Evaluation and treatment of the dominant dorsal duct syndrome (pancreas divisum redefined)

doi:10.1016/S0002-9610(05)80607-5

The American Journal of Surgery

Volume 159, Issue 1, January 1990, Pages 59-66

https://doi.org/10.1016/S0002-9610(05)80607-5 Get rights and content

The controversial association of pancreatitis and pancreas divisum was studied in 100 patients (77 women, 23 men, median age 35) with episodic acute pancreatitis (49%) or “pancreatic pain” (51%). Seventy-one had classic pancreas divisum (type 1); 23 had only a dorsal duct with an absent Wirsung's duct (type 2); and 6 had a filamentous connection between the two duct systems (type 3). Accessory papilla sphincteroplasty was performed in 88 patients, with a mean follow-up of 53 months. The orifice was stenotic at the mucosal level in 66 patients. Seventy percent of patients have shown improvement: 85% if the accessory papilla was stenotic, compared with 27% if it was not (p <0.0001); and 82% with discrete attacks, compared with 56% with chronic pain (p=0.002). Judged against intraoperative calibration of accessory papilla orifice diameter, ultrasonography with secretin stimulation was 78% sensitive for accessory papilla stenosis, with 3% false-positive results. Ultrasonography with secretin stimulation was the best predictor of surgical success: positive=92% success (attacks or pain) versus negative=40% success (64% with attacks; 21% with pain). There have been seven restenoses with six reoperations. We conclude that (1) pancreas divisum is but one variety of pancreatic anatomy characterized by a dominant dorsal duct and dependence on secretion through the accessory papilla; (2) accessory papilla stenosis appears to be a necessary cofactor to produce a morbid state, whether episodic pancreatitis or pancreatic pain; (3) presentation with pancreatitis and a positive result on the ultrasound-secretin test are the best predictors of successful accessory papilla sphincteroplasty.

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Citation Excerpt :
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Surgery may be superior to endoscopy in terms of treatment success and complications. There is no study comparing these two therapies. Consequently, a randomized trial is needed to clarify if endoscopy or surgery is superior in the therapy of pancreas divisum.

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^**: Presented at the 30th Annual Meeting of the Society for Surgery of the Alimentary Tract, Washington, D.C. May 16–17, 1989.

¹: From the Surgical Services, Gastrointestinal Radiology Unit, and Gastrointestinal Unit of the Massachusetts General Hospital, and the Departments of Surgery, Radiology, and Medicine, Harvard Medical School, Boston, Massachusetts.

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Evaluation and treatment of the dominant dorsal duct syndrome (pancreas divisum redefined)**

Gastroenterology

Am J Surg

Am J Surg

Gastroenterology

Am J Surg

Am J Surg

Am J Surg

Gastrointest Endosc

A historical perspective on the discovery of the accessory duct of the pancreas, the ampulla “of Vater” and pancreas divisum

Gut

Congenital anomaly of pancreas divisum as cause of obstructive pain and pancreatitis

Gut

Clinico-pathological conditions associated with pancreas divisum

Digestion

Treatment of pancreatitis associated with pancreas divisum by dorsal duct sphincteroplasty alone

Can J Surg

The cause and treatment of pancreatitis associated with pancreas divisum

Ann Surg

Accessory sphincterotomy (endoscopic and surgical) in patients with pancreas divisum

Br J Surg