From the Guidelines
For symptomatic patients with pancreas divisum, particularly those with recurrent acute pancreatitis and objective signs of outflow obstruction, minor papilla endotherapy via endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy is the recommended first-line intervention. This approach aims to improve drainage from the dorsal pancreatic duct, thereby reducing the frequency of pancreatitis episodes 1. The decision to proceed with ERCP should be carefully considered, taking into account the potential risks, including a 10%–15% risk of post-ERCP pancreatitis and the consequences of post-papillotomy stenosis, which occurs in up to 1 of 5 patients (19%) 1.
Key Considerations
- Most patients with pancreas divisum are asymptomatic and do not require treatment.
- Symptomatic patients, especially those with recurrent acute pancreatitis, may benefit from endoscopic or surgical interventions.
- ERCP with minor papilla sphincterotomy is considered for patients with objective signs of outflow obstruction, such as a dilated dorsal pancreatic duct and/or santorinicele 1.
- There is no role for ERCP in treating abdominal pain alone in patients with pancreas divisum 1.
Management Options
- Endoscopic interventions: ERCP with minor papilla sphincterotomy, potentially combined with stent placement to maintain ductal patency.
- Surgical options: Considered if endoscopic approaches fail, including surgical sphincteroplasty or, in severe cases, partial pancreatectomy.
- Medical management: Focuses on symptom control with pancreatic enzyme supplements, pain management, and lifestyle modifications, including alcohol avoidance and a low-fat diet.
The rationale behind these interventions is to alleviate ductal hypertension caused by inadequate drainage through the minor papilla, which is believed to trigger pancreatitis in susceptible individuals 1. Treatment decisions should be individualized based on symptom severity, anatomical considerations, and the patient's overall health status.
From the Research
Management Options for Pancreas Divisum
The management of pancreas divisum involves various endoscopic procedures to alleviate symptoms and prevent complications. Some of the management options include:
- Endoscopic pancreatic sphincterotomy or temporary stenting, or both, which appear to be beneficial in idiopathic recurrent pancreatitis 2
- Short-term stent placement in the dorsal duct, with or without papillotomy of the minor papilla, which is a promising approach in patients with symptomatic pancreas divisum, particularly if it is associated with acute recurrent pancreatitis 2
- Minor papilla sphincterotomy, which is feasible and may be effective in some patients with pancreas divisum, but carries a significant complication rate 3
- Endoscopic stenting and sphincterotomy of the minor papilla, which can improve symptom scores in patients with pancreatitis and chronic pain due to pancreas divisum 3
- Endoscopic ultrasonography-guided technique, which extends the options for obtaining access to fluid collections in difficult locations and may further increase the safety of the procedure 2
Endoscopic Retrograde Cholangiopancreatography (ERCP)
ERCP is a diagnostic and therapeutic procedure that can be used to manage pancreas divisum. The procedure involves:
- Placement of a stent into the dorsal pancreatic duct, which can help to reduce the risk of pancreatitis and improve symptoms 4
- Sphincterotomy of the minor papilla, which can help to improve drainage of the pancreatic duct and reduce symptoms 5, 4
- Cannulation and sphincterotomy of the minor papilla using an ultrasound-assisted Rendez-Vous technique, which can be used in patients with anatomical variants such as ansa pancreatica 6
Complications and Outcomes
The management of pancreas divisum can be associated with complications, including:
- Pancreatitis, which can occur after sphincterotomy or stent placement 3, 5
- Pain, which can occur after sphincterotomy or stent placement 3, 5
- Stent migration or fracture, which can occur after stent placement 3
- Restenosis, which can occur after sphincterotomy 5 Despite these complications, the management of pancreas divisum can be effective in improving symptoms and reducing the risk of pancreatitis. Studies have shown that endoscopic procedures can improve symptom scores and reduce the frequency of pancreatitis episodes 3, 5, 4