ENDOSCOPIC APPROACH TO PANCREAS DIVISUM

Pancreas divisum has been claimed to be a harmless congenital variant or to occasionally cause acute relapsing pancreatitis (ARP), chronic p ancreatitis (CP), or a chronic abdominal pain (CAP) syndrome. Both sur gical and endoscopic approaches to accessory papilla decompression hav e been promulgated and widely disparate results reported in the litera ture. We retrospectively reviewed a five-year experience with dorsal p ancreatic duct decompression at our institution utilizing a variety of endotherapeutic techniques. Data collected included procedural compli cations; patient interpretation of pre- and posttherapy pain, frequenc y, and intensity graded on an analog pain scale; frequency of hospital ization; and patient perception of ''global'' improvement to endothera py. At a mean follow-up of 20 months, there was a statistically signif icant decrease in pancreatitis incidence in 15 patients with ARP (P = 0.016) and 19 patients with CP (P = 0.025). The frequency and intensit y of chronic pain was also significantly improved (P < 0.001) in the l atter group. In contrast, only one of five patients with CAP and norma l dorsal pancreatography and secretin tests experienced global improve ment, 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 pro cedure or subsequent stent-related pancreatitis and an 11.5% accessory papilla restenosis rate. It is concluded that a subset of carefully s elected 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.