Clinical characteristics and efficacy of ERCP therapy in pancreatic divisum-associated pancreatitis_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

HUANG Yuxin ¹ , SONG Shuailing ^1,2 , LI Yanni ^1,3 , GENG Chong ¹ , WANG Chunhui ¹ ,  LI Xiao ¹

1. Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu 610041, P. R. China;
2. Department of Gastroenterology, The Fourth Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215000, P. R. China;
3. Department of Gastroenterology, The Third People’s Hospital of Chengdu, Chengdu 610014, P. R. China;

Corresponding?author：

LI Xiao, Email: lixiao5166@hotmail.com

Keywords：

pancreas divisum; recurrent acute pancreatitis; chronic pancreatitis; endoscopic retrograde cholangiopancreatography; complication

DOI：

10.7507/1007-9424.202605065

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Objective To summarize the clinical characteristics and evaluate the long-term outcomes of endoscopic retrograde cholangiopancreatography (ERCP) therapy in patients with pancreatic divisum (PD)-associated pancreatitis (PDAP). Methods Clinical data of patients diagnosed with PDAP at West China Hospital of Sichuan University from June 2011 to June 2024 were retrospectively collected. The pancreatitis remission rate at the last follow-up, the incidence of post-ERCP pancreatitis and the cannulation failure rate were calculated. Results A total of 65 patients were enrolled, with an age of (44±17) years. Thirty-four (52.3%) patients were diagnosed with chronic pancreatitis, and 31 (47.7%) patients had recurrent acute pancreatitis (RAP). In terms of PD classification, incomplete-type PD was identified in 38 (58.5%) patients, complete-type PD in 24 (36.9%) patients, and classification data were unavailable for the remaining 3 (4.6%) patients. Patients with complete-type PD were diagnosed at a significantly younger age than those with incomplete-type PD [(37±18) years vs. (48±15) years, P=0.014], and no other baseline characteristics differed significantly between the two groups (P>0.05). ERCP was performed in 58 (89.2%) patients, the cannulation failure rate was 12.1% (7/58). Major papilla cannulation failed in all patients with complete-type PD. Post-ERCP pancreatitis occurred in 22.4% (13/58), with no severe adverse events (e.g., massive hemorrhage or perforation). After excluding 2 patients lost to follow-up, valid data were available for 56 patients (follow-up rate: 96.6%). The overall remission rate was 62.5% (35/56). Compared with the achieved clinical improvement, the proportion of the patients with RAP was lower [19.0% (4/21) vs. 54.3% (19/35), P=0.009], ERCP failure rate was higher [28.6% (6/21) vs. 2.9% (1/35), P=0.009], pancreatic stent placement ratio was lower [57.1% (12/21) vs. 85.7% (30/35), P=0.017] in the patients with non-achieved clinical improvement. No statistically significant differences were found in other baseline characteristics between the two groups (P>0.05). Conclusions These findings suggest that therapeutic ERCP is both feasible and efficacious for PDAP. Furthermore, patients with PD-related RAP might achieve better outcomes than those with chronic pancreatitis, indicating a potential phenotype-specific response to endoscopic therapy.

Citation： HUANG Yuxin, SONG Shuailing, LI Yanni, GENG Chong, WANG Chunhui, LI Xiao. Clinical characteristics and efficacy of ERCP therapy in pancreatic divisum-associated pancreatitis. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2026, 33(8): 1072-1078. doi: 10.7507/1007-9424.202605065 Copy

