Pancreas zyxwvutsrqponmlkj Vol. zyxwvutsrqponm 1 I, No. 3, pp. 289-293 zyxwvutsrqp 0 1995 Lippincott-Raven Publishers, Philadelphia Pancreaticoduodenojejunostomy for Chronic Pancreatitis Presenting with an Inflammatory Mass in the Head of the Pancreas Sergio Pedrazzoli, Cosimo Sperti, and Claudio Pasquali zyx Istituto di Semeiotica Chirurgica, Universita degli Studi di Padova, Padova, Italy zyx Summary: An inflammatory mass in the head of the pancreas is reported in 18-50% of patients with chronic pancreatitis. When the clinical history is misleading, dif- ferential diagnosis between chronic pancreatitis and pancreatic cancer may be very difficult. Pancreatico- duodenectomy is considered the treatment of choice, if cancer is still suspected despite negative biopsy. From January 1987 to December 1992 we performed 42 pancre- aticoduodenectomies, 36 for malignancies of the pancre- aticoduodenal area and 6 for chronic pancreatitis sus- pected to have a pancreatic cancer. In three additional cases of chronic pancreatitis, we performed a pancreati- coduodenojejunal anastomosis after complete opening of the pancreatic duct and excision of the papilla of Vater. Frozen section and definitive histological examination of the pancreas and ampulla excluded malignancy in all three patients. They are alive and well 60, 36, and 20 months after operation. With this procedure, frozen- section examination of the distal part of the pancreatic and biliary duct, the papilla, and the periductal pancreatic tissue can be performed, while this is impossible with the usual pancreaticojejunostomy zyxw . We can therefore reason- ably exclude a small cancer of the periampullary area and perform a wider derivative procedure, instead of a pan- creaticoduodenectomy , in patients with an inflammatory mass of the head of the pancreas. Key Words: Chronic pancreatitis-Longitudinal pancreaticojejunostomy- z Pancreaticoduodenectomy-Pylorus-preserving resec- tion of pancreatic head-Warren derivation procedure- Frey coring-out derivation procedure. Pancreaticojejunostomy is considered the surgi- cal treatment of choice for chronic pancreatitis with an enlarged pancreatic duct (1-3). An inflammatory mass of the head of the pancreas with or without a dilated pancreatic duct is reported in 18-50% of cases of chronic pancreatitis (4-6). The standard surgical procedure for such cases is the Whipple operation (2) or, more recently, the Traverso- Longmire operation (7), which preserves the stom- ach and pylorus. To avoid duodenal resection and reduce the amount of pancreatic tissue removal, other surgical procedures have been proposed: de- nervated splenopancreatic flap (8), duodenum- preserving resection of the head of the pancreas (4), Manuscript received August 2, 1994; revised manuscript ac- cepted October 26, 1994. Address correspondence and reprint requests to Dr. S. Pedrazzoli, Direttore, Istituto di Semeiotica Chirurgica, Univer- sith di Padova, Via Facciolati 71, 35127 Padova, Italy. and coring-out of the pancreatic head and uncinate process (9). In the latter three procedures the com- mon bile duct is freed from the surrounding fibrosis and a rim of pancreatic tissue, containing the pan- creaticoduodenal vessels, is preserved. The termi- nal part of Wirsung and the papilla are also pre- served. Moreover, in some cases of cephalic pan- creatic mass, particularly when associated with obstruction of the common bile duct or of the duo- denum, differential diagnosis with a pancreatic or periampullary tumor is needed. Pancreaticoduo- denectomy avoids overlooking small periampullary cancers having a favorable prognosis (10) but is un- necessary if the diagnosis of chronic pancreatitis is certain. The other three aforementioned procedures are not adequate to rule out the possibility of over- looking a cancer of the periampullary region. From January 1987 to December 1992, we per- formed 42 pancreaticoduodenectomies, 36 for ma- zy 289