Clinical outcomes and nonendoscopic interventions after minor papilla endotherapy in patients with symptomatic pancreas divisum

Background: Long-term outcomes of minor papilla endotherapy (MPE) in pancreas divisum are limited. Objective: To determine the efficacy of MPE in symptomatic pancreas divisum subgroups. Design: This was a retrospective study of patients from an endoscopy database. The data collection instrument included preprocedure and postprocedure pain score, narcotic use, acute pancreatitis episodes, emergency department visits, and hospitalizations. A follow-up was obtained by chart review and telephone contact with a questionnaire. Setting: A tertiary-referral center. Main Outcome Measurements: (1) Clinical improvement defined as a >= 50% reduction in the evaluated data points and (2) non-WE interventions for pain. Results: Between January 2000 and April 2006, 57 patients were identified. Indications were recurrent acute pancreatitis (RAP) (n = 27 [47%]), abdominal pain and chronic pancreatitis (CP) (n = 20 [35%1), abdominal pain alone (n == 8 [14%]), other (n = 2 [4%]). Successful MPE occurred in 49 of 57 patients (86%). initial MPE entailed minor papilla sphincterotomy (n = 46), stenting without sphincterotomy (n = 2), and tamponade of bleeding (n =: 1). Follow-up was obtained in 56 of 57 patients (98%) for a median of 20 months (interquartile range 12-39 months); 28 of 48 patients (58%) with Successful MPE had clinical improvement: 16 of 21 (76%) with RAP, 8 of 19 (42%) with CP and 2 of 6 (33%) with pain alone (RAP vs non-RAP; P =.019). Two patients had resolution of a dorsal-duct leak and bleeding, respectively Twelve of 57 patients (21%) underwent 16 additional interventions for incomplete response: celiac plexus block (4), intrathecal narcotic pump (2), sphincteroplasty (7), bilateral thoracic splanchnicectomy (2), and Puestow procedure (1); 7 of 12 patients (58%) Clinically improved. Limitation: This was a retrospective study. Conclusions: (1) MPE is most effective in patients with pancreas divisum and with RAP with or without pancreatic ductal changes, (2) although patients with chronic pain and pancreas divisum respond poorly to MPE, majority will have clinical improvement after additional nonendoscopic interventions for pain management.