Incomplete Pancreas Divisum: Is It Merely a Normal Anatomic Variant without Clinical Implications?

Background and Study Aims: Incomplete pancreas divisum (PD) has been generally regarded as merely a normal anatomic variant, without clinical implications. This study compares the prevalence, symptom occurrence rate, clinical presentation, and outcomes of endoscopic treatment in patients with incomplete PD and those with complete PD.

Patients and Methods: The study population consisted of 56 patients (27 with complete PD and 29 with incomplete PD), identified from 4473 newly performed endoscopic retrograde cholangiopancreatography examinations. Endoscopic treatment (minor papilla sphincterotomy with stents or nasopancreatic drainage tube insertion) was attempted in 25 symptomatic patients with PD, which was suspected to be causing the associated pancreatic diseases: acute recurrent pancreatitis (ARP) (n = 13; five patients with complete PD and eight with incomplete PD); chronic pancreatitis (CP) (n = 10: five patients with complete PD and five with incomplete PD); and pancreatic-type pain (PP) (n = 2; one patient with complete PD and one with incomplete PD). The mean follow-up period was 17 months (range 9 - 49 months).

Results: In 12 of the 27 patients with complete PD - six with ARP, five with CP, and one with PP - it was suspected that PD was the cause of pancreatic disease. Ten of the 11 symptomatic patients with complete PD underwent successful endoscopic treatment (five with endoscopic minor papilla sphincterotomy and stenting, and five with endoscopic minor papilla sphincterotomy and endoscopic nasopancreatic drainage), and seven of these ten patients benefited from the endoscopic treatment. In 14 of the 29 patients with incomplete PD - eight with ARP, five with CP, and one with PP - it was suspected that pancreas divisum was the cause of pancreatic disease. Thirteen of the 14 symptomatic patients with incomplete PD underwent successful endoscopic treatments (six with endoscopic minor papilla sphincterotomy and stenting, and seven with endoscopic minor papilla sphincterotomy and endoscopic nasopancreatic drainage), and eight of these 13 patients experienced clinical improvement.

Conclusions: The prevalence rate, symptom occurrence rate, clinical presentation, and outcomes of endoscopic treatment were similar in patients with complete PD and incomplete PD. Incomplete PD may therefore have similar clinical implications to those of complete PD.

References

• 1 Lehman G A, Sherman S. Pancreas divisum: diagnosis, clinical significance, and management alternatives.  Gastrointest Endosc Clin North Am. 1995;  5 145-170
• 2 Ng J W, Wong M K, Huang J, et al. Incomplete pancreas divisum associated with abnormal junction of the pancreaticobiliary duct system.  Gastrointest Endosc. 1992;  38 105-106
• 3 Lehman G A, Sherman S, Nisi R, Hawes R H. Pancreas divisum: results of minor papilla sphincterotomy.  Gastrointest Endosc. 1993;  39 1-8
• 4 Satterfield S T, McCarthy J H, Geenen J E, et al. Clinical experience in 82 patients with pancreas divisum: preliminary results of manometry and endoscopic therapy.  Pancreas. 1988;  3 248-253
• 5 Cotton P B. Congenital anomaly of pancreas divisum as cause of obstructive pain and pancreatitis.  Gut. 1980;  21 105-114
• 6 Gregg J A. Pancreas divisum: its association with pancreatitis.  Am J Surg. 1977;  134 539-543
• 7 Sugawa C, Walt A J, Nunez D C, et al. Pancreas divisum: is it a normal anatomic variant?.  Am J Surg. 1987;  153 62-67
• 8 Moreira V F, Merono E, Ledo L. Incomplete pancreas divisum.  Gastrointest Endosc. 1991;  37 104-107
• 9 Bernard J P, Sahel J, Giovannini M, et al. Pancreas divisum is a probable cause of acute pancreatitis: a report of 137 cases.  Pancreas. 1990;  5 248-254
• 10 Funch-Jensen P. The clinical value of sphincter of Oddi manometry.  Gastrointest Clin North Am. 1993;  3 119-131
• 11 Delhaye M, Engelholm L, Cremer M. Pancreas divisum: congenital anatomic variant or anomaly? Contribution of endoscopic retrograde dorsal pancreatography.  Gastroenterology. 1985;  89 951-958
• 12 Kamijawa K, Egawa T, Ishiwata J, et al. Pathophysiology of pancreas divisum: its association with pancreatitis (in Japanese).  J Bil Panc. 1997;  18 821-827
• 13 The Korean Study Group for Pancreaticobiliary Diseases. The study on the normal structures, variations and anomalies of Korean pancreaticobiliary ducts: nationwide cooperative multicenter study.  Korean J Gastrointest Endosc. 1999;  19 (Suppl 3) S87
• 14 Warshaw A L, Richter J M, Schapiro R H. The cause and treatment of pancreatitis associated with pancreas divisum.  Ann Surg. 1983;  198 443 -452
• 15 Rusnak C H, Hosie R T, Kuechler P M, et al. Pancreatitis associated with pancreas divisum: results of surgical intervention.  Am J Surg. 1988;  155 641-643
• 16 Sahel J, Cros R C, Bourry J, et al. Clinicopathological conditions associated with pancreas divisum.  Digestion. 1982;  23 1-8
• 17 Warshaw A L, Simeone J F, Schapiro R H, et al. Evaluation and treatment of the dominant dorsal duct syndrome (pancreas divisum redefined).  Am J Surg. 1990;  159 59-64
• 18 Cotton P B. Pancreas divisum: curiosity or culprit?.  Gastroenterology. 1985;  89 1431-1435
• 19 Warshaw A L, Simeone J, Schapiro R H, et al. Objective evaluation of ampullary stenosis with ultrasonography and pancreatic stimulation.  Am J Surg. 1985;  149 65-72
• 20 Lowes J R, Lees W R, Cotton P B. Pancreatic duct dilatation after secretin stimulation in patients with pancreas divisum.  Pancreas. 1989;  4 371-374
• 21 Gregg J, Solomon J, Clark G. Pancreas divisum and its association with choledochal sphincter stenosis: diagnosis by endoscopic retrograde cholangiopancreatography and endoscopic biliary manometry.  Am J Surg. 1984;  147 367-371
• 22 Whitcomb D C. Hereditary pancreatitis: new insights into acute and chronic pancreatitis.  Gut. 1999;  45 317-322
• 23 Quest L, Lombard M. Pancreas divisum: opinio divisa.  Gut. 2000;  47 317-319
• 24 Jacob L, Geenen J E, Catalano M F, et al. Clinical presentation and short-term outcome of endoscopic therapy of patients with symptomatic incomplete pancreas divisum.  Gastrointest Endosc. 1999;  49 53-57