7241 Endoscopic therapy in chronic pancreatitis through the minor papilla in non-divisum patients.

Abstract

INTRODUCTION: A subset of patients with chronic pancreatitis (CP) have symptoms related to obstruction of the main pancreatic duct (MPD). Endoscopic decompression via stricture dilation or stone removal may alleviate symptoms. In patients with distal MPD obstruction and proximal dilation (Cremer IV), access to the MPD via the major papilla may be impossible. We describe 5 such cases in which endoscopic therapy was accomplished following access to the MPD through the minor papilla. METHODS:We reviewed 5 patients with CP undergoing ERCP for evaluation of recurrent pancreatitis (3) or chronic unremitting pain (2). There were 4 males, mean age 54yrs (range 34-81yrs). The etiology was ETOH in 4/5. On CT all had parenchymal calcifications, 4 had CBD dilation, 2 had PD dilation and 1 had PD calculi. RESULTS: After failed access to the MPD via the major papilla due to obstructing distal stricture (4) or stone (1), successful access to the Santorini's duct through the minor papilla revealed dilation of the MPD (5-20mm). Additionally 2 patients had free floating MPD stones. Endoscopic therapy included minor papilla sphincterotomy in 4, minor papilla push dilation (10fr) in 1, MPD stone extraction in 1 and minor papilla stent in 4. In addition 3 required biliary sphincterotomy and biliary stents. Excellent MPD drainage was observed in all patients. 4 had immediate complete symptom relief while 1 had partial relief. Repeat ERCP with minor papilla dilation and temporary stenting was performed in 2. In long term follow-up, surgery was performed in 2 (pylorus-preserving Whipple-1, Beger procedure-1) and recommended to a 3rd. The 2 remaining patients had durable symptom relief (1yr and 1.5yrs). CONCLUSIONS: In patients with CP and distal MPD obstruction, endoscopic therapy can be applied accessing the MPD through the minor papilla. As with endoscopic therapy for CP via the major papilla, short term pain relief can be expected and durable relief is seen in a subset.