Endoscopic Treatment of Pancreas Divisum: Facts and Unsettled Issues

Pancreas Divisum (PD) is the most common congenital malformation of the pancreas and leads to a dominant dorsal pancreatic duct draining through the minor papilla. The prevalence in western populations is about 10% and more than 95% of these patients are asymptomatic. Clinical manifestations of symptomatic PD include pancreatic pain, Recurrent Acute Pancreatitis (RAP) and Chronic Pancreatitis (CP). The etiological role of PD in the occurrence of pancreatic disease has not yet been clearly defined, but it may predispose to pancreatic disease in co-existence with other factors, such as genetic mutations. Patients with symptomatic PD could be treated by minor papilla therapy, either surgical or endoscopic, which have comparable outcomes. Minor papilla endotherapy (papillotomy and/ or dorsal duct stenting) is considered the first-line therapy due to a favorable adverse event profile. However, the response to therapy is variable with maximal benefit in patients with RAP and least with CP and pancreatic pain, and whether endotherapy is really effective in preventing progression to CP still remains an unsettled issue.