Treatment of pancreas divisum
- Evan Fogel, MD
Evan Fogel, MD
- Professor of Clinical Medicine
- Indiana University Hospital
- Stuart Sherman, MD
Stuart Sherman, MD
- Professor of Medicine and Radiology
- Indiana University School of Medicine
Pancreas divisum is the most common congenital pancreatic anomaly, occurring in approximately 7 percent of subjects in autopsy series [1,2]. It is usually diagnosed during endoscopic retrograde cholangiopancreatography (ERCP), although magnetic resonance cholangiopancreatography (MRCP), especially with secretin stimulation, can detect more than 90 percent of such patients [3,4]. More than 95 percent of patients with pancreatic divisum are asymptomatic and it remains controversial whether the symptoms that occur in the remaining patients are etiologically related to pancreas divisum. (See "Anatomy and clinical significance of pancreas divisum".)
We believe that there is a group of patients with pancreas divisum who are subject to recurrent bouts of pancreatitis. Why such patients are at increased risk for recurrent pancreatitis is not well understood. In some, the minor papilla orifice may be so small that excessively high intrapancreatic dorsal ductal pressure occurs during active secretion, which may result in inadequate drainage, ductal distension, pain, and, in some cases, pancreatitis . It is possible that pancreas divisum can lead to chronic pancreatitis or "pancreatic" pain. Genetic studies have also suggested that as many as 10 to 20 percent of patients with pancreas divisum who have pancreatitis carry at least one allele of the cystic fibrosis gene product, suggesting a multifactorial origin of pancreatitis in such patients .
This topic review will discuss the two major therapeutic issues in symptomatic patients with pancreas divisum: the detection of pathologic minor papilla narrowing and the techniques and results of surgical and endoscopic approaches to correct the minor papilla narrowing. The anatomy and controversies surrounding the clinical significance of pancreas divisum are discussed separately. (See "Anatomy and clinical significance of pancreas divisum".)
DETECTION OF PATHOLOGIC MINOR PAPILLA NARROWING
The important diagnostic issue in a patient with pancreas divisum and pancreatic symptoms is whether there is remediable papillary narrowing. A number of methods have been used in an attempt to identify patients with pathologic papillary narrowing. These tests attempt to demonstrate dorsal duct dilation, papillary narrowing, increased papillary or ductal pressure, or the selective occurrence of pancreatitis in the dorsal as opposed to the ventral portion of the pancreas (table 1). The sensitivity and specificity of these tests are largely undefined and correlation with a response to therapy has not been clearly shown in most studies.
Computerized tomography scan — A standard computed tomography (CT) scan of the pancreas may identify dilation of the dorsal duct and/or changes of chronic pancreatitis that are confined to the dorsal area of the pancreas. More commonly, the CT scan just shows nonspecific prominence of the pancreatic head and is not of diagnostic value . Visualization of a fat plane between the dorsal and ventral portions can suggest pancreas divisum but does not generally separate symptomatic from coincidental states .
- Smanio T. Proposed nomenclature and classification of the human pancreatic ducts and duodenal papillae. Study based on 200 post mortems. Int Surg 1969; 52:125.
- Stimec B, Bulajić M, Korneti V, et al. Ductal morphometry of ventral pancreas in pancreas divisum. Comparison between clinical and anatomical results. Ital J Gastroenterol 1996; 28:76.
- Matos C, Metens T, Devière J, et al. Pancreas divisum: evaluation with secretin-enhanced magnetic resonance cholangiopancreatography. Gastrointest Endosc 2001; 53:728.
- Manfredi R, Costamagna G, Brizi MG, et al. Pancreas divisum and "santorinicele": diagnosis with dynamic MR cholangiopancreatography with secretin stimulation. Radiology 2000; 217:403.
- Lehman GA, Sherman S. Pancreas divisum. Diagnosis, clinical significance, and management alternatives. Gastrointest Endosc Clin N Am 1995; 5:145.
- Gelrud A, Sheth S, Banerjee S, et al. Analysis of cystic fibrosis gener product (CFTR) function in patients with pancreas divisum and recurrent acute pancreatitis. Am J Gastroenterol 2004; 99:1557.
- Lindström E, Ihse I. Computed tomography findings in pancreas divisum. Acta Radiol 1989; 30:609.
- Zeman RK, McVay LV, Silverman PM, et al. Pancreas divisum: thin-section CT. Radiology 1988; 169:395.
- Tulassay Z, Jakab Z, Vadàsz A, et al. Secretin provocation ultrasonography in the diagnosis of papillary obstruction in pancreas divisum. Gastroenterol J 1991; 51:47.
- Warshaw AL, Simeone JF, Schapiro RH, Flavin-Warshaw B. Evaluation and treatment of the dominant dorsal duct syndrome (pancreas divisum redefined). Am J Surg 1990; 159:59.
- Lindström E, Ihse I. Dynamic CT scanning of pancreatic duct after secretin provocation in pancreas divisum. Dig Dis Sci 1990; 35:1371.
- Lowes JR, Lees WR, Cotton PB. Pancreatic duct dilatation after secretin stimulation in patients with pancreas divisum. Pancreas 1989; 4:371.
- Eisen G, Schutz S, Metzler D, et al. Santorinicele: new evidence for obstruction in pancreas divisum. Gastrointest Endosc 1994; 40:73.
- Staritz M, Meyer zum Büschenfelde KH. Elevated pressure in the dorsal part of pancreas divisum: the cause of chronic pancreatitis? Pancreas 1988; 3:108.
