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Is Incomplete Pancreas Divisum Merely a Normal Anatomic Variant Without Clinical Implications?
*T1528 Pancreas Divisum: 3-6 Years Follow-up After Endoscopic Therapy Mohammad Alsolaiman, Peter Cotton, Robert Hawes Background Several small studies with relatively short follow-up suggest that most patients with pancreas divisum and recurrent pancreatitis have good outcomes from ERCP with minor papilla sphincterotomy and/or stenting, but that patients with chronic pancreatitis and those with only pain gain less benefit. Our goal was to evaluate results from this institution with a follow-up of 3-6 years. Method Subjects with documented pancreas divisum and endoscopic treatment (but no prior endoscopic treatment) were identified from our routine endoscopy database. Patients were categorized as recurrent acute pancreatitis, chronic pancreatitis, or pain with no documented pancreatitis. Treatment consisted of temporary stenting of the minor papilla with a sphincterotomy (usually performed with a needle knife.). Short-term response and early complications were assessed by chart review. Subjects were contacted by telephone with a standard questionnaire. The Institutional Review Board approved the study. Results A total of 174 subjects were identified. Up to November 2003, we have attempted to contact 54 patients. Three had died from unrelated causes, and 4 declined participation. Follow-up information was obtained on 47 subjects with a mean delay of 61 months (range 40-75 months sphincterotomy). Results are tabulated (table I). Complications of the initial endoscopic treatment occurred in 2 patients who developed mild and moderate pancreatitis. Conclusion These preliminary data confirm prior reports that patients with recurrent acute pancreatitis associated with pancreas divisum are likely to do well after endoscopic treatment. Results in other patients were mixed, but also encouraging. The study is ongoing.
*T1529 Is the Rate of Iatrogenic Acute Pancreatitis the Same with Manipulation of the Major Papilla Versus Minor Papilla? Isaac Raijman Sr., Susana Escalante-Glorsky, Marc Catalano, Atilla Ertan Introduction: Iatrogenic acute pancreatitis (IAP) may occur after ERP. It is unclear if the rate of IAP is the same with manipulation of the major papilla or the minor papilla. We report our experience with patients undergoing ERP for pancreatic disease. Patients and Methods: Between 1/2000 to 9/2003, 1647 ERP were performed in 1647 pts with acute recurrent pancreatitis (ARP), chronic pancreatitis (CP), pancreatic ascites (PAsc), pancreatic pseudocysts (PPc) or pancreatic cancer/cyst. Of these, 452 pts (27%) were found to have pancreas divisum as identified by injecting the minor papilla and obtaining a complete dorsal pancreatogram. In the ventral pancreatic duct (VD), there were 810 men, 385 women, mean age 59 years. Indications for ERP were: ARP in 613, CP in 389, PPc in 47, PAsc in 12, and pancreatic cancer/cyst in 134. In the pancreas divisum group (DD), there were 347 men, 105 women, mean age 46 years. Indications for ERP were: ARP in 310, CP in 113, PPc in 26, PAsc in 1, and pancreatic cancer/cyst in 2. IAP was diagnosed by: severe abdominal pain, elevation of amylase >3 3 normal, and radiographic evidence of acute pancreatitis. Only acute pancreatitis occurring within 24 hours from the procedure and only the first procedure performed in the patient is reported. All ERP were performed by experienced bilio-pancreatic endoscopists. Results: In the VD group, there were 452 diagnostic and 743 therapeutic procedures (all pancreatic sphincterotomy and stent placement). In the DD group, there were 129 diagnostic and 323 therapeutic procedures (all pancreatic sphincterotomy and stent placement). IAP occurred in 104 pts (8.7%) in the VD group (mild 92, moderate 5, severe 7). Of these, 69 occurred in the diagnostic group (15%) and 35 in the therapeutic group (4.7%). In the DD group, 27 pts (6%) had IAP(26 mild, 1 severe). Of these, 21 were in the diagnostic group (16.2%) and 6 in the therapeutic group (1.8%) Conclusions: 1. Therapeutic ERP of the VD or DD carries similar risk of IAP; 2. Diagnostic ERP of the VD or DD carries similar risk of IAP; 3. There is a significant increase in IAP when ERP is performed for diagnostic purposes; 4. When IAP occurs, there is a trend to less severe disease in those with PD; 5. Diagnostic ERP should be avoided if at all possible; 6. A prospective multicenter study is encouraged to determine the validity of our findings and possible mechanisms of causation.
