size pancreatic head ("mass") in the German group. Bile duct stenosis (8/47 vs. 12/43, p = 0.31) and suspicion of malignancy (5/47 vs. 11/43; p = 0.097) were comparable, but intractable chronic pain (14/47 vs. 29/43; p = 0.001) was the most frequent principal indication in the US. Pancreaticoduodenectomy was performed in most US cases (37/45), whereas in Germany the Frey or Beger duodenum-preserving pancreatic head resection was preferred in 24/41 cases. Lateral pancreaticojejunostomy (Puestow procedure) was chosen infrequently in both centres. Conclusion: The patient populations and indications for surgical treatment differed greatly between a German and a US pancreatic surgery centre. In the German patients complications of advanced CP were more prevalent, whereas chronic pain and the suspicion of malignancy were the dominant reasons for resection in the US. The morphologic and functional disparities contribute to differences in the choice of surgical technique and may reflect intrinsic differences in the patient populations or the pathogenesis of CP in the two countries.