An improved technique for accessory papilla cannulation in pancreas divisum

Cannulation of the accessory papilla with dorsal pancreas ductography was accomplished in 13 of 15 consecutive cases of pancreas divisum. When routine cannulation of the main pancreatic papilla fails to produce a pancreatogram or yields only a ventral pancreas, the use of intravenous secretin and a 23-gauge needle catheter is recommended to facilitate accessory duct cannulation.     

Endoscopic minor papilla interventions in patients without pancreas divisum

BACKGROUND: Endoscopic treatment through the minor papilla is well known in patients with pancreas divisum. However, there are few data concerning endoscopic minor papilla interventions in patients without pancreas divisum when access to the main pancreatic duct via the major papilla is technically difficult. METHODS: Records for 213 patients without pancreas divisum who, from April 2001 to June 2003, underwent ERCP for various pancreatic diseases were retrospectively reviewed. Patients were included if they had endoscopic interventions via the minor papilla because access through the major papilla was not possible. OBSERVATIONS: Minor papilla papillotomy or fistulotomy with endoscopic interventions was successful in 10 (91%) of 11 patients. Of these 10 patients, 9 had chronic pancreatitis and one had pancreatic ductal leak from previous pancreatic surgery. The reasons for the inability to access the main pancreatic duct to the tail of the gland via the major papilla included a distorted course of the main pancreatic duct (n=5), impacted stone (n=5), and stricture (n=8). In 8 patients, there were two causes. No complication related to the minor papilla interventions was observed in any patient. CONCLUSIONS: Endoscopic minor papilla interventions are technically feasible in patients with pancreatic diseases but not pancreas divisum when access to the main pancreatic duct via the major papilla is not possible.     

Adenoma of the minor papilla associated with pancreas divisum

Tumors of the minor papilla of the duodenum are quite rare. We report the first documented case of an adenoma of the minor papilla complicating pancreas divisum. A 52-year-old woman was admitted to our hospital for treatment of an asymptomatic duodenal tumor detected by computed tomography scan. Endoscopy showed an 18-mm, whitish-colored, sessile mass located in the descending duodenum proximal to a normal appearing major papilla. Endoscopic retrograde pancreatography revealed divisum of the pancreas with dilatation of pancreatic duct ranged in the dorsal pancreas. Transduodenal minor papillectomy was performed because there is malignant potential of the tumor and the possibility of acute pancreatitis. The Santorini orifice was then re-approximated to the duodenal wall for protection against acute pancreatitis caused by scarring and stenosis of the duct orifice as a possible late complication. The patient's postoperative course was uneventful and she has been asymptomatic without evidence of tumor recurrence or stenosis of the Santorini orifice on endoscopic examination for the last 4 years.     

Annular pancreas associated with carcinoma in the dorsal part of pancreas divisum

Summary A carcinoma in the dorsal part of the pancreas divisum with an annular pancreas in the anterior part is reported. A 79-yr-old female was admitted in our hospital complaining of epigastralgia. Computed tomography (CT) and ultrasound (US) showed an irregular mass in the pancreatic body. A pancreatogram obtained through the major duodenal papilla demonstrated only the ventral pancreatic duct that encircled the duodenum. Contrast medium injected from the minor duodenal papilla showed Santorini’s duct obstruction at the neck portion of the pancreas without communication with the ventral pancreatic duct. The patient died with liver metastases. Autopsy confirmed annular pancreas and a 6-cm tumor in the pancreatic body extending to the pancreatic head and pancreas divisum. Pancreatic carcinoma; histologically a moderately differentiated adenocarcinoma; originated from the dorsal part of pancreas divisum. To our knowledge this is the first report of pancreatic carcinoma associated with annular pancreas coexistent with pancreas divisum.     

An endoscopic sphincterotomy of the minor papilla in the management of symptomatic pancreas divisum

BACKGROUND/AIMS: The efficacy of endoscopic treatment in pancreas divisum remains controversial. This study evaluated the results of an endoscopic sphincterotomy of the minor papilla and temporary transpapillary pancreatic stenting in patients with pancreas divisum. METHODOLOGY: Pancreas divisum was diagnosed in four patients between 1994 and 2004. All patients demonstrated episodes of recurrent upper abdominal and back pain were with a median follow-up period of 14.5 months. One patient was treated by a sphincterotomy of the minor papilla alone, while three others also underwent transpapillary pancreatic stent insertion for seven days. RESULTS: A Sphincterotomy of the minor papilla could be successfully achieved in all patients. There was no instance of bleeding, perforation or sepsis after the procedure. The postoperative serum amylase level in the patients without stent insertion (1352 IU/L) was higher than that the patients with stents (mean level 515 IU/L, range 358 to 680). The dilatated dorsal pancreatic ducts were found to improve after a sphincterotomy in all patients. None of the patients had any further episodes of pancreatitis. In addition, all patients demonstrated a considerable improvement in their upper abdominal or back pain symptoms, which did not require either analgesic medication or hospitalization. CONCLUSIONS: An endoscopic sphincterotomy and temporary transpapillary pancreatic stenting were therefore suggested to be a beneficial treatment modality for patients with pancreas divisum.     

