Pancreas Divisum in Children and Duodenum-Preserving Resection of the Pancreatic Head
07 October 2016
30 January 2017
29 March 2017 (eFirst)
Introduction A retrospective study was performed to evaluate the clinical features, diagnostic methods, and treatment alternatives in children with pancreas divisum (PD).
Materials and Methods Patients who underwent treatment for PD between 1999 and 2014 at our department were evaluated for sex, age, presenting symptoms, physical examination findings, biochemical markers, diagnostic methods, treatment modalities, and results of treatment during follow-up.
Results Seven patients who underwent treatment of symptomatic PD were included in the study. The median for follow-up period was 8 years (from 26 months to 16 years). Male-to-female ratio was 4:3 and the median age at presentation was 11 years (2–14 years). Presenting symptoms were recurrent episodic epigastric pain. Pancreatitis was documented by elevated amylase or lipase levels. Endoscopic retrograde cholangiopancreatography (ERCP) was the method of diagnosis of PD in all patients. Five patients had complete PD and two had incomplete variants. Three patients improved after ERCP papillotomy. In three patients, papillotomy was unsuccessful but they have only mild episodes of pancreatitis. One patient presented at the age of 4 years with recurrent pancreatitis. She was treated surgically by duodenum-preserving resection of the pancreatic head (DPRPH) because of severe recurrent pancreatitis occurring even after ERCP papillotomy. The patient is 26 months after operation without any reported problems.
Conclusion Patients with symptomatic PD are indicated for ERCP papillotomy attempt. If there is not improvement after ERCP, then recurrent bouts of severe pancreatitis are considered as an indication for surgical procedure. DPRPH is a safe and feasible surgical alternative.
- 1 Türkvatan A, Erden A, Türkoğlu MA, Yener Ö. Congenital variants and anomalies of the pancreas and pancreatic duct: imaging by magnetic resonance cholangiopancreaticography and multidetector computed tomography. Korean J Radiol 2013; 14 (06) 905-913
- 2 Rösch W, Koch H, Schaffner O, Demling L. The clinical significance of the pancreas divisum. Gastrointest Endosc 1976; 22 (04) 206-207
- 3 Gregg JA. Pancreas divisum: its association with pancreatitis. Am J Surg 1977; 134 (05) 539-543
- 4 Heiss FW, Shea JA. Association of pancreatitis and variant ductal anatomy: dominant drainage of the duct of Santorini. Am J Gastroenterol 1978; 70 (02) 158-162
- 5 Cotton PB. Congenital anomaly of pancreas divisum as cause of obstructive pain and pancreatitis. Gut 1980; 21 (02) 105-114
- 6 Kanth R, Samji NS, Inaganti A. , et al. Endotherapy in symptomatic pancreas divisum: a systematic review. Pancreatology 2014; 14 (04) 244-250
- 7 Beger HG, Büchler M. Duodenum-preserving resection of the head of the pancreas in chronic pancreatitis with inflammatory mass in the head. World J Surg 1990; 14 (01) 83-87
- 8 DiMagno EP, DiMagno MJ. Chronic pancreatitis: landmark papers, management decisions, and future. Pancreas 2016; 45 (05) 641-650
- 9 Jalleh RP, Williamson RCN. Pancreatic exocrine and endocrine function after operations for chronic pancreatitis. Ann Surg 1992; 216 (06) 656-662
- 10 Klempa I, Spatny M, Menzel J. , et al. Pancreatic function and quality of life after resection of the head of the pancreas in chronic pancreatitis. A prospective, randomized comparative study after duodenum preserving resection of the head of the pancreas versus Whipple's operation [in German]. Chirurg 1995; 66 (04) 350-359
- 11 Huang JJ, Yeo CJ, Sohn TA. , et al. Quality of life and outcomes after pancreaticoduodenectomy. Ann Surg 2000; 231 (06) 890-898
- 12 Ishikawa O, Ohigashi H, Eguchi H. , et al. Long-term follow-up of glucose tolerance function after pancreaticoduodenectomy: comparison between pancreaticogastrostomy and pancreaticojejunostomy. Surgery 2004; 136 (03) 617-623
- 13 Rault A, SaCunha A, Klopfenstein D. , et al. Pancreaticojejunal anastomosis is preferable to pancreaticogastrostomy after pancreaticoduodenectomy for longterm outcomes of pancreatic exocrine function. J Am Coll Surg 2005; 201 (02) 239-244
- 14 Nakamura H, Murakami Y, Uemura K. , et al. Predictive factors for exocrine pancreatic insufficiency after pancreatoduodenectomy with pancreaticogastrostomy. J Gastrointest Surg 2009; 13 (07) 1321-1327
- 15 Lemaire E, O'Toole D, Sauvanet A, Hammel P, Belghiti J, Ruszniewski P. Functional and morphological changes in the pancreatic remnant following pancreaticoduodenectomy with pancreaticogastric anastomosis. Br J Surg 2000; 87 (04) 434-438
- 16 Jang JY, Kim SW, Park SJ, Park YH. Comparison of the functional outcome after pylorus-preserving pancreatoduodenectomy: pancreatogastrostomy and pancreatojejunostomy. World J Surg 2002; 26 (03) 366-371
- 17 O'Rourke RW, Harrison MR. Pancreas divisum and stenosis of the major and minor papillae in an 8-year-old girl: treatment by dual sphincteroplasty. J Pediatr Surg 1998; 33 (05) 789-791
- 18 Neblett III WW, O'Neill Jr JA. Surgical management of recurrent pancreatitis in children with pancreas divisum. Ann Surg 2000; 231 (06) 899-908
- 19 Rabinovich A, Rescorla FJ, Howard TJ, Grosfeld J, Lillemoe KD. Pancreatic disorders in children: relationship of postoperative morbidity and the indication for surgery. Am Surg 2006; 72 (07) 641-643
- 20 Shukri N, Wasa M, Hasegawa T, Okada A. Diagnostic significance of pancreas divisum in early life. Eur J Pediatr Surg 2000; 10 (01) 12-16
- 21 Schneider L, Müller E, Hinz U, Grenacher L, Büchler MW, Werner J. Pancreas divisum: a differentiated surgical approach in symptomatic patients. World J Surg 2011; 35 (06) 1360-1366
- 22 Schlosser W, Rau BM, Poch B, Beger HG. Surgical treatment of pancreas divisum causing chronic pancreatitis: the outcome benefits of duodenum-preserving pancreatic head resection. J Gastrointest Surg 2005; 9 (05) 710-715
- 23 Diener MK, Rahbari NN, Fischer L, Antes G, Büchler MW, Seiler CM. Duodenum-preserving pancreatic head resection versus pancreatoduodenectomy for surgical treatment of chronic pancreatitis: a systematic review and meta-analysis. Ann Surg 2008; 247 (06) 950-961
- 24 Sukharamwala PB, Patel KD, Teta AF. , et al. Long-term outcomes favor duodenum-preserving pancreatic head resection over pylorus-preserving pancreaticoduodenectomy for chronic pancreatitis: a meta-analysis and systematic review. Am Surg 2015; 81 (09) 909-914