1.	Liao Z, Gao R, Wang W, et al. A systematic review on endoscopic detection rate, endotherapy, and surgery for pancreas divisum [J]. Endoscopy, 2009, 41(5): 439-444.
2.	Kamisawa T, Tu Y, Egawa N, et al. Clinical implications of incomplete pancreas divisum [J]. JOP, 2006, 7(6): 625-630.
3.	Quest L, Lombard M. Pancreas divisum: opinio divisa [J]. Gut, 2000, 47(3): 317-319.
4.	Cavestro GM, Leandro G, Di Leo M, et al. A single-centre prospective, cohort study of the natural history of acute pancreatitis [J]. Dig Liver Dis, 2015, 47(3): 205-210.
5.	Strand DS, Law RJ, Yang D, et al. AGA Clinical Practice Update on the endoscopic approach to recurrent acute and chronic pancreatitis: expert review [J]. Gastroenterology, 2022, 163(4): 1107-1114.
6.	Ferri V, Vicente E, Quijano Y, et al. Diagnosis and treatment of pancreas divisum: a literature review [J]. Hepatobiliary Pancreat Dis Int, 2019, 18(4): 332-336.
7.	Lu Y, Xu B, Chen L, et al. Endoscopic intervention through endoscopic retrograde cholangiopancreatography in the management of symptomatic pancreas divisum: a long-term follow-up study [J]. Gut Liver, 2016, 10(3): 476-482.
8.	Rustagi T, Golioto M. Diagnosis and therapy of pancreas divisum by ERCP: a single center experience [J]. J Dig Dis, 2013, 14(2): 93-99.
9.	Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis–2012: revision of the Atlanta classification and definitions by international consensus [J]. Gut, 2013, 62(1): 102-111.
10.	Schneider A, L?hr JM, Singer MV. The M-ANNHEIM classification of chronic pancreatitis [J]. J Gastroenterol, 2007, 42(1): 101-119.
11.	Catalano MF, Sahai A, Levy M, et al. EUS-based criteria for the diagnosis of chronic pancreatitis: the Rosemont classification [J]. Gastrointest Endosc, 2009, 69(7): 1251-1261.
12.	Bernard JP, Sahel J, Giovannini M, et al. Pancreas divisum is a probable cause of acute pancreatitis: a report of 137 cases [J]. Pancreas, 1990, 5(3): 248-254.
13.	Gutta A, Fogel E, Sherman S. Identification and management of pancreas divisum [J]. Expert Rev Gastroenterol Hepatol, 2019, 13(11): 1089-1105.
14.	Kim MH, Lee SS, Kim CD, et al. Incomplete pancreas divisum: is it merely a normal anatomic variant without clinical implications? [J]. Endoscopy, 2001, 33(9): 778-785.
15.	Carnes ML, Romagnuolo J, Cotton PB. Miss rate of pancreas divisum by magnetic resonance cholangiopancreatography in clinical practice [J]. Pancreas, 2008, 37(2): 151-153.
16.	Shen Z, Munker S, Zhou B, et al. The accuracies of diagnosing pancreas divisum by magnetic resonance cholangiopancreatography and endoscopic ultrasound: a systematic review and meta-analysis [J/OL]. Sci Rep, 2016, 6: 35389. doi: 10.1038/srep35389.
17.	Kushnir VM, Wani SB, Fowler K, et al. Sensitivity of endoscopic ultrasound, multidetector computed tomography, and magnetic resonance cholangiopancreatography in the diagnosis of pancreas divisum: a tertiary center experience [J]. Pancreas, 2013, 42(3): 436-441.
18.	Lai R, Freeman ML, Cass OW, et al. Accurate diagnosis of pancreas divisum by linear-array endoscopic ultrasonography [J]. Endoscopy, 2004, 36(8): 705-709.
19.	Rustagi T, Njei B. Magnetic resonance cholangiopancreatography in the diagnosis of pancreas divisum: a systematic review and meta-analysis [J]. Pancreas, 2014, 43(6): 823-828.
20.	Swensson J, Zaheer A, Conwell D, et al. Secretin-enhanced MRCP: how and why—AJR expert panel narrative review [J]. AJR Am J Roentgenol, 2021, 216(5): 1139-1149.
21.	Wan J, Ouyang Y, Yu C, et al. Comparison of EUS with MRCP in idiopathic acute pancreatitis: a systematic review and meta-analysis [J/OL]. Gastrointest Endosc, 2018, 87(5): 1180-1188. e9. doi: 10.1016/j.gie.2017.11.028.
22.	Adike A, El Kurdi BI, Gaddam S, et al. Pancreatitis in patients with pancreas divisum [J/OL]. Pancreas, 2017, 46(10): e80-e81. doi: 10.1097/MPA.0000000000000938.
23.	Pallagi P, Tóth E, G?r?g M, et al. Heavy metals in cigarette smoke strongly inhibit pancreatic ductal function and promote development of chronic pancreatitis [J/OL]. Clin Transl Med, 2024, 14(6): e1733. doi: 10.1002/ctm2.1733.
24.	Kamisawa T, Egawa N, Tu Y, et al. Pancreatographic investigation of embryology of complete and incomplete pancreas divisum [J]. Pancreas, 2007, 36(4): 448-452.
25.	Shanbhogue AK, Fasih N, Surabhi VR, et al. A clinical and radiologic review of uncommon types and causes of pancreatitis [J]. Radiographics, 2009, 29(4): 1003-1026.
26.	Yang AL, McNabb-Baltar J. Hypertriglyceridemia and acute pancreatitis [J]. Pancreatology, 2020, 20(5): 795-800.
27.	Tringali A, Voiosu T, Schepis T, et al. Pancreas divisum and recurrent pancreatitis: long-term results of minor papilla sphincterotomy [J]. Scand J Gastroenterol, 2019, 54(3): 359-364.
28.	Yamamoto N, Isayama H, Sasahira N, et al. Endoscopic minor papilla balloon dilation for the treatment of symptomatic pancreas divisum [J]. Pancreas, 2014, 43(6): 927-930.
29.	Pan G, Yang K, Gong B, et al. Analysis of the efficacy and safety of endoscopic retrograde cholangiopancreatography in children with symptomatic pancreas divisum [J/OL]. Front Pediatr, 2021, 9: 761331. doi: 10.3389/fped.2021.761331.
30.	Coté GA, Durkalski-Mauldin V, Fogel EL, et al. Minor papillotomy for treatment of idiopathic acute pancreatitis with pancreas divisum: a randomized clinical trial [J]. JAMA, 2026, 335(8): 682-692.
31.	Will U, Reichel A, Fueldner F, et al. Endoscopic ultrasonography-guided drainage for patients with symptomatic obstruction and enlargement of the pancreatic duct [J]. World J Gastroenterol, 2015, 21(46): 13140-13151.
32.	Coleman SD, Eisen GM, Troughton AB, et al. Endoscopic treatment in pancreas divisum [J]. Am J Gastroenterol, 1994, 89(8): 1152-1155.
33.	Lehman GA, Sherman S, Nisi R, et al. Pancreas divisum: results of minor papilla sphincterotomy [J]. Gastrointest Endosc, 1993, 39(1): 1-8.
34.	Moffatt DC, Coté GA, Avula B, et al. Risk factors for ERCP-related complications in patients with pancreas divisum: a retrospective study [J]. Gastrointest Endosc, 2011, 73(5): 963-970.
35.	Michailidis L, Aslam B, Grigorian A, et al. The efficacy of endoscopic therapy for pancreas divisum: a meta-analysis [J]. Ann Gastroenterol, 2017, 30(5): 550-558.
36.	Heyries L, Barthet M, Delvasto C, et al. Long-term results of endoscopic management of pancreas divisum with recurrent acute pancreatitis [J]. Gastrointest Endosc, 2002, 55(3): 376-381.