Predicting pancreas divisum by inspection of the minor papilla: a prospective study

BACKGROUND: Minor papilla (MP) cannulation remains difficult in some patients despite improved cannulation devices and techniques. Therefore, noninvasive methods to predict presence of pancreas divisum (Pdiv) are desired. If Pdiv could be recognized before any cannulation is attempted, appropriate attention could be focused on MP cannulation and prolonged major papilla attempt at pancreatogram can be avoided. AIM: To evaluate whether simple inspection of the MP during initial duodenal entry during endoscopic retrograde cholangiopancreatography (ERCP) can predict the presence of Pdiv. METHODS: Patients undergoing ERCP with intended pancreatic duct cannulation were included in the study. Assessment of the MP was made during a 30 to 60-second period of inspection including aspiration of duodenal luminal air with the endoscope. The probability of Pdiv based on the appearance of the MP was then estimated by assessing the size of the MP, the diameter of MP orifice, and whether juice was seen draining through the MP orifice. RESULTS: Two hundred and twelve patients were prospectively analyzed. The most common indications for ERCP were suspected sphincter of Oddi dysfunction (44.3%) and idiopathic pancreatitis (34.4%). Pancreatograms revealed Pdiv in 42 (19.8%). The MP appearance had 54.7% sensitivity and 90% specificity in detecting Pdiv (positive predictive value 57.5%, negative predicting value 88.9%). Seventy percent of the false positive patients had an obstructing pathology at the ventral duct that would explain the MP appearance. CONCLUSIONS: Certain features of the MP (enlarged papilla, open orifice) had a moderate predictive value for the presence of Pdiv or an obstruction at the major papilla. However, a significant number of patients with Pdiv did not have these features.     

Endoscopic ultrasound and pancreas divisum

Pancreas divisum is the most common congenital anatomic variation of the pancreatic ductal anatomy and in most of the individuals it is asymptomatic. However, in minority of individuals it is presumed to cause recurrent acute pancreatitis and chronic pancreatitis. Endoscopic retrograde cholangiopancreatography is the gold standard for its diagnosis, but is invasive and associated with significant adverse effects. Endoscopic ultrasound (EUS) allows the detailed evaluation of the pancreaticobiliary ductal system without injecting contrast in these ducts. Moreover, it provides detailed images of the parenchyma also. Therefore EUS, both radial and linear, has potential for being a minimally invasive diagnostic modality for pancreas divisum. A number of EUS criteria have been suggested for the diagnosis of pancreas divisum. These criteria have varying sensitivity and specificity and hence there is a need for objective and uniform criteria that have the best diagnostic accuracy. Secretin EUS has a potential for diagnosing minor papilla stenosis and thus help in planning appropriate therapy. EUS guided pancreatic duct interventions can help in draining dorsal duct in symptomatic patients with failed minor papilla cannulation. But these techniques are technically demanding and associated with potential severe complications.     

Management of pancreas divisum

Pancreas divisum is the most common congenital anomaly of the pancreas. Abnormal hedgehog protein signaling appears related to the formation of several pancreatic malformations, including annular pancreas, pancreatic-biliary malunion, pancreatic rests, and pancreas divisum. Pancreas divisum by itself should not necessarily require intervention. A careful evaluation should be performed to exclude other causes of symptoms. If the patient is asymptomatic, no further evaluation is necessary. However, a significant percentage of patients with pancreas divisum and acute recurrent pancreatitis benefit from intervention. Surgical sphincteroplasty and endoscopic interventions appear similar in outcome. Thus, endoscopic intervention with prophylactic temporary stenting is advised as initial therapy. Surgery should be reserved for patients with chronic pancreatitis.     

Use of methylene blue to identify the minor papilla or its orifice in patients with pancreas divisum

BACKGROUND: In some patients with pancreas divisum, minor papilla cannulation is difficult because of uncertain identification of the papilla or its orifice, even after pancreatic secretory stimulation with secretin or cholecystokinin agonist. METHODS: Two techniques with methylene blue were used to identify the minor papilla and its orifice more clearly in a series of patients: spraying methylene blue over duodenal mucosa in the region suspected to contain the minor papilla with/without secretin or cholecystokinin agonist administration, and injection of contrast medium containing methylene blue into the ventral pancreatic duct by means of the major papilla in cases of incomplete pancreas divisum. Results were reviewed retrospectively. RESULTS: From January 2001 to May 2002, minor papilla cannulation with conventional methods initially failed in 38 of 305 patients with pancreas divisum because of an inconspicuous minor papilla orifice. Methylene blue was used to identity the minor papilla orifice in 14 of 38 patients (spraying, 13; injection, 1). Minor papilla cannulation was successful in 12 of 14 (86%) patients (spraying 11, injection 1). Mild pancreatitis developed in 1 patient. CONCLUSIONS: Methylene blue spraying or injection appears to be a helpful technique for identification of the inconspicuous minor papilla orifice in patients with pancreas divisum.     

Total dorsal pancreatectomy for intraductal papillary mucinous neoplasm in a patient with pancreas divisum.

We report a case of intraductal papillary mucinous neoplasm confined to the dorsal (Santorini) pancreatic duct. A 51-year-old woman presented with a cystic lesion in the head of her pancreas and pancreas divisum. A biopsy taken during cyst-enteric drainage revealed dysplastic epithelium so the patient was scheduled for resection. At operation, excision of the entire dorsal pancreas was performed with preservation of the unaffected ventral pancreas and the spleen and its vessels. Over 6 years later she remains well with stable weight and a good quality of life. This case illustrates the benefits of anatomical preservation in pancreatic resection, and was performed some years prior to the only other reported similar case.