What is the management approach for pancreatic divisum?

Management of Pancreatic Divisum

Pancreatic divisum requires an individualized treatment approach based on symptoms, with endoscopic therapy for symptomatic patients with recurrent acute pancreatitis and surgical intervention reserved for those who fail endoscopic management. 1

Understanding Pancreatic Divisum

• Pancreatic divisum is the most common congenital pancreatic anomaly, occurring in approximately 6-10% of individuals, resulting from failure of fusion between dorsal and ventral pancreatic ductal systems during embryogenesis 1
• The majority of patients with pancreatic divisum remain asymptomatic, but a subset may develop impaired drainage of pancreatic secretions through the dorsal-dominant system, potentially resulting in increased intraductal pressures and recurrent acute pancreatitis (RAP) 1
• Diagnosis is typically made using magnetic resonance imaging (MRI) with cholangiopancreatography (MRCP), which is particularly helpful in identifying pancreatic ductal etiologies including anatomical variants such as pancreas divisum 1

Diagnostic Approach

• Endoscopic ultrasound (EUS) is the preferred initial modality for evaluation of unexplained acute and recurrent pancreatitis, with MRI/MRCP as a complementary or alternative test 1
• Secretin-enhanced MRCP can improve diagnostic yield compared to standard MRI/MRCP for detecting pancreas divisum, though its clinical utility may be limited by availability and variability in acquisition and interpretation 1
• In patients with recurrent acute pancreatitis of unclear etiology, evaluation for pancreas divisum should be included in the diagnostic workup 1

Management of Asymptomatic Pancreas Divisum

• No intervention is required for asymptomatic patients with incidentally discovered pancreas divisum 1, 2
• Regular surveillance is not necessary for asymptomatic pancreas divisum 2

Management of Symptomatic Pancreas Divisum

Endoscopic Management

• Endoscopic therapy aims to relieve outflow obstruction by enlarging the minor papilla through sphincterotomy, balloon dilation, stent placement, or a combination of these approaches 1
• The decision to proceed with endoscopic therapy should be carefully considered, as there is a 10-15% risk of post-ERCP pancreatitis 1
• The only randomized trial evaluating minor papilla therapy showed that minor papilla stenting was associated with a significant decrease in future episodes of acute pancreatitis compared to controls (10% vs 67%) 1
• Stent placement alone is not recommended as a definitive therapy as it is unlikely to produce durable reshaping of the dorsal drainage system and has disadvantages including need for frequent exchanges, stent migration/occlusion, and potential stent-related ductal injury 1

Surgical Management

• Surgical intervention should be considered when endoscopic management fails to provide symptom relief 3, 4
• Surgical options should be tailored to the specific pancreatic pathology:
  • For patients with a soft pancreas without fibrotic changes, reinsertion of the papilla should be considered as the first surgical intervention 3
  • For patients with fibrotic alterations of the pancreas, duodenum-preserving pancreatic head resection (DPPHR) is recommended 3, 5
  • In cases with suspected malignancy or inflammatory mass in the head of pancreas, pancreaticoduodenectomy may be necessary 6
• Surgical treatment has shown significant reduction in pain in properly selected patients with symptomatic pancreas divisum 3, 5

Special Considerations

• For patients with pancreatic duct ectasia due to chronic pancreatitis associated with pancreas divisum, longitudinal pancreaticojejunostomy may be appropriate 6
• In cases complicated by pseudocysts, external drainage followed by internal drainage using Roux-en-Y fistulojejunostomy has been reported as effective 7
• The American Gastroenterological Association suggests that surgical intervention provides better long-term outcomes for pain relief and quality of life compared to endoscopic therapy in patients with painful obstructive chronic pancreatitis 6

Limitations and Future Directions

• High-quality studies supporting endoscopic therapy in patients with pancreas divisum and recurrent acute pancreatitis are lacking 1
• An ongoing international, multicenter, randomized sham-controlled trial evaluating minor papilla sphincterotomy in patients with pancreas divisum and recurrent acute pancreatitis is currently underway and should provide more clarity 1
• Further research is needed to better define the association between pancreas divisum and pancreatic disease and to establish optimal management strategies 2