1. Liao Z, Gao R, Wang W, et al. A systematic review on endoscopic detection rate, endotherapy, and surgery for pancreas divisum [J]. Endoscopy, 2009, 41(5): 439-444.
2. Kamisawa T, Tu Y, Egawa N, et al. Clinical implications of incomplete pancreas divisum [J]. JOP, 2006, 7(6): 625-630.
3. Quest L, Lombard M. Pancreas divisum: opinio divisa [J]. Gut, 2000, 47(3): 317-319.
4. Cavestro GM, Leandro G, Di Leo M, et al. A single-centre prospective, cohort study of the natural history of acute pancreatitis [J]. Dig Liver Dis, 2015, 47(3): 205-210.
5. Strand DS, Law RJ, Yang D, et al. AGA Clinical Practice Update on the endoscopic approach to recurrent acute and chronic pancreatitis: expert review [J]. Gastroenterology, 2022, 163(4): 1107-1114.
6. Ferri V, Vicente E, Quijano Y, et al. Diagnosis and treatment of pancreas divisum: a literature review [J]. Hepatobiliary Pancreat Dis Int, 2019, 18(4): 332-336.
7. Lu Y, Xu B, Chen L, et al. Endoscopic intervention through endoscopic retrograde cholangiopancreatography in the management of symptomatic pancreas divisum: a long-term follow-up study [J]. Gut Liver, 2016, 10(3): 476-482.
8. Rustagi T, Golioto M. Diagnosis and therapy of pancreas divisum by ERCP: a single center experience [J]. J Dig Dis, 2013, 14(2): 93-99.
9. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis–2012: revision of the Atlanta classification and definitions by international consensus [J]. Gut, 2013, 62(1): 102-111.
10. Schneider A, L?hr JM, Singer MV. The M-ANNHEIM classification of chronic pancreatitis [J]. J Gastroenterol, 2007, 42(1): 101-119.
11. Catalano MF, Sahai A, Levy M, et al. EUS-based criteria for the diagnosis of chronic pancreatitis: the Rosemont classification [J]. Gastrointest Endosc, 2009, 69(7): 1251-1261.
12. Bernard JP, Sahel J, Giovannini M, et al. Pancreas divisum is a probable cause of acute pancreatitis: a report of 137 cases [J]. Pancreas, 1990, 5(3): 248-254.
13. Gutta A, Fogel E, Sherman S. Identification and management of pancreas divisum [J]. Expert Rev Gastroenterol Hepatol, 2019, 13(11): 1089-1105.
14. Kim MH, Lee SS, Kim CD, et al. Incomplete pancreas divisum: is it merely a normal anatomic variant without clinical implications? [J]. Endoscopy, 2001, 33(9): 778-785.
15. Carnes ML, Romagnuolo J, Cotton PB. Miss rate of pancreas divisum by magnetic resonance cholangiopancreatography in clinical practice [J]. Pancreas, 2008, 37(2): 151-153.
16. Shen Z, Munker S, Zhou B, et al. The accuracies of diagnosing pancreas divisum by magnetic resonance cholangiopancreatography and endoscopic ultrasound: a systematic review and meta-analysis [J/OL]. Sci Rep, 2016, 6: 35389. doi: 10.1038/srep35389.
17. Kushnir VM, Wani SB, Fowler K, et al. Sensitivity of endoscopic ultrasound, multidetector computed tomography, and magnetic resonance cholangiopancreatography in the diagnosis of pancreas divisum: a tertiary center experience [J]. Pancreas, 2013, 42(3): 436-441.
18. Lai R, Freeman ML, Cass OW, et al. Accurate diagnosis of pancreas divisum by linear-array endoscopic ultrasonography [J]. Endoscopy, 2004, 36(8): 705-709.
19. Rustagi T, Njei B. Magnetic resonance cholangiopancreatography in the diagnosis of pancreas divisum: a systematic review and meta-analysis [J]. Pancreas, 2014, 43(6): 823-828.
