What are the indications for pancreatic stenting in patients with pancreatic divisum?

Indications for Pancreatic Stenting in Pancreatic Divisum

Pancreatic stenting in pancreatic divisum is indicated specifically for patients with recurrent acute pancreatitis (at least 2 documented episodes) who have radiologic evidence of dorsal duct outflow obstruction, such as dilated dorsal pancreatic duct or santorinicele. 1, 2

Key Patient Selection Criteria

The following patients should be considered for stenting:

• Patients with documented recurrent acute pancreatitis (≥2 episodes) and confirmed pancreatic divisum on imaging 2, 3
• Radiologic evidence of outflow obstruction (dilated dorsal duct and/or santorinicele) 1, 2
• All other causes of pancreatitis have been excluded 3
• Imaging performed 2-6 weeks after acute episode resolution to avoid inflammatory changes 2

Important caveat: The vast majority (90-94%) of patients with pancreatic divisum remain asymptomatic throughout their lives and require no intervention. 2

Who Should NOT Receive Stenting

Stenting is contraindicated or inappropriate in:

• Asymptomatic patients with incidentally discovered pancreatic divisum 2
• Patients with chronic pain alone without documented episodes of acute pancreatitis 2
• Patients without objective radiologic signs of dorsal duct obstruction (poor response rates) 2

Stenting Technique and Duration

Contemporary approach prioritizes minor papilla sphincterotomy over stenting alone:

• Minor papilla sphincterotomy is the preferred definitive treatment 1, 2
• Stent placement alone is NOT recommended as definitive therapy because it fails to produce durable reshaping of the dorsal drainage system 1, 2
• When stents are used, they should be temporary (typically 5-7 Fr stents placed for 2-3 month intervals) 4
• Stenting alone requires frequent exchanges and carries risks of migration, occlusion, and ductal injury 1, 2

Evidence Supporting Stenting

The only randomized controlled trial demonstrated significant benefit: patients with pancreatic divisum and recurrent acute pancreatitis who received minor papilla stenting had substantially fewer future pancreatitis episodes (10% vs 67% in controls). 1, 3 However, this evidence is limited to a single small trial, and an ongoing international multicenter randomized sham-controlled trial should provide more definitive guidance. 1, 2

Risk-Benefit Considerations

Procedural risks include:

• Post-ERCP pancreatitis risk: 10-15% 1, 2
• Post-papillotomy stenosis: up to 19% 2
• Stent migration (both proximal and distal) 5
• Dorsal duct changes of unknown clinical significance 4

Special Clinical Scenarios

For chronic pancreatitis with pancreatic divisum:

• Surgical intervention (longitudinal pancreaticojejunostomy) provides better long-term outcomes for pain relief and quality of life compared to endoscopic therapy 1, 6
• Endoscopic stenting may provide temporary benefit in chronic pancreatitis patients, with approximately one-third remaining symptom-free after a single stenting episode 7
• Intensive pancreatic endotherapy with repeated stenting sessions (mean 2.6 sessions) achieved 95.7% success in patients with chronic pancreatitis and pancreatic divisum 8

For pancreatic duct ectasia due to chronic pancreatitis:

• Longitudinal pancreaticojejunostomy is the appropriate surgical management 1, 6
• Pancreaticoduodenectomy reserved for suspected malignancy or inflammatory mass in pancreatic head 1, 6