Digestive Diseases and Sciences

, Volume 40, Issue 9, pp 1974–1981 | Cite as

Endoscopic approach to pancreas divisum

  • R. A. Kozarek
  • T. J. Ball
  • D. J. Patterson
  • J. J. Brandabur
  • S. L. Raltz
Pancreatic and Biliary Disorders


Pancreas divisum has been claimed to be a harmless congenital variant or to occasionally cause acute relapsing pancreatitis (ARP), chronic pancreatitis (CP), or a chronic abdominal pain (CAP) syndrome. Both surgical and endoscopic approaches to accessory papilla decompression have been promulgated and widely disparate results reported in the literature. We retrospectively reviewed a five-year experience with dorsal pancreatic duct decompression at our institution utilizing a variety of endotherapeutic techniques. Data collected included procedural complications; patient interpretation of pre- and posttherapy pain, frequency, and intensity graded on an analog pain scale; frequency of hospitalization; and patient perception of “global” improvement to endotherapy. At a mean follow-up of 20 months, there was a statistically significant decrease in pancreatitis incidence in 15 patients with ARP (P=0.016) and 19 patients with CP (P=0.025). The frequency and intensity of chronic pain was also significantly improved (P<0.001) in the latter group. In contrast, only one of five patients with CAP and normal dorsal pancreatography and secretin tests experienced global improvement, and there was no improvement utilizing an analog pain scale (P=0.262) in the group as a whole. There was a 20% incidence of mild procedure or subsequent stent-related pancreatitis and an 11.5% accessory papilla restenosis rate. It is concluded that a subset of carefully selected patients with pancreas divisum may respond to endotherapy but that long-term follow-up will be required to define its ultimate place in the management of symptomatic patients with this anomaly.

