Endoscopic approach to pancreas divisum

Abstract

Pancreas divisum has been claimed to be a harmless congenital variant or to occasionally cause acute relapsing pancreatitis (ARP), chronic pancreatitis (CP), or a chronic abdominal pain (CAP) syndrome. Both surgical and endoscopic approaches to accessory papilla decompression have been promulgated and widely disparate results reported in the literature. We retrospectively reviewed a five-year experience with dorsal pancreatic duct decompression at our institution utilizing a variety of endotherapeutic techniques. Data collected included procedural complications; patient interpretation of pre- and posttherapy pain, frequency, and intensity graded on an analog pain scale; frequency of hospitalization; and patient perception of "global" improvement to endotherapy. At a mean follow-up of 20 months, there was a statistically significant decrease in pancreatitis incidence in 15 patients with ARP (P = 0.016) and 19 patients with CP (P = 0.025). The frequency and intensity of chronic pain was also significantly improved (P < 0.001) in the latter group. In contrast, only one of five patients with CAP and normal dorsal pancreatography and secretin tests experienced global improvement, and there was no improvement utilizing an analog pain scale (P = 0.262) in the group as a whole. There was a 20% incidence of mild procedure or subsequent stent-related pancreatitis and an 11.5% accessory papilla restenosis rate. It is concluded that a subset of carefully selected patients with pancreas divisum may respond to endotherapy but that long-term follow-up will be required to define its ultimate place in the management of symptomatic patients with this anomaly.

Physician Controlled Wire Guided Cannulation of the Minor Papilla

“…This approach also appears to be safe; the 12% rate of post-ERCP pancreatitis is similar to pancreatitis incidence in prior series of MiP access and papillotomy (8%-20%) [3][4][5][6][7][8]. Though undoubtedly historically utilized, this report is the first to our knowledge to describe and evaluate this technique.…”

Long-term follow-up of endoscopic stenting in patients with chronic pancreatitis secondary to pancreas divisum

“…This low rate of pancreatitis can be explained by the fact that almost all patients had a stent placed in the pancreatic duct which reduced the risk of pancreatitis [12]. Endoscopic therapy for symptomatic pancreas divisum consists of minor papilla sphincterotomy plus/minus dorsal duct pancreatic stenting or stone extraction [13]. Endoscopic sphincterotomy of the minor papilla was performed in 30 patients with complete pancreas divisum.…”

“…Pancreas divisum is a normal anatomical variant in 5-7% of patients, based on autopsy and endoscopic retrograde cholangiopancreatography (ERCP) studies [5,13,16,19,20]. Pancreas divisum results from failure of the duct systems of the ventral and dorsal pancreas to fuse embryologically.…”

Endoscopic Therapy of Chronic and Recurrent Pancreatitis

“…90% of the patients in the stent group showed objective and subjective improvement at 29 months as compared with the controls. Table 3 summarizes the results of endoscopic therapy for pancreas divisum [45][46][47][48][49]. An important point from Kozarek et al [45] Endoscopic Therapy of Pancreatitis Dig Dis 1998;16:134-143 141 both endoscopic and surgical studies on therapy of pancreas divisum is that patients with clinically documented attacks of recurrent pancreatitis respond much better to treatment than patients who present with chronic abdominal pain or chronic pancreatitis.…”

“…Current endoscopic treatment is aimed at improving drainage via the minor papilla either by placement of an endoprosthesis or sphincterotomy [41][42][43][44][45] (fig. 5).…”