Management of Pancreatic Divisum
For symptomatic pancreatic divisum causing recurrent acute pancreatitis, endoscopic minor papilla sphincterotomy with or without stent placement is the first-line intervention, reducing future pancreatitis episodes from 67% to 10% in controlled trials, while surgical duodenum-preserving pancreatic head resection should be reserved for patients who fail endoscopic therapy or develop chronic pancreatitis with ductal changes. 1
Initial Diagnostic Workup
Endoscopic ultrasound (EUS) is the preferred initial diagnostic modality for evaluating unexplained recurrent acute pancreatitis, with MRI/MRCP serving as a complementary test particularly helpful for identifying pancreatic ductal anatomical variants like pancreas divisum 1, 2
Secretin-enhanced MRCP improves diagnostic yield over standard MRI/MRCP for detecting pancreas divisum, though availability and interpretation variability may limit its clinical utility 1
Pancreatic divisum occurs in 6-10% of the general population, but only approximately 5% of those with the anatomical variant develop symptomatic disease requiring intervention 1, 3
Endoscopic Management Strategy
When to Pursue Endoscopic Therapy
Endoscopic intervention should be considered for patients with recurrent acute pancreatitis attributed to pancreas divisum, particularly when stenosis of the minor papilla is suspected 1
The primary goal is relieving outflow obstruction by enlarging the minor papilla through sphincterotomy, balloon dilation, stent placement, or combination approaches 1
Evidence for Endoscopic Efficacy
The only randomized controlled trial demonstrated that minor papilla stenting significantly decreased future acute pancreatitis episodes (10% vs 67% in controls), providing the strongest evidence for endoscopic intervention 1
Long-term observational data shows that both dorsal duct stent insertion and minor papilla sphincterotomy significantly reduce recurrent acute pancreatitis rates, though relief of chronic pain is less predictable 4
In one series of 24 patients followed for a median of 39 months, endoscopic management reduced acute pancreatitis recurrence from all patients to only 2 patients (p<0.01) 4
Patients with documented stenosis at the accessory papilla (≤0.75mm) have significantly better outcomes with sphincterotomy compared to those without stenosis 5
Important Caveats About Endoscopic Therapy
There is a 10-15% risk of post-ERCP pancreatitis that must be weighed against potential benefits 1
Stent placement alone is not recommended as definitive therapy because it rarely produces durable reshaping of the dorsal drainage system and carries disadvantages including need for frequent exchanges, stent migration/occlusion, and potential stent-related ductal injury 1
Complications occur in approximately 38% of patients, mainly acute pancreatitis or stenosis of the minor papilla, though most are managed conservatively 4
Patients presenting with discrete attacks of acute pancreatitis fare significantly better (p<0.05) than those presenting with chronic pain 5
Surgical Management
Indications for Surgery
Surgical intervention should be pursued after endoscopic therapy failure or when chronic pancreatitis with irreversible fibrosis has developed 1, 3, 5
Surgery is indicated when there is progression from recurrent acute pancreatitis to established chronic pancreatitis with ductal changes, as endoscopic sphincterotomy becomes ineffective once chronic inflammation is established 5
For patients with pancreatic duct ectasia due to chronic pancreatitis associated with pancreas divisum, longitudinal pancreaticojejunostomy may be appropriate 1
Surgical Options and Outcomes
Duodenum-preserving pancreatic head resection (DPPHR) is the preferred surgical approach for symptomatic pancreas divisum with chronic pancreatitis, as it addresses the underlying duct anomalies and pathomorphological changes in the pancreatic head 6
In a series of 36 patients treated with DPPHR, 50% became completely pain-free and 31% had significant pain reduction (median pain score decreased from 8 to 2, p<0.001) with median follow-up of 39 months 6
DPPHR preserved endocrine function in the majority of patients and represents an alternative to other resective or drainage procedures after interventional treatment failure 6
In cases with suspected malignancy or inflammatory mass in the pancreatic head, pancreaticoduodenectomy may be necessary 1
Once chronic pancreatitis is established, ductal drainage procedures or resection (distal pancreatectomy, total pancreatectomy) become necessary as sphincterotomy alone is ineffective 5
Treatment Algorithm Based on Clinical Presentation
For Recurrent Acute Pancreatitis Without Chronic Changes
- Confirm diagnosis with EUS or MRI/MRCP 1, 2
- Proceed with minor papilla sphincterotomy ± short-term stenting (avoid long-term stenting as definitive therapy) 1
- Monitor for recurrence over 24+ months 4
- If endoscopic therapy fails, consider surgical DPPHR 6
For Chronic Pancreatitis With Established Fibrosis
- Bypass endoscopic therapy and proceed directly to surgical evaluation 5
- DPPHR is the preferred approach for ductal anomalies with head-predominant disease 6
- Longitudinal pancreaticojejunostomy for dilated duct disease 1
- Resection procedures (distal or total pancreatectomy) for refractory cases 5
Key Pitfalls to Avoid
Do not use long-term pancreatic stenting as definitive therapy - it requires frequent exchanges and can cause ductal injury without providing durable benefit 1
Do not perform endoscopic therapy in patients who have already progressed to chronic pancreatitis with fibrosis - these patients require surgical intervention 5
Do not assume all patients with pancreas divisum and pancreatitis will benefit from intervention - only those with documented stenosis or clear recurrent acute pancreatitis pattern are likely to respond 5
Recognize that high-quality evidence supporting endoscopic therapy remains limited, with an ongoing international multicenter randomized sham-controlled trial currently underway to provide more definitive guidance 1