- Madura JA. Pancreas divisum: stenosis of the dorsally dominant pancreatic duct. A surgically correctable lesion. Am J Surg 1986; 151:742.
- Bradley EL 3rd, Stephan RN. Accessory duct sphincteroplasty is preferred for long-term prevention of recurrent acute pancreatitis in patients with pancreas divisum. J Am Coll Surg 1996; 183:65.
- Guelrud M, Mendoza S, Viera L, Gelrud D. Somatostatin prevents acute pancreatitis after pancreatic duct sphincter hydrostatic balloon dilation in patients with idiopathic recurrent pancreatitis. Gastrointest Endosc 1991; 37:44.
- Lans JI, Geenen JE, Johanson JF, Hogan WJ. Endoscopic therapy in patients with pancreas divisum and acute pancreatitis: a prospective, randomized, controlled clinical trial. Gastrointest Endosc 1992; 38:430.
- Ertan A. Long-term results after endoscopic pancreatic stent placement without pancreatic papillotomy in acute recurrent pancreatitis due to pancreas divisum. Gastrointest Endosc 2000; 52:9.
- Heyries L, Barthet M, Delvasto C, et al. Long-term results of endoscopic management of pancreas divisum with recurrent acute pancreatitis. Gastrointest Endosc 2002; 55:376.
- Ikenberry SO, Sherman S, Hawes RH, et al. The occlusion rate of pancreatic stents. Gastrointest Endosc 1994; 40:611.
- Johanson JF, Schmalz MJ, Geenen JE. Incidence and risk factors for biliary and pancreatic stent migration. Gastrointest Endosc 1992; 38:341.
- Johanson JF, Schmalz MJ, Geenen JE. Simple modification of a pancreatic duct stent to prevent proximal migration. Gastrointest Endosc 1993; 39:62.
- Kozarek RA. Pancreatic stents can induce ductal changes consistent with chronic pancreatitis. Gastrointest Endosc 1990; 36:93.
- Smith MT, Sherman S, Ikenberry SO, et al. Alterations in pancreatic ductal morphology following polyethylene pancreatic stent therapy. Gastrointest Endosc 1996; 44:268.
- Sherman S, Alvarez C, Robert M, et al. Polyethylene pancreatic duct stent-induced changes in the normal dog pancreas. Gastrointest Endosc 1993; 39:658.
- Sherman S, Hawes RH, Savides TJ, et al. Stent-induced pancreatic ductal and parenchymal changes: correlation of endoscopic ultrasound with ERCP. Gastrointest Endosc 1996; 44:276.
- Siegel JH, Cohen SA, Kasmin FE, Veerappan A. Stent-guided sphincterotomy. Gastrointest Endosc 1994; 40:567.
- Lehman GA, Sherman S, Nisi R, Hawes RH. Pancreas divisum: results of minor papilla sphincterotomy. Gastrointest Endosc 1993; 39:1.
- Attwell A, Borak G, Hawes R, et al. Endoscopic pancreatic sphincterotomy for pancreas divisum by using a needle-knife or standard pull-type technique: safety and reintervention rates. Gastrointest Endosc 2006; 64:705.
- Rashdan A, Fogel EL, McHenry L Jr, et al. Improved stent characteristics for prophylaxis of post-ERCP pancreatitis. Clin Gastroenterol Hepatol 2004; 2:322.
- Coleman SD, Eisen GM, Troughton AB, Cotton PB. Endoscopic treatment in pancreas divisum. Am J Gastroenterol 1994; 89:1152.
- Liguory C, Lefebvre JF, Canard JM, et al. [Pancreas divisum: clinical and therapeutic study in man. Apropos of 87 cases]. Gastroenterol Clin Biol 1986; 10:820.
- Chacko LN, Chen YK, Shah RJ. Clinical outcomes and nonendoscopic interventions after minor papilla endotherapy in patients with symptomatic pancreas divisum. Gastrointest Endosc 2008; 68:667.
- Sherman S, Hawes R, Nisi R, et al. Randomized controlled trial of minor papilla sphincterotomy (MiES) in pancreas divisum (Pdiv) patients with pain only. Gastrointest Endosc 1994; 40:125P.
- Sherman S, Lehman GA. Endoscopic pancreatic sphincterotomy: techniques and complications. Gastrointest Endosc Clin N Am 1998; 8:115.
- Moffatt DC, Coté GA, Avula H, et al. Risk factors for ERCP-related complications in patients with pancreas divisum: a retrospective study. Gastrointest Endosc 2011; 73:963.
- Kozarek RA, Ball TJ, Patterson DJ, et al. Endoscopic approach to pancreas divisum. Dig Dis Sci 1995; 40:1974.
- Wagner CW, Golladay ES. Pancreas divisum and pancreatitis in children. Am Surg 1988; 54:22.
- DETECTION OF PATHOLOGIC MINOR PAPILLA NARROWING
- Computerized tomography scan
- Secretin ultrasound
- Diagnostic endoscopic retrograde cholangiopancreatography (ERCP)
- Special ERCP techniques
- - Pancreatic juice collection
- - Papillary manometry
- - Therapeutic trial
- Intraoperative patency determination
- SURGICAL AND ENDOSCOPIC MANAGEMENT
- Surgical minor papilla sphincterotomy and sphincteroplasty
- Endoscopic minor papilla dilation and stenting
- Endoscopic minor papilla sphincterotomy
- SUMMARY AND RECOMMENDATIONS