What is the recommended treatment for a patient with pancreatic divisum, with or without recurrent pancreatitis?

Treatment of Pancreatic Divisum

For asymptomatic pancreatic divisum, no treatment is required; for symptomatic patients with recurrent acute pancreatitis and documented stenosis of the accessory papilla, surgical sphincteroplasty of the minor papilla is the preferred definitive treatment, with endoscopic therapy reserved for poor surgical candidates. 1, 2

Asymptomatic Pancreatic Divisum

• The vast majority of patients with pancreatic divisum (approximately 90-95%) remain asymptomatic throughout their lives and require no intervention. 1, 3
• Imaging follow-up is not routinely required unless clinical deterioration occurs. 4

Symptomatic Pancreatic Divisum with Recurrent Acute Pancreatitis

Initial Diagnostic Evaluation

• After unexplained recurrent acute pancreatitis, EUS is the preferred initial diagnostic test to confirm pancreatic divisum and evaluate for other etiologies. 1, 4
• MRI/MRCP serves as a reasonable complementary or alternative test when EUS expertise is unavailable, particularly for identifying anatomical variants like pancreatic divisum. 1
• Delay EUS evaluation for 2-6 weeks after resolution of acute pancreatitis, as persistent inflammatory changes may obscure subtle findings. 1

Treatment Decision Algorithm

The critical distinction is between patients presenting with discrete attacks of acute pancreatitis versus chronic pain:

• Patients with documented stenosis of the accessory papilla (≤0.75 mm) presenting with discrete episodes of acute pancreatitis achieve excellent outcomes (89% success rate) with surgical sphincteroplasty. 5
• Patients without stenosis or those presenting primarily with chronic pain have poor outcomes (14% success rate) with sphincteroplasty alone. 5
• A preoperative test for stenosis is essential to identify patients whose symptoms are genuinely caused by pancreatic divisum. 5

Surgical Management (Preferred Approach)

• Transduodenal sphincteroplasty of the accessory papilla is the preferred long-term treatment for patients with recurrent acute pancreatitis and stenotic accessory papilla. 2, 5
• Surgical sphincteroplasty provides 83.8% success in preventing recurrent acute pancreatitis in appropriately selected patients. 2
• Sphincteroplasty of the accessory papilla alone is sufficient; adding major papilla sphincteroplasty provides no additional benefit. 5
• Patients with discrete attacks of pancreatitis (rather than chronic pain) achieve better outcomes: 80% good results versus 50% in chronic pain patients. 5

Endoscopic Management (Alternative Approach)

The decision to pursue endoscopic therapy must be carefully weighed against significant risks and uncertain benefits:

• The role of ERCP for reducing pancreatitis frequency in pancreatic divisum is controversial and should only be considered after comprehensive discussion of uncertain benefits and potentially severe adverse events. 1
• Post-ERCP pancreatitis occurs in 10-15% of cases, and post-papillotomy stenosis develops in up to 19% of patients, potentially causing more frequent pancreatitis than the original presentation. 1
• Endoscopic intervention may be reasonable for suboptimal surgical candidates or those preferring less invasive approaches, assuming clear informed consent that best practice primarily favors surgery. 1
• Endoscopists performing minor papilla interventions require specific training and experience in these technically demanding procedures. 4

Important caveat: Only one small randomized trial (19 patients) exists, showing minor papilla stenting reduced future pancreatitis episodes (10% vs 67%), but stenting alone is not representative of current practice and carries disadvantages including frequent exchanges, migration, and ductal injury. 1

• Surgical sphincteroplasty demonstrates superior long-term results compared to endoscopic sphincterotomy regarding relief of pain, restenosis rates, and procedure-specific complications. 2
• Prolonged stenting of the accessory duct cannot be recommended as definitive therapy. 2

Patients with Radiologic Evidence of Ductal Obstruction

• Patients with overt radiologic findings of ductal outflow obstruction (dilated dorsal duct) may be more likely to benefit from intervention, though high-quality evidence is lacking. 1

Progression to Chronic Pancreatitis

If chronic pancreatitis develops (documented by pancreatography and biopsy showing irreversible fibrosis):

• Sphincteroplasty alone becomes ineffective once chronic pancreatitis is established. 5
• Surgical options include pancreaticojejunostomy for ductal dilation, distal pancreatectomy, or in severe cases, total pancreatectomy. 5
• Approximately 35% of patients with recurrent acute pancreatitis will progress to chronic pancreatitis. 1

Common Pitfalls to Avoid

• Do not perform endoscopic or surgical intervention for pancreatic divisum in patients with pain alone without documented recurrent pancreatitis. 1
• Do not proceed with intervention in patients without documented stenosis of the accessory papilla, as outcomes are poor (14% success). 5
• Avoid endoscopic therapy as first-line treatment when surgical expertise is available, given superior long-term outcomes with surgery. 2
• Do not assume all patients with pancreatic divisum and pancreatitis will benefit from intervention—the natural history in untreated patients can be benign. 6