Surgical Management of Recurrent Pancreatitis in Children With Pancreas Divisum

Abstract

ObjectiveTo analyze an institutional experience with pancreatitis in childhood to clarify the frequency of pancreas divisum in that patient population, the characteristics of pancreatitis in children with pancreas divisum, and the role of surgical management in their treatment. Summary Background DataThe role of pancreas divisum in causing acute and relapsing pancreatitis and chronic, recurring abdominal pain is controversial. Although the anatomical abnormality is present from birth, most investigators have reported cases with onset of symptoms in adulthood. The reported pediatric experience with this disorder is small, and the natural history of pancreatitis in children with pancreas divisum has not been well elucidated. MethodsA retrospective chart review of all children 18 years of age and younger with a discharge diagnosis of pancreatitis identified 135 patients treated in the authors' institution from 1978 to 1998. Ten patients were found to have anatomical variants of pancreas divisum associated with recurrent or chronic pancreatitis. The medical records of these patients were reviewed for data on the presentation, diagnostic findings, imaging studies, treatment, surgical findings, and pathologic findings in these children. Chart review and telephone calls were used to assess the current state of health in nine patients available for follow-up. ResultsPancreas divisum was identified in 7.4% of all children with pancreatitis and 19.2% of children with relapsing or chronic pancreatitis. Patients had early onset of recurrent episodic epigastric pain and vomiting, at a mean age of 6 years. Three patients had a positive family history of pancreatitis and one was proven by DNA analysis to have hereditary pancreatitis. Pancreatitis was documented by elevated amylase or lipase levels, and endoscopic retrograde cholangiopancreatography was the method of diagnosis of pancreas divisum in all patients. Eight patients had complete pancreas divisum and two had incomplete variants. Eight patients underwent surgery to improve ductal drainage. Seven underwent transduodenal sphincteroplasty of the accessory papilla, along with sphincteroplasty of the major papilla in two (plus septoplasty in one). Three patients underwent longitudinal pancreaticojejunostomy, as a primary procedure in one patient with midductal stenosis and in two because of recurring pancreatitis after sphincteroplasty. The surgical findings and histologic examination of five patients undergoing distal pancreatectomy revealed striking changes of advanced chronic pancreatitis. Patients responding to sphincteroplasty alone showed less severe histologic changes. Overall, three of seven patients had excellent results, three were improved, and one had continued disabling attacks of pancreatitis. The mean duration of follow-up was 7.3 years, and there were no deaths. No patients had endocrine or exocrine pancreatic insufficiency, and none required chronic analgesics. ConclusionsPancreas divisum is an important cause of recurrent pancreatitis in childhood and sho...

Longitudinal pancreaticojejunostomy and selective biliary diversion for chronic pancreatitis in children

“…Reported outcome of LPJ in children with chronic pancreatitis has been more successful in the literature [10,11]. The pain-free period has been longer with minimal morbidity and no mortality.…”

Tailored resective pancreatic surgery for pediatric patients with chronic pancreatitis

“…For example, patient 1 presented with an enlarged pancreatic head with inflammatory changes and calcifications as well as with a pseudocyst in the tail of the pancreas. At this stage of the disease, sphincteroplasty of the pancreatic orifices-a reasonable and less invasive therapeutic approach for some patients with mild CP-was not a passable therapeutic option [26]. The early results regarding endocrine and exocrine function are promising.…”

Operative Management of Chronic Pancreatitis in Children

“…Most cases of acute pancreatis in children (secondary to trauma, medication use, and biliary tract calculi) are short-lived and rarely progress to a chronic state. However, chronic pancreatitis in children can be as debilitating as it is in the adult 1 and can Chronic pancreatitis in children can be broadly categorized by the presence or absence of hereditary factors, 4 abnormalities in ductal anatomy, 5 and the presence of associated metabolic disorders, such as cystic fibrosis, hyperparathyroidism, hyperlipidemia, and malnutrition. 6 Regardless of the cause, chronic pancreatitis in children typically has an unrelenting progression that has been notoriously difficult to treat medically.…”

“…The various ductal abnormalities that have been reported as causes of chronic pancreatitis in children include traumatic stricture, 10 pancreas divisum, 5 congenital sphincter of Oddi abnormality, 11 choledochal cyst, 12 duodenal duplication, 11 and annular pancreas. Obviously, lesions that obstruct the pancreatic duct or ampulla of Vater can cause episodes of acute pancreatitis, but generally the lesions are found and repaired before a more chronic condition develops.…”

“…When pancreatitis occurs, it is believed to be due to stenosis of the dorsal pancreatic duct (Santorini duct) draining through the minor papilla. Endoscopic retrograde cholangiopancreatography with papilla sphincterotomy has been proposed as primary therapy, 5 although this procedure has not been universally successful. Our series includes 2 patients with this anatomic variant who failed to improve with ERCP sphincterotomy, but who eventually improved markedly with distal pancreatectomy and pancreaticojejunostomy.…”