Digestive Diseases and Sciences, ['b/ 40, No. 9 (September I995), pp. 1974-1981 Endoscopic Approach to Pancreas Divisum R.A. KOZAREK, MD, T.J. BALL, MD, D.J. PATTERSON, MD, J.J. BRANDABUR, MD, and S.L. RALTZ, RN, MSW 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 decom- pression 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 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 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 divi- sum: minor papilla. Pancreas divisum has been claimed to be a normal anatomic variant without clinical consequences (1-3). Alternatively, it has been claimed to predispose to relapsing attacks of acute pancreatitis (ARP), chronic pancreatic-type pain with normal enzymes, and even chronic pancreatitis (CP) (5-9). Both surgical and endoscopic therapy have been applied in an attempt to enlarge a "physiologically" or anatomically ste- nosed minor papilla (9-16). From the latter stand- point, endoprostheses have been utilized as a diag- nostic and therapeutic trial in both the short and long term (17), to facilitate a dorsal pancreatic duct sphincterotomy with a needle-knife sphincterotome (15) and to protect against edematous closure of a minor papilla sphincterotomy undertaken with a con- ventional sphincterotome (18). Recent publications report conflicting data regarding the efficacy of dorsal duct endotherapy in so far as pain and pancreatitis relief are concerned. Accordingly, we have reviewed a five-year experience of patients undergoing such en- dotherapy at a pancreaticobiliary referral institution. Manuscript received September 23, 1994; revised manuscript received December 27, 1994; accepted January 31, 1995. From the Section of Gastroenterology, Virginia Mason Medical Center, Seattle, Washington. Address for reprint requests: Dr. Richard A. Kozarek, Section of Gastroenterology, 1100 Ninth Ave., PO Box 900 (C3-GAS), Seat- tie, Washington 98111. MATERIALS AND METHODS Between January 1989 and December 1993, 39 patients with pancreas divisum were referred to the therapeutic endoscopy service of the Virginia Mason Medical Center. Indications for therapy are noted in 1974 Digestive Diseases and Sciences, Vol. 40, No. 9 (September 1995) 0163-2116/95/09110-19745;07.50/0 9 1995PlenumPublishing Corporation