Patient Outcomes Following Minor Papilla Endotherapy (MPE) for Pancreas Divisum (PD)

Abstract

Patient Outcomes Following Minor Papilla Endotherapy (MPE) for Pancreas Divisum (PD) Lyssa Bierig, Yang K. Chen, Raj J. Shah Background: It is known that patients with recurrent acute pancreatitis (RAP) secondary to PD respond better to minor papilla endotherapy than patients with chronic pancreatitis (CP) or pain alone. However, long-term data on patient outcomes in each of these groups is limited. The aim of this study was to determine the efficacy of minor papilla endotherapy and evaluate the clinical course of symptomatic PD patients. Methods: Our endoscopic database was searched for patients undergoing an attempt at minor papilla endotherapy for PD between January 2000 and November 2005. Patients undergoing MPE without congenital PD were excluded. A data collection instrument included: pre-and post-procedure pain score, narcotic use, acute pancreatitis episodes, ER visits, and hospitalizations. Clinical improvement was defined as a O50% reduction in: pain score, use of narcotic analgesia, episodes of acute pancreatitis, ER visits or hospitalizations. Results: Fifty-two patients (38F, 14M; mean age 46 years) were identified. Indications: RAP (N Z 23; 44%), CP (N Z 18; 35%), pain alone (N Z 10; 19%), other (N Z 1; 2%). Mean symptom duration prior to undergoing MPE was 5.5 years (range: 2 weeks 35 years). A mean of 1.3 ERCPs (range: 0-10) were performed prior to MPE. 44/52 (85%) of patients had successful MPE and overall had a mean of 1.8 ERCPs (range: 1-9) for MPE. Interventions per patient included: stricture dilation (N Z 7; 16%), minor papilla sphincterotomy (N Z 41; 93%) and stenting (N Z 38; 86%). Overall, follow-up was obtained in 49/52 (94%) patients for a mean 19 months (1 54 months). Of those patients who underwent successful MPE, 26/41 (63%) had clinical improvement: 15/16 (94%) with RAP, 6/16 (38%) with CP, 3/7 (43%) with pain alone. Two others had resolution of dorsal duct leak and resolution of minor papilla bleeding, respectively. Overall complications during all MPE procedures: 8% (pancreatitis N Z 7, perforation N Z 1). Ten patients (20%) required 15 additional interventions: celiac plexus block (4), intrathecal pump (2), sphincteroplasty (6), bilateral thoracic splanchniectomy (2) and Puestow (1). Only five (3/3 with RAP) of these 10 patients (50%) reported clinical improvement. Conclusions: 1) Minor papilla endotherapy is most effective in pancreas divisum patients with recurrent acute pancreatitis. 2) Despite intensive minor papilla endotherapy and additional non-endoscopic interventions, patients with pancreas divisum associated with chronic pancreatitis or chronic pain alone fair poorly.