P206
GASTROINTESTINAL ENDOSCOPY
*T1530 Is Incomplete Pancreas Divisum Merely a Normal Anatomic Variant Without Clinical Implications? Terumi Kamisawa, Masami Yoshiike, Naoto Egawa, Hitoshi Nakajima, Atsutake Okamoto Background/Aims: Incomplete pancreas divisum has a communication between the ventral pancreatic duct (VPD) and dorsal pancreatic duct (DPD) via a tiny channel, and has been generally regarded as merely a normal anatomic variant without clinical implications. We divided the patients with incomplete pancreas divisum anatomically into 3 types, and studied their radiological and clinical characteristics, and compared with those with complete pancreas divisum. Methods: In 5000 ERPs, 31 and 32 patients were diagnosed as having incomplete pancreas divisum and pancreas divisum, respectively. Incomplete pancreas divisum was divided as follows: Type 1. Fusion of the extreme end of the upper branch of the VPD with the DPD, Type 2. Fusion of the lower branch of the DPD with the lower branch of the VPD, Type 3. Fusion of the lower branch of the DPD with the VPD. Results: In 9 patients with Type 1, chronic dorsal pancreatitis occurred in 1 patient, and the other 2 complained of pancreatic-type pain. Maximum diameter of Santorini’s duct was greater than that of the VPD in 5 patients, and marked hypoplasia of the VPD was observed in 2 of them. In 8 patients with Type 2, chronic pancreatitis occurred in 2 patients, and the other 2 complained of pancreatic-type pain. Santorini’s duct was predominant in 4. In 14 patients with Type 3, chronic pancreatitis occurred in 3 patients, and acute relapsing pancreatitis occurred in 2 patients, and the other 2 complained of pancreatic-type pain. Santorini’s duct was predominant in 8 patients, and marked hypoplasia of the VPD was observed in 1. Chronic pancreatitis, acute pancreatitis and pancreatic-type pain were observed in 19%, 6%, and 19% of patients with incomplete pancreas divisum, which was similar to 16%, 22%, and 3% of patients with complete pancreas divisum. Conclusions: Incomplete pancreas divisum was classified embryologically into 3 types of branch fusion. Predominant Santorini’s duct or marked hypoplasia of the VPD was often accompanied with incomplete pancreas divisum. The prevalence rate, symptom occurrence rate, and clinical presentations were similar in patients with incomplete and complete pancreas divisum.
*T1531 Endoscopic Evaluation of the Minor Papilla Prior to Pancreatography at ERCP: A Prospective Study Christopher Lawrence, Douglas A. Howell, Andreas M. Stefan, Frank J. Lukens Background: Difficulties in cannulation at ERCP may arise from severe ampullary stenosis, unrecognized presence of pancreas divisum, or low lying pancreatic ductal (PD) obstruction by tumor or stone. Such PD abnormalities downstream from the origin of the dorsal pancreatic duct may manifest with endoscopically visible changes at the minor papilla. Early recognition may assist in diagnosis and endotherapy. Patients & Methods: Consecutive patients referred for initial ERCP were prospectively evaluated from 7/03 - 11/03. Patients were excluded if MRCP had been performed prior to ERCP or if the minor papilla was not visible after 90 seconds (Secretin was not administered). The minor papilla was assessed endoscopically for each of three characteristics (minor papilla orifice, peripapillary bulging, and mucosal appearance) (see Table). A cumulative score was obtained by summing each category’s score. Student’s t test was utilized for all statistical evaluations; a p value of <.05 was considered significant. Results: 42 consecutive patients have been evaluated. 27 patients had a normal pancreatogram; 15 had an abnormal pancreatogram due to PD stricture/stone in the pancreatic head (n=8), severe ampullary stenosis with dilated PD (n=3), pancreas divisum (n=3), and ampullary adenoma (n=1). The orifice of the minor papilla in patients with a normal pancreatogram scored 0.35 (median 0) compared to 1.5 (median 1.5) in the patients with an abnormal pancreatogram (p < 0.0001). A peripapillary bulge was absent in 18/27 patients with a normal pancreatogram; this group had a mean score of 0.5 (median 0). Patients with an abnormal PD scored 1.8 (median 2) for the peri-papillary bulge (p = 0.0004). The cumulative score was 0.9 (median 1) for the normal PD group and 3.4 (median 3.5) for the abnormal PD group (p < 0.0001). Both groups had a median mucosa score of 0. Conclusions: A minor papilla that shows a prominent bulge and/or a gaping orifice predicts periampullary abnormalities of the pancreatic duct or pancreas divisum. The information may be useful in predicting difficult access, serving as a precaution to avoid early acinarization, and may direct the approach for endotherapy to the minor papilla.
