Pancreas divisum: a case for surgical treatment.

When all is said and done, the case for an association between pancreas divisum and accessory papilla stenosis is empirical. In our experience, there are more persons with long-standing, persistent or increasing symptoms who respond favorably to accessory papilla sphincteroplasty than chance or placebo effect can reasonably explain. These same patients tend to have what is thought to be pathologically increased resistance to excretion of pancreatic secretions via the accessory papilla (positive secretin-ultrasound test), which is corrected by the accessory papilla sphincteroplasty (conversion to negative secretin-ultrasound test). At operation the orifice in the accessory papilla is tiny. Secretin-induced flow is only a trickle in these patients, but when the limiting membranous web is cut, pancreatic secretions gush forth. Symptoms present before the operation are perceived as absent as soon as the pain of operation has subsided enough to allow assessment. Symptoms recur if the papillary orifice scars down and restenoses. Problems remain. Accurate selection of candidates for accessory papilla sphincteroplasty is not yet possible because of the lack of a highly reliable test for accessory papilla stenosis. The secretin-ultrasound test helps in this regard but still has a 10%-20% false positive rate and a 30%-35% false negative rate. The operation demands fine, precise, meticulous technique to avoid failure and the creation of even bigger problems with iatrogenic pancreatic duct obstruction. The final caveat is this: pancreas divisum as an anatomic form is common; pancreas divisum as a cause of pancreatic symptoms is very uncommon. Accessory papilla sphincteroplasty is no more a panacea for abdominal pain than sphincteroplasty of the major papilla has been. Nonetheless past failures do not negate the successes. With appropriate attention to patient selection and surgical technique, success can be the rule.