Clinical outcome of endoscopic therapy in patients with symptomatic pancreas divisum: a Dutch cohort study

Abstract

Background and study aims Although the majority of patients with pancreas divisum (PDiv) are asymptomatic, a subgroup present with recurrent pancreatitis or pain for which endoscopic therapy may be indicated. The aim of this study was to evaluate success rates and long-term outcomes of endoscopic treatment in patients with symptomatic PDiv. Patients and methods A multicenter, retrospective cohort study was performed. Patients with symptomatic PDiv presenting with recurrent acute pancreatitis (RAP), chronic pancreatitis (CP), or chronic abdominal pancreatic-type pain (CAP) who underwent endoscopic retrograde cholangiopancreatography (ERCP) between January 2000 and December 2019 were included. The primary outcome was clinical success, defined as either no recurrent episode of acute pancreatitis (AP) for RAP patients, no flares for CP patients, or absence of abdominal pain for patients with CAP after technically successful ERCP. Results In 60 of 81 patients (74.1 %) a technically successful papilla minor intervention was performed. Adverse events were reported in 30 patients (37 %), with post-ERCP pancreatitis in 18 patients. The clinical success rate for patients with at least 3 months of follow-up was 42.6 %, with higher rates of success among patients presenting with RAP (44.4 %) as compared to those with CP (33.3 %) or CAP (33.3 %). Long-term sustained response was present in 40.9 % of patients with a technically successful intervention. In patients with RAP who did not completely respond to treatment, the mean number of AP episodes after treatment decreased significantly from 3.5 to 1.1 per year, and subsequently the interval between AP episodes increased from 278 to 690 days (P = 0.0006). A potential predictive factor of failure of clinical success after technically successful ERCP, at univariate analysis, was male sex (OR = 0.25, P = 0.02). Conclusions Endoscopic therapy in patients with symptomatic PDiv is moderately effective, with its highest yield in patients presenting with RAP. Future studies are needed to assess factors predictive for success of endoscopic therapy and potential risk factors for relapse after ERCP.

Pancreatic duct stents

“…Subsequently, the small duct and minor papilla become the predominant drainage channel of pancreatic exocrine secretion. 62,63 Dorsal duct plastic stent placement has been verified to be an effective treatment option for PD. A temporary plastic pancreatic duct stent is placed to prevent PEP after minor papilla endoscopic sphincterotomy, and the stent spontaneously migrates out of the pancreatic duct within 2 weeks; otherwise, an upper endoscopy is performed to remove the retained stent.…”

“…64 A long-term plastic pancreatic duct stent has been recommended to relieve the symptoms of PD, either placed independently or in conjunction with minor papilla endoscopic sphincterotomy or minor papilla orifice dilation, with an effectiveness rate of approximately 80%. 62 In cases of plastic stent placement failure, FCSEMSs have been reported to have a high success rate in the treatment of PD. 65,66…”

“…PD is the most common congenital malformation of the pancreas that is caused by the failure of fusion of the dorsal and ventral pancreatic buds during embryogenesis. Subsequently, the small duct and minor papilla become the predominant drainage channel of pancreatic exocrine secretion 62,63 . Dorsal duct plastic stent placement has been verified to be an effective treatment option for PD.…”

“…A temporary plastic pancreatic duct stent is placed to prevent PEP after minor papilla endoscopic sphincterotomy, and the stent spontaneously migrates out of the pancreatic duct within 2 weeks; otherwise, an upper endoscopy is performed to remove the retained stent 64 . A long‐term plastic pancreatic duct stent has been recommended to relieve the symptoms of PD, either placed independently or in conjunction with minor papilla endoscopic sphincterotomy or minor papilla orifice dilation, with an effectiveness rate of approximately 80% 62 . In cases of plastic stent placement failure, FCSEMSs have been reported to have a high success rate in the treatment of PD 65,66 …”

Precut papillotomy on a minor papilla followed by balloon papilloplasty to provide a complete pancreatic-duct drainage in tropical pancreatitis with reverse pancreas divisum

“…The 2 most common causes for chronic pancreatitis in children are genetic mutation causing highly viscous pancreatic juice and congenital anomaly, including pancreas divisum and its variants. 1 The treatment of choice for patients with highly viscous pancreatic juice is to facilitate pancreatic-duct drainage and, most commonly, pancreatic sphincterotomy via major papilla is performed. In contrast, minor papilla sphincterotomy is recommended for a case with pancreas divisum.…”