VOLUME 59, NO. 5, 2004
*T1529 Is the Rate of Iatrogenic Acute Pancreatitis the Same with Manipulation of the Major Papilla Versus Minor Papilla? Isaac Raijman Sr., Susana Escalante-Glorsky, Marc Catalano, Atilla Ertan Introduction: Iatrogenic acute pancreatitis (IAP) may occur after ERP. It is unclear if the rate of IAP is the same with manipulation of the major papilla or the minor papilla. We report our experience with patients undergoing ERP for pancreatic disease. Patients and Methods: Between 1/2000 to 9/2003, 1647 ERP were performed in 1647 pts with acute recurrent pancreatitis (ARP), chronic pancreatitis (CP), pancreatic ascites (PAsc), pancreatic pseudocysts (PPc) or pancreatic cancer/cyst. Of these, 452 pts (27%) were found to have pancreas divisum as identified by injecting the minor papilla and obtaining a complete dorsal pancreatogram. In the ventral pancreatic duct (VD), there were 810 men, 385 women, mean age 59 years. Indications for ERP were: ARP in 613, CP in 389, PPc in 47, PAsc in 12, and pancreatic cancer/cyst in 134. In the pancreas divisum group (DD), there were 347 men, 105 women, mean age 46 years. Indications for ERP were: ARP in 310, CP in 113, PPc in 26, PAsc in 1, and pancreatic cancer/cyst in 2. IAP was diagnosed by: severe abdominal pain, elevation of amylase >3 3 normal, and radiographic evidence of acute pancreatitis. Only acute pancreatitis occurring within 24 hours from the procedure and only the first procedure performed in the patient is reported. All ERP were performed by experienced bilio-pancreatic endoscopists. Results: In the VD group, there were 452 diagnostic and 743 therapeutic procedures (all pancreatic sphincterotomy and stent placement). In the DD group, there were 129 diagnostic and 323 therapeutic procedures (all pancreatic sphincterotomy and stent placement). IAP occurred in 104 pts (8.7%) in the VD group (mild 92, moderate 5, severe 7). Of these, 69 occurred in the diagnostic group (15%) and 35 in the therapeutic group (4.7%). In the DD group, 27 pts (6%) had IAP(26 mild, 1 severe). Of these, 21 were in the diagnostic group (16.2%) and 6 in the therapeutic group (1.8%) Conclusions: 1. Therapeutic ERP of the VD or DD carries similar risk of IAP; 2. Diagnostic ERP of the VD or DD carries similar risk of IAP; 3. There is a significant increase in IAP when ERP is performed for diagnostic purposes; 4. When IAP occurs, there is a trend to less severe disease in those with PD; 5. Diagnostic ERP should be avoided if at all possible; 6. A prospective multicenter study is encouraged to determine the validity of our findings and possible mechanisms of causation.