20. Swensson J, Zaheer A, Conwell D, et al. Secretin-enhanced MRCP: how and why—AJR expert panel narrative review [J]. AJR Am J Roentgenol, 2021, 216(5): 1139-1149.
21. Wan J, Ouyang Y, Yu C, et al. Comparison of EUS with MRCP in idiopathic acute pancreatitis: a systematic review and meta-analysis [J/OL]. Gastrointest Endosc, 2018, 87(5): 1180-1188. e9. doi: 10.1016/j.gie.2017.11.028.
22. Adike A, El Kurdi BI, Gaddam S, et al. Pancreatitis in patients with pancreas divisum [J/OL]. Pancreas, 2017, 46(10): e80-e81. doi: 10.1097/MPA.0000000000000938.
23. Pallagi P, Tóth E, G?r?g M, et al. Heavy metals in cigarette smoke strongly inhibit pancreatic ductal function and promote development of chronic pancreatitis [J/OL]. Clin Transl Med, 2024, 14(6): e1733. doi: 10.1002/ctm2.1733.
24. Kamisawa T, Egawa N, Tu Y, et al. Pancreatographic investigation of embryology of complete and incomplete pancreas divisum [J]. Pancreas, 2007, 36(4): 448-452.
25. Shanbhogue AK, Fasih N, Surabhi VR, et al. A clinical and radiologic review of uncommon types and causes of pancreatitis [J]. Radiographics, 2009, 29(4): 1003-1026.
26. Yang AL, McNabb-Baltar J. Hypertriglyceridemia and acute pancreatitis [J]. Pancreatology, 2020, 20(5): 795-800.
27. Tringali A, Voiosu T, Schepis T, et al. Pancreas divisum and recurrent pancreatitis: long-term results of minor papilla sphincterotomy [J]. Scand J Gastroenterol, 2019, 54(3): 359-364.
28. Yamamoto N, Isayama H, Sasahira N, et al. Endoscopic minor papilla balloon dilation for the treatment of symptomatic pancreas divisum [J]. Pancreas, 2014, 43(6): 927-930.
29. Pan G, Yang K, Gong B, et al. Analysis of the efficacy and safety of endoscopic retrograde cholangiopancreatography in children with symptomatic pancreas divisum [J/OL]. Front Pediatr, 2021, 9: 761331. doi: 10.3389/fped.2021.761331.
30. Coté GA, Durkalski-Mauldin V, Fogel EL, et al. Minor papillotomy for treatment of idiopathic acute pancreatitis with pancreas divisum: a randomized clinical trial [J]. JAMA, 2026, 335(8): 682-692.
31. Will U, Reichel A, Fueldner F, et al. Endoscopic ultrasonography-guided drainage for patients with symptomatic obstruction and enlargement of the pancreatic duct [J]. World J Gastroenterol, 2015, 21(46): 13140-13151.
32. Coleman SD, Eisen GM, Troughton AB, et al. Endoscopic treatment in pancreas divisum [J]. Am J Gastroenterol, 1994, 89(8): 1152-1155.
33. Lehman GA, Sherman S, Nisi R, et al. Pancreas divisum: results of minor papilla sphincterotomy [J]. Gastrointest Endosc, 1993, 39(1): 1-8.
34. Moffatt DC, Coté GA, Avula B, et al. Risk factors for ERCP-related complications in patients with pancreas divisum: a retrospective study [J]. Gastrointest Endosc, 2011, 73(5): 963-970.
35. Michailidis L, Aslam B, Grigorian A, et al. The efficacy of endoscopic therapy for pancreas divisum: a meta-analysis [J]. Ann Gastroenterol, 2017, 30(5): 550-558.
36. Heyries L, Barthet M, Delvasto C, et al. Long-term results of endoscopic management of pancreas divisum with recurrent acute pancreatitis [J]. Gastrointest Endosc, 2002, 55(3): 376-381.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Clinical characteristics and efficacy of ERCP therapy in pancreatic divisum-associated pancreatitis

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