Management of Pancreatic Divisum
Endoscopic intervention through minor papilla endotherapy is the recommended first-line treatment for patients with pancreatic divisum who have recurrent acute pancreatitis, particularly those with objective signs of outflow obstruction such as a dilated dorsal pancreatic duct or santorinicele. 1
Diagnosis and Evaluation
Initial Diagnostic Approach
- Endoscopic ultrasound (EUS) is the preferred diagnostic test for evaluating pancreatic divisum after an unrevealing initial evaluation 1
- MRI with contrast and MRCP (magnetic resonance cholangiopancreatography) is a reasonable complementary or alternative test based on local expertise and availability 1
- Secretin-enhanced MRCP can improve diagnostic yield for detecting pancreatic divisum, though availability may be limited 1
When to Suspect Pancreatic Divisum
- Recurrent episodes of acute pancreatitis without other identifiable causes
- Chronic pancreatitis symptoms
- Persistent upper abdominal pain
- Evidence of dorsal pancreatic duct dilation on imaging
Diagnostic Features to Look For
- Failure of fusion of dorsal and ventral pancreatic ductal systems during embryogenesis
- Dominant pancreatic drainage through the minor papilla
- Dilated dorsal pancreatic duct
- Presence of santorinicele (cystic dilation of the distal dorsal duct)
Management Algorithm
1. Asymptomatic Pancreatic Divisum
- No intervention required (occurs in approximately 6-10% of individuals) 1
- Observation only
2. Symptomatic Pancreatic Divisum with Recurrent Acute Pancreatitis
First-Line Treatment:
- Endoscopic therapy via ERCP with minor papilla intervention 1
- Minor papilla sphincterotomy
- Balloon dilation
- Stent placement (temporary)
- Or combination of these approaches
When Endoscopic Therapy Fails:
- Surgical intervention based on pancreatic morphology 2:
- For soft pancreas: Reinsertion of the papilla (SP)
- For inflammatory altered pancreas: Duodenum-preserving pancreatic head resection (DPPHR)
- For severe cases: Pylorus-preserving Whipple procedure
3. Pancreatic Divisum with Chronic Pancreatitis
- Initial endoscopic therapy (40-60% response rate) 3
- Surgical options if endoscopic approach fails:
- Duodenum-preserving pancreatic head resection
- Puestow's operation (lateral pancreaticojejunostomy)
- Distal pancreatectomy for isolated distal disease
4. Pancreatic Divisum with Chronic Pain Only
- Limited response to endoscopic therapy (20-40%) 3
- Consider multidisciplinary pain management approach
- Surgical intervention only after failed conservative management
Important Clinical Considerations
Efficacy of Interventions
- Endoscopic minor papilla therapy reduces episodes of acute pancreatitis in 75-90% of patients with recurrent acute pancreatitis 3
- Surgical approaches achieve significant pain reduction in properly selected patients 2
- The only randomized trial (though small, n=19) showed minor papilla stenting significantly decreased future episodes of acute pancreatitis compared to controls (10% vs 67%) 1
Potential Complications
- Post-ERCP pancreatitis (10-15% risk) 1
- Stent-related complications with prolonged stent therapy:
- Need for frequent exchanges
- Stent migration/occlusion
- Potential stent-related ductal injury 1
Cautions
- ERCP should always be performed under antibiotic cover 1
- There is no role for ERCP to treat pain alone in patients with pancreas divisum 1
- Endoscopic therapy should be carefully considered in the context of potential adverse events 1
- Stent placement alone is not recommended as a definitive treatment as it's unlikely to produce durable reshaping of the dorsal drainage system 1
Special Considerations
- Patients with ventral duct disease and pancreaticolithiasis may require specific management approaches 4
- In patients with biliary sphincter abnormalities, dual sphincteroplasty may be considered 5
- An ongoing international, multicenter, randomized sham-controlled trial evaluating minor papilla sphincterotomy in patients with pancreatic divisum and recurrent acute pancreatitis should provide more definitive evidence in the future 1