P206
GASTROINTESTINAL ENDOSCOPY
*T1530 Is Incomplete Pancreas Divisum Merely a Normal Anatomic Variant Without Clinical Implications? Terumi Kamisawa, Masami Yoshiike, Naoto Egawa, Hitoshi Nakajima, Atsutake Okamoto Background/Aims: Incomplete pancreas divisum has a communication between the ventral pancreatic duct (VPD) and dorsal pancreatic duct (DPD) via a tiny channel, and has been generally regarded as merely a normal anatomic variant without clinical implications. We divided the patients with incomplete pancreas divisum anatomically into 3 types, and studied their radiological and clinical characteristics, and compared with those with complete pancreas divisum. Methods: In 5000 ERPs, 31 and 32 patients were diagnosed as having incomplete pancreas divisum and pancreas divisum, respectively. Incomplete pancreas divisum was divided as follows: Type 1. Fusion of the extreme end of the upper branch of the VPD with the DPD, Type 2. Fusion of the lower branch of the DPD with the lower branch of the VPD, Type 3. Fusion of the lower branch of the DPD with the VPD. Results: In 9 patients with Type 1, chronic dorsal pancreatitis occurred in 1 patient, and the other 2 complained of pancreatic-type pain. Maximum diameter of Santorini’s duct was greater than that of the VPD in 5 patients, and marked hypoplasia of the VPD was observed in 2 of them. In 8 patients with Type 2, chronic pancreatitis occurred in 2 patients, and the other 2 complained of pancreatic-type pain. Santorini’s duct was predominant in 4. In 14 patients with Type 3, chronic pancreatitis occurred in 3 patients, and acute relapsing pancreatitis occurred in 2 patients, and the other 2 complained of pancreatic-type pain. Santorini’s duct was predominant in 8 patients, and marked hypoplasia of the VPD was observed in 1. Chronic pancreatitis, acute pancreatitis and pancreatic-type pain were observed in 19%, 6%, and 19% of patients with incomplete pancreas divisum, which was similar to 16%, 22%, and 3% of patients with complete pancreas divisum. Conclusions: Incomplete pancreas divisum was classified embryologically into 3 types of branch fusion. Predominant Santorini’s duct or marked hypoplasia of the VPD was often accompanied with incomplete pancreas divisum. The prevalence rate, symptom occurrence rate, and clinical presentations were similar in patients with incomplete and complete pancreas divisum.
*T1531 Endoscopic Evaluation of the Minor Papilla Prior to Pancreatography at ERCP: A Prospective Study Christopher Lawrence, Douglas A. Howell, Andreas M. Stefan, Frank J. Lukens Background: Difficulties in cannulation at ERCP may arise from severe ampullary stenosis, unrecognized presence of pancreas divisum, or low lying pancreatic ductal (PD) obstruction by tumor or stone. Such PD abnormalities downstream from the origin of the dorsal pancreatic duct may manifest with endoscopically visible changes at the minor papilla. Early recognition may assist in diagnosis and endotherapy. Patients & Methods: Consecutive patients referred for initial ERCP were prospectively evaluated from 7/03 - 11/03. Patients were excluded if MRCP had been performed prior to ERCP or if the minor papilla was not visible after 90 seconds (Secretin was not administered). The minor papilla was assessed endoscopically for each of three characteristics (minor papilla orifice, peripapillary bulging, and mucosal appearance) (see Table). A cumulative score was obtained by summing each category’s score. Student’s t test was utilized for all statistical evaluations; a p value of <.05 was considered significant. Results: 42 consecutive patients have been evaluated. 27 patients had a normal pancreatogram; 15 had an abnormal pancreatogram due to PD stricture/stone in the pancreatic head (n=8), severe ampullary stenosis with dilated PD (n=3), pancreas divisum (n=3), and ampullary adenoma (n=1). The orifice of the minor papilla in patients with a normal pancreatogram scored 0.35 (median 0) compared to 1.5 (median 1.5) in the patients with an abnormal pancreatogram (p < 0.0001). A peripapillary bulge was absent in 18/27 patients with a normal pancreatogram; this group had a mean score of 0.5 (median 0). Patients with an abnormal PD scored 1.8 (median 2) for the peri-papillary bulge (p = 0.0004). The cumulative score was 0.9 (median 1) for the normal PD group and 3.4 (median 3.5) for the abnormal PD group (p < 0.0001). Both groups had a median mucosa score of 0. Conclusions: A minor papilla that shows a prominent bulge and/or a gaping orifice predicts periampullary abnormalities of the pancreatic duct or pancreas divisum. The information may be useful in predicting difficult access, serving as a precaution to avoid early acinarization, and may direct the approach for endotherapy to the minor papilla.
VOLUME 59, NO. 5, 2004