Key Words

acute/chronic pancreatitis ERCP endoscopy sphincterotomy stent endoprosthesis pancreas divisum minor papilla 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Delhaye M, Engelholm L, Cremer M: Pancreas divisum: Congenital anatomic variant or anomaly? Gastroenterology 89:951–958, 1985PubMedGoogle Scholar
  2. 2.
    Sugawa C, Walt AJ, Nunez DC, Masuyama H: Pancreas divisum: Is it a normal anatomic variant? Am J Surg 153:62–67, 1987PubMedGoogle Scholar
  3. 3.
    Burton P, Person B, Charneau J, Boyer J: Pancreas divisum and pancreatitis: A coincidental association? Endoscopy 23:55–58, 1991PubMedGoogle Scholar
  4. 4.
    Cotton PB: Pancreas divisum: Curiosity or culprit? Gastroenterology 89:1431–1435, 1985PubMedGoogle Scholar
  5. 5.
    Marshall JB, Eckhauser ML: Pancreas divisum: A cause of chronic relapsing pancreatitis. Dig Dis Sci 30:582–587, 1985PubMedGoogle Scholar
  6. 6.
    Benage D, McHenry R, Hawes RH, et al: Minor papilla cannulation and dorsal ductography in pancreas divisum. Gastrointest Endosc 36:553–557, 1990PubMedGoogle Scholar
  7. 7.
    Bernard JP, Sahel J, Giovanni M, Sarles H: Pancreas divisum is a probable cause of acute pancreatitis: A report of 137 cases. Pancreas 5:248–254, 1990PubMedGoogle Scholar
  8. 8.
    Staritz M, Meyer zum Büschenfelde KH: Elevated pressure in the dorsal part of pancreas divisum: The cause of chronic pancreatitis? Pancreas 3:108–110, 1988PubMedGoogle Scholar
  9. 9.
    Keith RG, Shapiro TF, Saibil FG, Moore TL: Dorsal duct sphincterotomy is effective long-term treatment of acute pancreatitis associated with pancreas divisum. Surgery 106:660–667, 1989PubMedGoogle Scholar
  10. 10.
    Warshaw AL, Simeone JF, Shapiro RH, Flavin-Warshaw B: Evolution and treatment of the dominant dorsal duct syndrome (pancreas divisum redefined). Am J Surg 159:59–66, 1990PubMedGoogle Scholar
  11. 11.
    Rusnak CH, Hosie RT, Kuechler PM, et al: Pancreatitis associated with pancreas divisum: Results of surgical intervention. Am J Surg 155:641–643, 1988PubMedGoogle Scholar
  12. 12.
    Satterfield ST, McCarthy JH, Geenen JE, et al: Clinical experience in 82 patients with pancreas divisum—preliminary results of manometry and endoscopic therapy. Pancreas 3:248–253, 1988PubMedGoogle Scholar
  13. 13.
    Siegel JH, Ben-Zvi JS, Pullano W, Cooperman A: Effectiveness of endoscopic drainage for pancreas divisum: Endoscopic and surgical results in 31 patients. Endoscopy 22:129–133, 1990PubMedGoogle Scholar
  14. 14.
    Soehendra N, Kempeneers I, Nam VC, Grimm H: Endoscopic dilation and papillotomy of the accessory papilla and internal drainage in pancreas divisum. Endoscopy 18:129–132, 1986PubMedGoogle Scholar
  15. 15.
    Lehman GA, Sherman S, Nisi R, Hawes RH: Pancreas divisum: Results of minor papilla sphincterotomy. Gastrointest Endosc, 39:1–8, 1993PubMedGoogle Scholar
  16. 16.
    Coleman SD, Eisen GM, Troughton AB, Cotton PB: Endoscopic treatment in pancreas divisum. Am J Gastroenterol 89:1152–1155, 1994PubMedGoogle Scholar
  17. 17.
    Jans JI, Geenen JE, Johanson JF, Hogan WJ: Endoscopic therapy in patients with pancreas divisum and acute pancreatitis: A prospective, randomized, controlled clinical trial. Gastrointest Endosc 38:430–434, 1992PubMedGoogle Scholar
  18. 18.
    Barkun AN, Jones S, Putnam WS, et al: Endoscopic treatment of patients with pancreas divisum and pancreatitis. Gastrointest Endosc 36:206–207, 1990 (abstract)Google Scholar
  19. 19.
    Harig JM, Hogan WJ: Pancreas divisum: A case against surgical treatment. Adv Surg 21:111–126, 1987Google Scholar
  20. 20.
    Madura JA: Pancreas divisum: Stenosis of the dorsally dominant duct—a surgically correctable lesion. Am J Surg 151:742–745, 1986PubMedGoogle Scholar
  21. 21.
    McCarthy J, Geenen JE, Hogan W: Preliminary experience with endoscopic stent placement in benign pancreatic diseases. Gastrointest Endosc 34:16–18, 1988PubMedGoogle Scholar
  22. 22.
    Cotton PB: Duodenoscopic papillotomy at the minor papilla for recurrent dorsal pancreatitis. Endosc Digest 3:27–28, 1978Google Scholar
  23. 23.
    Russell RGC, Wong NW, Cotton PB: Accessory sphincterotomy (endoscopic and surgical) in patients with pancreas divisum. Br J Surg 71:954–957, 1984PubMedGoogle Scholar
  24. 24.
    Kozarek RA: Pancreatic stents can induce ductal changes consistent with chronic pancreatitis. Gastrointest Endosc 36:93–95, 1990PubMedGoogle Scholar
  25. 25.
    Derfus GA, Geenen JE, Hogan WJ: Effect of endoscopic pancreatic duct stent placement on pancreatic ductal morphology. Gastrointest Endosc 36:206A, 1990 (abstract)Google Scholar
  26. 26.
    Sherman S, Alvarez C, Robert M, et al: Polyethylene pancreatic duct stent-induced changes in the normal dog pancreas. Gastrointest Endosc 39:331A, 1993 (abstract)Google Scholar
  27. 27.
    Delhaye H, Vadermeeren A, Baize M, Cremer M: Extracorporeal shock-wave lithotripsy of pancreatic calculi. Gastroenterology 102:610–620, 1992PubMedGoogle Scholar
  28. 28.
    Kozarek RA, Ball TJ, Patterson DJ, et al.: Endoscopic transpapillary therapy for disrupted pancreatic duct and peripancreatic fluid collections. Gastroenterology 100:1362–1370, 1991PubMedGoogle Scholar
  29. 29.
    Kozarek RA, Jiranek G, Traverso LW: Endoscopic management of pancreatic ascites. Am J Surg 168:223–228, 1994PubMedGoogle Scholar
  30. 30.
    McHenry L, Gore DC, DeMaria EJ, Zfass AM: Endoscopic treatment of dilated-duct chronic pancreatitis with pancreatic stents: preliminary results of a sham-controlled, blinded trial to predict surgical outcome. Am J Gastroenterol 88:221A, 1993 (abstract)Google Scholar

Copyright information

© Plenum Publishing Corporation 1995

Authors and Affiliations

  • R. A. Kozarek
    • 1
  • T. J. Ball
    • 1
  • D. J. Patterson
    • 1
  • J. J. Brandabur
    • 1
  • S. L. Raltz
    • 1
  1. 1.Section of GastroenterologyVirginia Mason Medical CenterSeattle

Personalised recommendations